1. INTRODUCTION:

All aspects of women’s health is directly affected by the availability and access to good quality health care services. To identify and prevent early health issues health care access is very critical so that the disease progression can be prevented. Women with poor health status, disabilities or chronic conditions need attention very much compared to normal women. (Women Health, 2011).

Women having very poor health and chronic conditions are in desperate need of proper health care. (Women Health, 2011). In developing countries, majority of the young men and women are facing difficulties due to limited accessibility to the resources of health care. (UNDP, 2014-17).

There is a very distinct influence in using the prevention methods caused by the accessibility, availability and acceptability of medical services which ultimately is the reason for getting infected and resulting in unnecessary pregnancies. (Holt et al., 2012).

2. REVIEW OF LITERATURE:

Physical accessibility “is understood as the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them”. Also Information accessibility - “includes the right to seek, receive and impart information and ideas concerning health issues”. This access to information, however, “should not impair the right to have personal health data treated with confidentiality.”

According to the human rights context, “health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups, such as ethnic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS, including in rural areas.” (Evans, D. B., Hsu, J., and Boerma, T, 2013).

According to Nygren-Krug’s (2002) definition affordability or Economic accessibility, “is a measure of people’s ability to pay for services without financial hardship. It takes into account not only the price of the health services but also indirect and opportunity costs (e.g. the costs of transportation to and from facilities and of taking time away from work).” Affordability is impacted by the household income and also wider health financing system.

Having about one-sixth of the population of the world, India has been tagged as the second most populous country in the universe (2015). India is adding more number of persons to the population yearly when compared to any other country in spite of consisting about 18% of the world’s total strength. It is also found that some of the states’ population is almost equal to the population of some countries around the world. Brazil’s population is more or less equal to the count of Uttar Pradesh (a state in India) population. Mexico’s population is equal to that of Maharashtra’s population and the growth rate is calculated to 9.42%. India has a growth rate of 16.16% with a population of 190 million according to the census of 2001.Germany’s population is lesser than Bihar’s population which has a growth rate of about 8%. India has a sex ratio of about 940. Currently, about half of the population is under age 25 and more than 65% are below 35 years of age. Majority about 72% live in villages and remaining 28% live in towns.

In 2011 census, Indian population has multiplied by about 181 million compared to the 2001 census which equals to almost Pakistan’s population. China will be overtaken by India as the largest country in the world during 2025, where the population is projected to reach 1.44 billion. The same by 2050 would have become as 1.65 billion. The fertility rate of India is 2.51 children born/woman (2014 est.). Even though the rate is encouraging, certain factors like unmet needs for contraception, child spacing, termination is on the higher side in the young married women group.

Back in 1952 itself, India planned and adopted an official policy for control of population by launching a family planning programme and in the process was the first country to do so which is considered as the main point in its efforts of family planning. Initially the main focus of family planning was on health rationale. After the 1971 population census only family planning was accepted as a main strategy for stabilizing the population and since more attention was sought on this programme. There was good affect when compared to the 1971-72 period between 1995-96 period where the protection rate percentage increased from 12.4% to 46.5% but was stagnant until 2003-04 and also came down to 40.4 during 2010-11.

Even though there were positive results, the ultimate goal was not achieved and when compared to the Independence stage in 1947, the population is almost three times more. In 2005, after launching the National Rural Health Mission, the programme for family planning focused upon child health and reproductive components of the mission. However, in India the small family norm adoption is still remaining as a distant dream.

Contraceptive usage of the married women or their husbands aged 15-49 years was only 54 percent during the period 2007-08. Also there was stagnation in the prevalence rate of contraception since 2004. In India, the contraception usage was mainly focused on the terminal methods, using for limitation of birth instead of using it for planning.

Keeping all these facts in view this study is carried out to assess the Availability and Accessibility of Health Services for women in rural blocks of Coimbatore District, Tamil Nadu. (Nygren-Krug H, 2002)

3. METHODS:

The study is a descriptive in nature conducted among the rural women in Coimbatore district of Tamil Nadu. The sampling technique adopted for the study was multi stage sampling technique, which consisted of 341 rural women.

Participants:

Married women between the age group of 18 to 40 years with at least one child were included and the women who had adopted permanent family planning method were excluded.

