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Relationship between’ patient’s rights charter’ and patients’ satisfaction in gynecological hospitals

  • Fereshteh Farzianpour1, 4Email author,
  • Abbas Rahimi Foroushani2,
  • Niusha Shahidi Sadeghi3 and
  • Saeede Ansari Nosrati3
BMC Health Services ResearchBMC series – open, inclusive and trusted201616:476

https://doi.org/10.1186/s12913-016-1679-9

Received: 14 June 2016

Accepted: 16 August 2016

Published: 7 September 2016

Abstract

Background

Patient’s satisfaction with hospital services is one of the most important indicators of efficiency and quality of services of different hospital wards.

Methods

This cross-sectional descriptive analytical study was conducted in 2015. The study population included patients in gynecological hospitals of TUMS, and by using questionnaires; data were collected from 304 patients. Statistical analysis was performed using the SPSS 22.

Results

The rights of patients were mainly observed through “quality of care” (Mean ± SD: 9.65 ± 2.62), “knowing the charges and the right to complain”; (Mean ± SD: 6.00 ± 2.5) “presence of an active system to handle complaints of patients in the hospital and explanation of the error that occurred during service provision to patients by the wrongdoer” is the lowest (7.5 ± 2.62). It was found that patients’ satisfaction is below the mean and its different aspects are higher than the mean level. However, the services of physicians and feeding recorded the highest and lowest satisfaction, respectively (19.4 ± 4.25, 20.77 ± 4.39). The mean score of satisfaction of patients admitted with nursing physical care was 24.5 ± 6.2.

Conclusion

Overall, patients’ satisfaction with hospital services was close to the mean. Deficiencies and grievances should be resolved with a correct measure.

Keywords

Patient’s rights charterPatient’s rightsPatient’s satisfactionGynecological hospitals

Background

Members of a society are committed to preserving and respecting the dignity of human beings [1]. People in every part of the health spectrum, have rights. When their rights are respected by others, especially health care providers, they will be more satisfied and secured [2, 3]. The rights of a patient includes the tasks that a medical center and the treatment team are obliged to implement and abide to for the physical, mental, spiritual and social legitimate needs embodied as standards, rules and regulations of therapy [4]. Dramatic changes have occurred in the way health services are received in the past few decades; for years, staff of organizations providing health services thought that they can make the best decision about patients, regardless of the their rights. But now the situation has changed and patients have expectations and demand for their rights [5]. Most health care providers are in a position that allows them determine patients’ fate, and in some cases, they behave like fathers. Although they see patients as intellectually mature and know they are allowed to decide on their own, but in the real sense, they do what they prefer [6]. Economic pressures, modern medicine and patients’ expectations are important factors that affect the identification of patients’ rights. Thus, multiple factors necessitated the development of principles dependent on support from individuals and health care and lay emphasis on patients’ rights which supports the present research [7]. An emphasis on basic human rights in health care, especially respect for patient’s dignity as a human becomes important when the patient’s vulnerability easily exposes him to violations and loopholes of the health and social system. The current era characteristics include not only the individual but social dimension of patients’ rights [810]. For this purpose, the healthcare system in most countries, has developed a charter for patient’s rights, to establish the rights of health care recipients and promote the ethical aspects of health care in one of the most important areas of health services, that is, treatment, and make it known to the executive levels to implement its provisions [11] which includes defending one’s rights in order to protect the sanctity and dignity at the time of illness to ensure strength of body and soul, and health care in the event of illness without age, sex discrimination and possessing sufficient financial power [1220]. When patients are hospitalized, hospitals are obliged to submit this charter to the patients, to familiarize them with their rights [2124].

Consumers are valuable sources of information to judge the quality of care services and their opinions feedback can be effective in organizing the hospital systematically. On the other hand, due to the importance of women in population growth, and the limited studies in this field, and also due to the need for a homogeneous population in terms of sex and disease, and the personnel taking care of patients who are women, the women were selected.

In this regard, the present study investigated the relationship between observance of patient’s rights charter and patient’s satisfaction with hospital inpatient services in specialized and ultra-specialized women’s hospitals of the Medical University of Tehran.

