Discussion

So far, no attempts have been made to evaluate responsiveness in obstetrics and gynecological departments in Iran. According to the results, the mean score of responsiveness in obstetrics and gynecological wards was at a good level. This finding is consistent with the results of a study conducted in Thailand in the delivery room. In the mentioned study, most 

of the women reported a high rate of responsiveness, which was directly connected to a higher level of satisfaction (3). In a study performed by Mousavi Bazzaz et al. (2015) in the wards of both teaching and non-teaching hospitals in Mashhad city, the overall responsiveness mean score of both kinds of hospitals was at a good level (1).

However, the results obtained by Forouzan et al. (2016) showed that 47% of the participants ranked mental healthcare responsiveness as poor. This discrepancy might be due to the difference in the sampling place and measurement of different types of responsiveness (13). Given the important role of women in society, attention to their health and well-being could have positive effects on family and community. Based on the evidence, responsiveness in obstetrics and gynecological wards results in women’s satisfaction, and therefore health outcomes (3, 14). Although the total score was at a good level, some domains need to be improved.

In the present study, the confidentiality of the patient’s information was obtained as the best responsiveness score, while having power for choosing care provider was found to have the lowest score in this regard. This finding is in line with the results of several studies carried out in Iran and other countries (5, 15-18). This shows that patients have a positive view about their privacy and confidentiality of information, and that they can easily discuss their problems with health providers.

In the current study, the choice of provider obtained the lowest rate by the participants. This is in line with the results of the studies assessing the importance of each responsiveness domain in which the patients rated this item as the less important aspect (3, 19).

In general, it is not common to choose the therapist in most of the countries due to the uncertainty of the patients about themselves and their lack of awareness to choose their health provider (18, 20). Liabsuetrakul et al. (2012) observed a significant relationship between all seven responsiveness components and patient satisfaction in the maternity wards of some hospitals in Thailand. However, they detected no significant association between patient satisfaction and choice of care-provider. The explanation for this was the awareness of women in Thailand about the health system rules of hospital in which they are not allowed to pick any special therapist (3).

In the current study, while confidentiality, social support networks, and prompt attention were ranked as very good, total HSR score showed the highest correlation with dignity, communication, and autonomy.

Dignity is one of the essential principles of humanity. Caregivers who work with patients should try to preserve their dignity (21). All human beings need to be respected; however, patients are the most vulnerable social groups; therefore, they need special consideration and respect. If the dignity of the patients is maintained, they can make decisions about their healing process (22).

In the studies performed by Mohammadi and Kamali (2014) and Rashidian et al. (2011), participants ranked dignity as the most essential domain (15). Communication skills are considered as the most important aspect for those working in the healthcare services (23). The establishment of an effective communi-cation with the patients facilitates the accurate identification of their problems, higher patient satisfaction with care, and recognition of possible therapeutic options, better admission and treatment procedure, and ultimately reduction of patient’s stress and anxiety (24).

In a study performed by Zarei, dignity, communication, and confidentiality demon-strated the highest correlation with HSR (18). Similarly, in a study conducted by Liabsuetrakul et al. (2012), prompt attention, dignity, clear communication, autonomy, basic amenities, confidentiality, choice of provider, and social support were respectively rated as the prioritized domains of HSR (3). The relationship of responsiveness with age, education, and length of hospital stay varies depending different target groups. In the present study, the areas with the highest correlation with three demographic variables were dignity, appropriate communication, and autonomy, respectively.