Instrument:

The semi structure interview schedule was adopted to collect data. High level of confidentiality and anonymity was maintained throughout the study. A semi-structure interview schedule and a validated measurement scale were prepared by the researcher for collecting the primary data. Demographic and obstetrical profile information was collected from each respondent. In-depth interview was conducted to collect data regarding reproductive autonomy. The tool had the following sections:

Section I: Personal information of the respondents included age, education, marital status, employment, type and head of the family, family size and total monthly income of the family.

Section II: Obstetrical history of the respondents includes duration of Married life, Physical problems during last pregnancy, Duration of Breast feeding to the child etc.

Section III: The availability and accessibility of health and family planning services of the respondents was assessed by using open ended questions. The items included aspects of availability of health services, what type of health facility were available nearby, availability of doctors, medical lab ambulance services, specialized services and Family planning services, consultation for emergency health services, waiting time for the consultation, Privacy to discuss about family planning, counseling facility, referral services and provision for emergency contraception in the health center. The accessibility was assessed by including items like distance of the health facility and mode of transportation for reaching the facility, accessing emergency health services, preference of government hospitals for medical management, home visit by the health workers, difficulty in consulting the male doctor regarding Family planning issues, and accessibility to free medical services were included in this section.

Analysis:

The collected data was analysed using statistical package. Frequency distribution and percentage was used to express the demographic characteristics of rural women. Chi square test was applied to find the association between the independent and dependent variables. P value of <0.05 was considered as statistically significant.

Procedure:

The investigator was appropriately selected, trained and assigned to recruit participants, and collected the data from the respondents. Oral consent was obtained and performed the interview. All interviews were conducted in ‘Tamil’ with privacy after building rapport with the respondents.

4. RESULTS:

A total of 341 rural women were interviewed. All the personal information and Obstetric profile are tabulated in the below Table 1. On considering their age nearly 50% of them are between 26 -30 years and about seventy percent of them had education till Diploma/graduate level. While looking into the family profile of the samples, majority of them live as a nuclear family with three persons and in most of the families’ husband is the head of the family. Socio-economic status 40% of them are housewives and 40% are employed in the private concerns and a large number of them earn more than Rs 10,000 per month.

Table: 1 Personal Information

S. No	Personal Information		Total n = 341
S. No	Personal Information		Frequency	%
1	Age in years	20 – 25	70	20.5
		26 – 30	168	49.3
		31 – 35	82	24.0
		36 – 40	21	6.2
2	Education	Illiterate	11	3.2
		Primary	54	15.8
		Secondary	43	12.6
		Diploma/graduate	233	68.3
3	Type of Family	Nuclear family	300	88.0
3	Type of Family	Joint family	41	12.0
4	Head of the Family	Husband	324	95.0
4	Head of the Family	Parents	17	5.0
5	Total number of family members	3 members	300	88.0
		4 members	14	4.1
		5 members	20	5.8
		6 members	7	2.1
6	Employment status	House wife	134	39.3
		Coolie	46	13.5
		Private concern	131	38.4
		Government	20	5.9
		Self employed	10	2.9
7	Income in rupees per month	Below 10,000	13	3.8
		10,001 – 20,000	94	27.6
		20,001 – 30,000	110	32.3
		Above 30,000	124	36.4

Table: 2– Obstetric Profile

S. No.	Obstetric profile		Total number n = 341
S. No.	Obstetric profile		Frequency	%
1	Duration of married life in years.	Below 5 yrs	225	66.0
		5 – 10 yrs	72	21.1
		Above 10 yrs	44	12.9
2	Age at marriage in years	18-25 yrs	312	91.5
		26-30 yrs	24	7.0
		31-35 yrs	5	1.5
3	Number of pregnancies	1^st	294	86.2
		2^nd	44	12.9
		3^rd	3	0.9
4	Number of abortions	Nil	306	89.7
		1 time	32	9.4
		2 time	3	0.9
5	Number of still births	Nil	336	98.5
5	Number of still births	One	5	1.5
6	Physical Problems in last pregnancy	Anaemia	74	21.7
		Fever/vomiting	244	71.6
		Hypertension / Diabetes mellitus	23	6.7
7	Medical check-up during last pregnancy	Regular	337	98.8
		Irregular	4	1.2
		7 – 9 months	25	7.3
		10 – 12 months	229	67.2
		Above 1 year	86	25.2