Methods

This cross-sectional descriptive analytical study was conducted in the inpatient wards of all gynecological hospitals of the University of Medical Sciences. This research project approved in 2015 with code number 25831 and with the support of Research Deputy of Tehran University of Medical Sciences and Health Services. Data were collected by questionnaires given to patients of inpatient wards in gynecological hospitals of Tehran University of Medical Sciences in 2015. The research population consisted of the women’s comprehensive hospitals of MirzaKochakKhan and Arash. The number of sample was obtained from the correlation coefficient so that at 0.95 % confidence level and 0.90 % test power, if the correlation coefficient is 0.2 or more, it is statistically significant. The number of sample was obtained by the following formula:
$$ \mathrm{r} = 0.2;\mathrm{w} = 0.203 $$
$$ n=\frac{{\left({Z}_{1-\alpha /2} + {\mathrm{Z}}_{1\hbox{-} \mathrm{B}}\ \right)}^2}{W^2}+3 $$
$$ n=\frac{{\left(1.96+1.65\right)}^2}{(0.203)^2}+3=320 $$

For samples selection, first, the list of gynecological hospitals of Tehran University of Medical Sciences was provided with a number of hospitalizations per day. Patients were randomly selected from hospitalized patients in various wards. Data collection tools included two questionnaires whose validity and reliability were determined in previous studies [25]. The first questionnaire was developed in two parts, the first part included demographic variables while the second part included 13 paragraphs as follows: Information on patient’s rights (Likert from 1 = very unsatisfied to 5 = very satisfied), providing personal information including the full name of members of the care team and presenting professional information which includes the occupation, responsibility of the care team members to the patient, or his alternative decision-maker when admitted at the medical center, patient’s right to receive respectful and non-discriminatory diagnostic-medical services, delivering good care, providing sufficient information about the disease, treatment methods and common complications, patient’s and the alternative decision-maker’s access to health care team during hospitalization and after discharge from the hospital in an understandable language, accountability of the care team for the questions of patient or alternative decision-maker about disease and treatment, the patient’s right to choose and decide, authority and independence, the right to replace doctor and refuse treatment and its consequences, patient’s access to his/her medical records and information on the content, maintaining patient’s privacy, information confidentiality and secrecy, patient’s training, patient’s right for consideration of the complaints and expression of medical error, presence of an active system to handle complaints by patients in the hospital, explanation of the error that occurred during service provision to patients by the wrongdoer, and knowing about the charges and the right to complain, in the form of 90 multiple-choice questions in Likert scale. It assesses the level of respect for patients’ rights charter. The second questionnaire includes the following 6 parts which assessed patient’s satisfaction, and its validity and reliability have been confirmed in previous studies [25, 26]: satisfaction of admitted patients with nursing physical care Likert from 1 = very unsatisfied to 5 = very satisfied), admitted patients’ satisfaction with nursing psychological and mental care, patients’ satisfaction with medical services, patients’ satisfaction with feeding, patients’ satisfaction with the physical environment, as well as facilities and reception services which are determined based on past studies and literature review. Finally, the questionnaires (Additional files 1 and 2). were distributed among the patients in the hospitals studied, according to the mentioned method. Analysis of data was performed using SPSS 22 statistical software and descriptive statistics together with Pearson’s correlation coefficients and, two-sample T-test, as well as ANOVA tests.

Results

In the current study, an age group of 27–35 years (50.7 %), married (93.8 %), those with bachelor’s degree or higher (54.27 %) and duration of stay at the time of completing the questionnaire (40.4 %) had the largest volume of the sample.

Most of these patients (68.8 %) had a history of one hospitalization. 43.7 % of them had a history of hospitalization in other hospitals and 64.4 % in public hospitals (Table 1).
Table 1

Frequency distribution of the people who completed the questionnaire according to demographic the questionnaire according to demographic variables

Variable

Number

Percentage

Age group

 17-26

74

24.3

 27-35

154

50.7

 36-57

76

35

Marital status

 Single

19

6.25

 Married

285

93.8

Level of education

 Elementary

35

11.51

 diploma

104

34.21

 Bachelor and higher

165

54.27

Job type

 Employed(teacher + others)

57

18.8

 Unemployed(housewife)

247

81.2

Reason for hospitalization

  

 giving birth(delivery)

42

13.8

 Medical

224

73.3

 Surgery

38

12.5

Number of hospitalization days

 1-2

115

38.1

 3-5

122

40.4

 6-60

65

21.5

Number of hospitalizations

 0(outpatient)

27

8.9

 1(inpatient)

209

68.8

 2-7(inpatient)