Considering the inverse correlation between responsiveness score and participant’s literacy, educated people gave a lower score to HSR. In linear regression, the level of education was the only variable that maintained its correlation with responsiveness. This finding is consistent with the results of some studies. Fazaeli et al. (2016) demonstrated that graduated patients evaluated outpatient services with a lower score, especially in prompt attention and communication domains (25). Mohammadi and Kamali (2014) also showed that the mean score of dignity, communication, autonomy, and overall responsiveness would vary based on literacy level; in this regard, the enhancement of education level decreased the mean score of these items (15). In contrast, Ebrahimpour et al. (2013) and Mousavi Bazzaz et al. (2015) found no significant difference among the different levels of education in terms of rating the responsiveness components. In many studies, the concept of responsiveness has been shown to have association with patients’ rights (4, 26, 27). Educated people know more about their rights; therefore, they have higher expectations (27). As a result, the patient's unawareness of his/her rights can affect his/her evaluation, which leads to a higher assessment of reality.

In the present study, there was a negative correlation between age and HSR score. In this respect, young patients rated responsiveness at higher levels, and this can be explained by the lack of awareness about their rights. Since most of researchers evaluate both genders in their studies, they failed to find a significant relationship between these two variables (1). However, there was a significant association between these two variables in our study and another research conducted by Liabsuetrakul (2012) in obstetrics and gynecology wards (3).

The elongation of hospital stay results in the rise of patients’ expectations for more care, attention, and treatment. Therefore, they rate responsiveness at a lower level. Furthermore, a long-term hospital stay causes patients to feel bad about their condition and think that their illness is so severe that they have to have a long hospital stay, which adds to the patient's anxiety and sadness. Under this condition, the patients’ view about the hospital would deteriorate each day and lead to the under evaluation of responsiveness score (18).

Since the majority of the studies focus on evaluating the medical side of clinical care, the main strength of the present study is the evaluation of non-medical care factors, which are the neglected aspects of healthcare services. However, this study also contains a number of limitations. First, given the cross-sectional design of the study, the mean score of HSR domains varied overtime; as a result, the relationship between factors and HSR could not be established.

Secondly, despite giving assurance to the patients about the confidentiality of information, some participants might not tell the truth or answer the questions truly about the different factors of responsiveness due to the fear of not receiving good healthcare services later. Thirdly, outpatient service users were not included in this study, and the findings are only limited to inpatients. Finally, non-teaching hospitals were not evaluated in this study. Therefore, it is better to compare HSR in teaching and non-teaching hospitals in the future studies.

It is recommended to perform further studies using a qualitative design to better define each domain of HSR. This study could be a baseline for planning a monitoring system and evaluating each HSR domain in different wards and hospitals. Therefore, it is essential to direct attention toward the domains requiring promotion to enhance the quality of services.

Conclusion

In conclusion, it is important to pay more attention to non-medical aspects in providing healthcare services at hospitals. Responsiveness can be helpful for any programs attempting to improve the quality of healthcare services. Total non-medical responsiveness components of hospitals in obstetrics and gynecology wards were rated as good. However, several items, including having the right to choose health care provider, having autonomy for participating in healthcare decision-making process, and giving opinion about basic amenities (e.g., cleanliness, adequate space, good ventilation, and healthy foodneeded) needed to be improved.

Since the patients’ evaluation of HSR in the investigated ward had the highest correlation with dignity, communication, and autonomy, hospitals should pay more attention to these factors to make their clients satisfied. This study suggests that policymakers need to pay attention to responsiveness as a factor for the quality of health care system. Responsiveness can be a useful tool for evaluating the performance of midwives and gynecologists, beside healthcare system.

Policymakers should pay more attention to the domains of responsiveness that need improvement in all departments. Responsiveness items should be taught to the healthcare providers and policymakers should make these trainings as compulsory education for in-service training. Furthermore, policymakers should provide an opportunity to publicize guidelines
to inform patients about their rights, responsiveness domains, and cases of violation of their rights.

Acknowledgements

Our warm acknowledgements go to the participants for their contributions to the study. We received financial support from the Deputy of Research of the Mashhad University of Medical Sciences (Grant NO.960323). This study was approved by the Ethics Committee of Mashhad University of Medical Sciences.

Conflicts of interest

The authors declare no conflicts of interest.