The table-2 reveals the Obstetric Profile of the rural women, in which nearly 70% of them got married at the age between 18-25 years. Among the samples, 80% of the women, who have been pregnant for only one time and about 10% mothers, had one abortion and about five mothers had a still birth. Regarding the physical problems encountered by the mothers, 244 had fever (or) vomiting and almost 99% of the mothers went for regular medical check-up during their last pregnancy and about 229 mothers were feeding their child for 10-12 months from birth.

Table-3 Availability of Health Care Services

S. No	Availability of health care facilities		n= 341
S. No	Availability of health care facilities		Frequency	%
1	Hospital near their home	No hospital	5	1.5
		Government	313	91.8
		Private	23	6.7
2	Availability of doctors	Available	330	96.8
2	Availability of doctors	Available in specified time	11	3.2
3	Health services on weekends or holidays	Health services available	335	98.2
3	Health services on weekends or holidays	Pharmacy available	6	1.8
4	Lab and scan facilities	Available	332	97.4
4	Lab and scan facilities	Not available	9	2.6
5	Availability of specialized care nearby	Government hospital	336	98.5
5	Availability of specialized care nearby	Private hospital	5	1.5
6	Consultation for emergency health services	Government	16	4.7
6	Consultation for emergency health services	Private	325	95.3
7	Waiting time for the consultation	Need not wait	33	9.7
7	Waiting time for the consultation	Need to wait	308	90.3
8	Family planning services available nearby health facility	Services available	329	96.5
8	Family planning services available nearby health facility	Services not available	12	3.5
9	Privacy to discuss about family planning in the health centre	Available	335	98.5
9		Not available	6	1.8
10	Counseling facility	Not available	38	11.1
		Counselor	4	1.2
		Nurse	102	29.9
		Doctor	197	57.8
11	Availability of referral services	Services available	334	97.9
	Availability of referral services	Services not available	7	2.1
	Place of referral services	Private hospital	36	10.6
	Place of referral services	Government hospital	298	87.4
12	Provision for emergency contraception	Accessible in nearby source	331	97.1
12	Provision for emergency contraception	Government hospital	10	2.9

Among the whole respondents, more than three fourth of them had a health center near their house, of which majority was of government institutions. For the substantiate number of women, doctor was available for consulting for 24x7 days, and also most of the respondents had weekend health care services available. Consultations for emergency health care services were available for more than three-fourth of the respondents. Majority of the respondents replied that they need to wait for a couple of hours to meet their doctor and all of them opinion that the ambulance services available. More than three-fourth of the respondents have lab, scan and specialized care facilities available in the nearby hospital itself. Family planning facilities were available for most of the respondents in their nearby hospitals with privacy counseling and emergency contraception facilities were available. About ninety eight percent of the respondents had referral services available, out of which ninety percent of the respondents had referral services to government institutions.

Table-4 Accessibility of Health Care Services

S. No	Accessibility of health care services		N = 341
S. No	Accessibility of health care services		Frequency	%
1	Access to health center	Car/Taxi/Auto	201	58.9
		Two wheeler	32	9.4
		Bus	47	13.4
		Ambulance	1	0.3
		By walk	60	17.6
2	Preference of Government Hospital for treatment	Preferred	334	97.9
		Improper care	1	0.3
		No medicines	1	0.3
		Distance	5	1.5
3	Medicine availability in Government hospital	Medicines available	340	99.7
3	Medicine availability in Government hospital	Medicines not available	1	0.3
4	Free medical services from any hospital	Not accessed	40	11.7
		Eye checkup	5	1.5
		Maternal and Child health care	83	24.3
		Medical checkup	197	57.8
		Dental checkup	11	3.2
5	Home visit by health center staff	Visit	330	96.8
5	Home visit by health center staff	Not visit	11	3.2
6	Difficulty in consulting the male Doctor regarding Family planning issues	Feeling difficult	310	90.9
6		No difficulty	31	9.1
7	Cost of health services	Satisfied	336	98.5
7	Cost of health services	Not satisfied	5	1.5

More than eighty percent of the total respondents accessed the hospital by transportation like bus, bike, or auto. Nearly ninety eight percent of the members preferred government hospital for treatment and almost all of them said that they get all the medicines in government hospital. When asked whether they have utilized free medical services from any hospital, nearly ninety percent of the respondents said they utilized and about ninety five percent of them said that they were visited by health center staff once in a while. About ninety percent of the respondents expressed their difficulty in consulting with male doctors. Nearly all the respondents were satisfied with cost of health care availability.