68

22.4

Type of insurance

 Public social security

197

64.8

 Public health servise

83

27.3

 Private

24

7.9

Supplemental Insurance

 Yes

229

75.3

 No

75

24.7

Referral to other hospitals

  

 Yes

131

43.7

 No

163

56.3

Number of referral to other hospitals

Less than 2 times

73

54.1

 Between 2-4

55

40.7

 More than 4 times

7

5.2

Economic status

 High

83

27.3

 Medium

197

64.8

 Low

24

7.9

The patients’ view on “the right to replace the doctor and refuse treatment and its consequences” on the patient’s rights charter with mean score of 10.12 ± 3.94 is more than low and less than neither low, nor high.

The patients’ view on “access to his/her medical records and information on the content” of the patient’s rights charter with a mean score of 2.41 ± 1.27 is more than neither low, nor high and less than high. View of the patients on “maintaining patient”s privacy“ of the patient’s rights charter with mean score of 17.84 ± 4.99 is more than neither low, nor high and less than high. The patients’ view on “information confidentiality and secrecy” of the patient’s rights charter has a mean score of 4.67 ± 1.48, is more than neither low, nor high and less than high (Table 2 and Additional files 1 and 2).
Table 2

Average of the various aspects of patients' rights in the hospital under study

Dimension

Number

Least

Most

Total

Mean

SD

Notification

304

6

28

3382

11.13

5.05

Patient’s right to receive diagnostic-medical services

304

5

18

3037

9.99

2.56

Quality of care

304

3

15

2935

9.65

2.62

Providing adequate information on the disease

304

9

44

6330

20.82

7.28

Medical team accountability for the questions of patient

304

2

10

1662

5.47

2.03

Patient’s right to decide

304

7

26

3749

12.33

4.72

The right to replace the doctor and refuse treatment

304

6

23

3076

1.12

3.94

Patient access to records

304

1

5

734

2.41

1.27

Maintaining patient’s privacy

304

9

32

5423

17.84

4.99

Confidentiality of information

304

2

10

1421

4.67

1.48

Patients’ straining

304

4

20

3080

10.13

3.61

Knowing about the charges and the right to complain

304

4

19

1824

6.00

2.5

Patient’s right to consider the complaints and expression of medical error

304

5

15

2280

7.5

2.62

Patients’ satisfaction with “nursing physical care” with mean score of 24.5 ± 6.2 is more than satisfied and less than neither satisfied nor dissatisfied. Patients’ satisfaction with “medical services” with mean score of 19.14 ± 4.25 is more than satisfied and less than neither satisfied nor dissatisfied (Table 3 and Additional files 1 and 2).
Table 3

Average of various aspects of satisfaction among hospitalized patients under study

Dimension

Number

Least

Most

Total

Mean

SD

Satisfaction of patients admitted with nursing physical care

304

10

41

7450

24.5

6.2

Satisfaction of patients admitted with nursing psychological care

304

11

46

8195

26.96

6.47

Satisfaction with medical services

304

8

32

5819

19.14

4.25

Satisfaction with feeding

304

7

32

6315

20.77

4.39

Satisfaction with amenities

304

11

52

8992

29.58

7.38

Satisfaction with admission

304

6

30

4905

16.13

4.02

The Kolmogorov-Smirnov test was used to test normality of the satisfaction level. Since test statistic = 1.37 and P > 0.05, the distribution of this score is not normal, hence the correlation coefficient of Spearman, Mann–Whitney or Kruskal-Wallis were used to examine the effect of demographic factors on the median of the score.

Satisfaction is different in groups with different causes of hospitalization (P-value < 0.001). ‘Delivery’ and ‘surgical’ groups have the highest dissatisfaction and satisfaction, respectively.

Satisfaction is different in groups with different insurances (P-value < 0.001) (Table 4 and Additional files 1 and 2). ‘Other insurances’ and ‘medical services’ groups recorded the highest dissatisfaction and satisfaction, respectively.
Table 4

Analysis of the statistic test for the relationship between demographic characteristics and patients’ level of satisfaction with health care services

 

Group

Number

Average rank

Test result

Satisfaction

Employed(teacher + other)

57

159.84

Z = −0.7

 

Unemployed(housewife)

274

150.81

Z = 0.48

Satisfaction

Single

19

148.63

Z = −0.2

 

married

285

152.76

Z = 0.843

Satisfaction

With supplemental insurance

75

149.52

Z = −0.34

 

Without supplemental insurance

229

153.48

P = 0.74

Satisfaction

Age group of 17-26

74

146.7

Chi-square = 7.21

 

Age group of 27-35

154

164.94

df = 2

 

Age group of 36-57

76

132.89

P = 0.027

Satisfaction

Elementary

35

35

Chi-square = 4.68

 

diploma

104

104

df = 2

 

Bachelor an higher

165

165

P = 0.096

Satisfaction

Delivery hospitalization

42

190.38

Chi-square = 19.6

 

Medical hospitalization

224

153.7

df = 2

 

Surgical hospitalization

38

103.63

p < 0.001

Satisfaction

Hospital stay: 1–2 days

115

138.25

Chi-square 4.85

 

Hospital stay: 3–5 days

122

156.13

df = 2

 

Hospital stay: 6–60 days

65

166.25

P = 0.088

Satisfaction

number of hospitalization: 0*

27

155.59

Chi-square = 0.48

 

Number of hospitalization: 1**

209

154.2

df = 2

 

Number of hospitalization: 2-7**

68

146

P = 0.79

Satisfaction

Public social security insurance

197

161.46

Chi-square = 26.63

 

Public medical services insurance

83

115.16

df = 2

 

Other insurances(Private)

24

208.08

p < 0.001

Satisfaction

Economic status appropriate

83

115.16

Chi-square = 26.63

 

Relatively good

197

161.46

df = 2

 

Inappropriate

24

208.08

p < 0.001

*Outpatient, **Inpatient

Spearman correlation test was used to assess the relationship between respect for patient’s rights charter and patient’s satisfaction with hospital services, and the results are as follows. Notification about patient’s rights, Patient’s right to receive diagnostic-medical services, Quality of care, providing adequate information on the disease, Medical team accountability for the questions of patient, Patient’s right to decide, choose, authority and independence, Patient training, Knowing about the charges and the right to complain, Presence of an active system for complaints of patients(P-value < 0.01) and The right to replace the doctor and refuse treatment (P-value < 0.05), Patient’s access to medical records and contents (P-value < 0.001), Maintaining patient’s privacy, Confidentiality of information (P-value < 0.251) (Table 5 and Additional files 1 and 2).
Table 5

Statistical test results of the relationship between respect for patient’s rights charter and patient’s satisfaction with health care services

hospital services patient’s satisfaction with

Dimensions of patient’s rights charter

Test results

 

Notification about patient’ sright

Correlation coefficient = −0.249

  

P-value <0.01

 

Patient’s right to receive diagnostic-medical services

Correlation coefficient = −0.304

  

P-value < 0.01

 

Quality of care

Correlation coefficient = −0.532

  

P-value < 0.01

 

Providing adequate information on the disease

Correlation coefficient = −0.284

  

P-value < 0.01

 

Medical team accountability for the questions of patients

Correlation coefficient = −0.354

  

P-value < 0.01

 

Patient’s right to decide, choose, authority and independence

Correlation coefficient = −0.206

  

P-value < 0.01

 

The right to replace the doctor and refuse treatment

Correlation coefficient = −0.147

  

P-value < 0.05

 

patient’s access to medical records and contents

Correlation coefficient = −0.206

  

P-value < 0.001

 

Maintaining patient’s privacy

Correlation coefficient = −0.477

  

P-value < 0.01

 

Confidentiality of information

Correlation coefficient = −0.066

  

P-value <0.251

 

Patient training

Correlation coefficient = −0.370

  

p-value < 0.01

 

Knowing about the charges and the right to complain

Correlation coefficient = −0.150

  

P-value < 0.01

 

Presence of an active system for complaints of patients

Correlation coefficient = −0.260

  

P-value < 0.01

Discussion

According to results of the age group of 27–35 years (50.7 %), those married (93.8 %), those with Bachelor’s degree or higher (54.27 %) and duration of stay at the time of completing the questionnaire (40.4 %) had the largest volume of respondents.

Most of these patients (68.8 %) had a history of one hospitalization. A total of 43.7 % of them had a history of hospitalization in other hospitals and 64.8 % in public hospitals. This will help in interpreting the research findings. Most of them had social security insurance (64.8 %) and none had supplemental insurance (75.3 %). In this study, the highest amount of compliance with patient’s rights charter was related to the “quality of care”. Also, patients’ view on observance of “knowing the charges and the right to complain” and “presence of an active system to handle complaints of patients in the hospital, and explanation of the error that occurred during service provision to patients by the wrongdoer” had the lowest value among 13 dimensions of the patient’s rights charter.

Patients’ view on observance of “providing sufficient information about the disease, treatment methods and common complications, patient’s and the alternative decision-maker’s access to health care team during hospitalization and after discharge from the hospital in an understandable language”, with mean score of 6.00 ± 2.5 are more than neither low nor high and less than high (Additional files 1 and 2). In their study, Nasiriyani et al. [23] noted that patients considered improper accountability of doctors and nurses, as the reason for not asking questions. Also, Bazmi et al. [24] reported the lowest score for the right to receive necessary information on possible side effects, as well as other treatment options and participation in the final selection of treatment. This is due to the instruments used or the year of the study, because during the study of Bazmi et al. [24], patient’s rights charter had 5 dimensions, but now it has 13 dimensions.

Patients’ view on observance of “information confidentiality” of the patient’s rights charter with mean score of 2.23 is more than neither low nor high and less than high. According to Bazmi et al. [24], patients assigned the highest score to confidentiality of information with the doctors and the medical team. This can be due to the instruments used or the year of the study, because in Bazmi’s study, patient’s rights charter had 5 dimensions, but presently, there are13 dimensions.

Patients’ view on observance of “informing about patient’s rights, providing personal information including full name of the care team members and presenting professional information including the occupation, responsibility of the care team members for the patient, or his alternative decision-maker when admitted at the medical center”, with mean score of 1.85 is more than low and less than neither low nor high. Nasiriyani et al. [23] showed that the least observance of the rights of study participants is when care team members are not introduced to patients, which is partly consistent with this study. Anbari et al. [25] showed that the highest mean score for patients’ rights at “the time of admission” is for “mostly observed”.

Hospitalized patients’ satisfaction with “nursing physical care” and “nursing psychological care” is more than average. Most psychological satisfaction with nursing care in the present study was to deal respectfully with patients which is consistent with the study of Ghanbari and colleagues [22].

Hasaniyan [21] showed that most of the patients’ dissatisfaction with nurses is in non-allocation of sufficient time, in order to give information on the plan and procedures in progress. They argued that patients’ anxiety can be reduced by speaking to nurses and getting information which will make them feel more relaxed.

However, in the study of Hasaniyan [21], patients admitted to Ajay hospitals in the city of Tehran were more satisfied with the performance of doctors and nurses, and their dissatisfaction with the performance of nurses was twice more than that with the performance of doctors. Of course, in the study conducted by Nemati et al. [26], satisfaction with nursing care (72.3) was significantly more than that with medical services (57.6). These different results can be caused by the research environment and the tools used.

In this study, patients’ satisfaction with “Medical Services” is more than the average, and has the highest score with a little difference. In the study conducted by Nemati et al. [26], satisfaction with “Medical Services” was reported to be more than the average which is consistent with the current study.

The least satisfaction with medical services is the availability of doctor when needed and also, with a little difference in medical explanation of disease. Also, in the study of Nemati et al. [26], the least satisfaction was with access to medical staff when needed.

Ghanbari et al. [22] also showed that the lowest satisfaction with medical services (12 %) was medical explanation in the field of disease.

The lowest score of patients’ satisfaction in this study, with minor differences from the other axes, is in the “feeding” axis.

In general, the analysis of results of the current study shows that patients’ satisfaction in different axes is in one level and higher than average. However, physicians’ services and feeding axes had the highest and lowest satisfaction, respectively.

In this study, the mean score of satisfaction was below average. Nemati [26] showed that the percentage of satisfaction with total service was at a quite satisfied level which is inconsistent with the current study. Perhaps, this difference is as a result of the different dimensions measured in the two studies; 7 and 3 dimensions were studied in the present study and Nemati’s study, respectively.

Mean score of patient’s rights charter observance (2.09 %) was almost low. The results of this study confirmed that of Aghighi et al. [27] who reported that the patient’s rights charter observance was equal to 8.75 %. Asterki et al. [28] also showed that in general, patients know the observance of rights charter on average. Anbari et al. [25] also stated that patient’s rights observance in surgical wards is not appropriate in patients’ view Vakili et al. [29] reported that the patient’s rights charter observance was equal to 2.63 % which is inconsistent with the current study. This difference can be due to the instruments used or the year of the study, because in Vakili’s study, patient’s rights charter had 5 dimensions, but in the present study, it is 13 dimensions.

Patients’ rights observance is the most important part of ethical issues that requires consideration. If the rights of patients and their families are respected by therapists, it has the advantage that patients can be aware of the course of treatment and make sure that hospitalization is effective [25].

Satisfaction is different in different age groups (P-value = 0/027). Age group of 27.35 years had the highest dissatisfaction with inpatient services. According to a study conducted at Aja hospitals, old people had higher satisfaction mean scores.

Kavari, Garosi, Mack and Nemati [26, 3032] conducted separate studies and concluded on the same results, which means that younger patients are less satisfied than middle-aged and older people because of higher awareness of this young and active age group, of their rights.

Satisfaction is different in groups with different causes of hospitalization (P-value < 0.001). “Delivery” and “surgical” groups had the highest dissatisfaction and satisfaction, respectively.

Satisfaction is different in groups with different insurances (P-value < 0.001). “Other insurances” and “medical services” groups had the highest dissatisfaction and satisfaction, respectively. Nemati et al. [26] showed that satisfaction of those with insurance is higher than those without insurance.

There was no statistical relationship between satisfaction and other demographic variables. Results studies by Hasaniyan, Yaghmaei and Akbari [21, 33, 34] are entirely consistent with the results of the present study. But the study of Mack [32] showed that patients with a history of hospitalization were more satisfied with the service received.

At P <0.001 level, patient’s rights charter observance in patients’ perspective and dissatisfaction scores were negatively correlated. This means that by increasing the observance of the patient’s rights charter, satisfaction score increases. In the study of Vakili et al. [29], patients’ satisfaction with the hospital was significantly correlated with the level of patients’ observance in all domains, which is consistent with the present study.

To find more accurate results for the relationship between patient’s rights charter and patient’s satisfaction with health care services we suggest to conduct other studies such as intervention or clinical studies in which the effect of intervention on patient’s right character on patient’s satisfaction can be estimated after controlling for confounding factors.

Conclusion

According to the observance of patients’ rights and its relationship with patients’ satisfaction with hospital, to increase patients’ satisfaction and improve service delivery to them, patient’s rights compliance is necessary. And one of the main strategies to increase patients’ rights compliance is to increase their awareness of patients’ rights charter.

With regards to correlation between patients’ satisfaction and their rights charter axes, the highest correlation belonged to the “quality of care” and with a little difference from “maintaining patient’s privacy”; also, the lowest correlation belonged to the “right to replace the doctor and refuse treatment and its consequences”. In addition, there is no significant correlation between patients’ satisfaction and “information confidentiality and secrecy ”of the patient’s rights charter.

Abbreviations

ANOVA: 

Analysis of variance

SD: 

Standard deviation

TUMS: 

Tehran University of medical sciences

Declarations

Acknowledgement

This article is the result of a research project approved in 2015 with code number 25831 and with the support of Research Deputy of Tehran University of Medical Sciences and Health Services. The authors thank all the managers, nurses and patients hospitalized in gynecological hospitals of Tehran University of Medical Sciences.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: which received financial support from Tehran University of Medical Sciences. We would like to thank all the managers and users who helped the researchers in this study.

Availability of data and materials

The data set, Iranian transcripts of the interview generated during and/or analyzed during the current study are not publicly available due to concerns about preserving the privacy of individual study participants, but are available from the corresponding author on reasonable request.

Authors’ contributions

FF is the principal investigator on this study. All authors participated in designing the study. ARF performed the study and the data analysis, and worked together with NSS and SAN to interpret the data and the outcomes. FF, ARF generated the first draft of the manuscript, which was revised by FF, SAN and NSS. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

All respondents signed consent to participate in which they also agreed with the anonymised use of the interviews for publication.

Ethics approval and consent to participate

All study protocols were approved by the Ethics Committee of TUMS Review Board. Written informed consent was obtained from all study participants.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Health Management & Economic Department, School of Public Health, Tehran University of Medical Sciences
(2)
Epidemiology and Statistic Department, School of Public Health, Tehran University of Medical Sciences
(3)
Health care management, Health Management & Economic Department, School of Public Health, Tehran University of Medical Sciences
(4)
Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences

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