5. RESULTS AND DISCUSSION:

Availability of Health Care Services:

The data related to availability of hospital or clinic near home, availability of doctors, waiting time for consultation, investigative facilities such as scan and lab tests availability and referral services were collected. The analysis reveals that among the total samples, 91.8% them had a hospital or health centre near their house, of which majority was of government institutions. Majority of the women expressed that doctor was available for consultation for 24x7 days, and most of them said that weekend health care services were available. Substantiate number of women replied that they need to wait for a couple of hours to meet their doctor. All of the respondents said ambulance services were available and 75 percent of them revealed that, lab, scan and specialized care facilities were available at nearby hospital itself.

Family planning facilities were available for most of the women in the nearby hospitals with privacy counseling and emergency contraception facilities. About 98% of the respondents had referral services available, out of which 90% of the respondents had referral services to government institutions. In the current study majority of them approached public health sectors and responded that emergency services, lab and investigative facilities and ambulance services were available. The health care in India especially in Tamil Nadu has been improving to provide better facilities for local people which includes maternal and child health care and family planning services. As per the findings reported by Aziz et al (2016) lack of geographic access for family planning services was not a risk factor for contraceptives or unintended pregnancies. The findings of the current study are consistent with that of Aziz et al (2016) as all respondents have indicated that majority have adequate availability to health care.

Accessibility of Health Care Services:

The information related to accessibility of health care services include details on access of health care facility, preference of public or private health care facilities, availability of medications, free services, home visits by health care workers and cost of services. The study outcome shows that higher margin of women having access the hospitals by transportation like bus, two wheelers or auto and almost every women preferred government hospital for treatment and they get all the medicines. With regard to utilization of free medical services from any hospital, nearly ninety percent of them said that they are visited by health center staff occasionally and most of the women expressed their difficulty in consulting male doctors. The cost of the health care wise the women had no issue and further they opined that health care facilities reached them and it was possible because multipurpose health visitors visited every village and rural areas, the public transport system was affordable and very few had their own private transport systems like two wheelers and cars to reach the health care facility. The findings are in the same line with Rushender et al (2017) that use of primary level health care services such as Primary health centers and Sub-centers are better for preventive methods and for promotion of care. Nevertheless the primary level health care services have a poor utilization and access for acute illness, delivery, family welfare and specialized services.

6. CONCLUSION:

While making an attempt for assessing the various characteristics of at the primary health care centres for providing good quality health care it was found that there were some areas that needs to be improvised and corrected to provide good quality health care. By increasing the facilities with regards to inpatient and diagnostics the level of satisfaction of the patients can be improved and the need for referral can be reduced. To address the issues of the rest of the members of the family, additional needs should be tapped so the unexpressed needs can be covered. The nonusers should be targeted in particular by campaigning family planning services which should include information on emergency contraceptives and modern methods to people in reproductive age group through nationwide program and campaigns.

With regard to the availability and accessibility of family planning services the women have reported that they utilize the public sectors which is within their geographical range (Primary health centres, sub-centres and home visit by multi-purpose health workers). This is an acceptable finding as we know that the government has established Primary Health Centres (PHCs) for every 30,000 of the population, additionally sub-centres and home visits by health workers to cover up the basic health facilities for rural population. Ambulance services are available for all and this is true as we can find ambulance services in all PHCs.

7. ACKNOWLEDGMENT:

The authors express their sincere thanks to Dr Thavamani, Retd., Professor and HOD, Department of Sociology, Bharathidasan University, Tiruchirapalli, for his valuable guidance. We also convey our sincere gratitude to study participants.

8. REFERENCES:

1. UNDP Youth Strategy 2014-17, 2014. Retrieved from http://www.undp.org/content/dam/undp/library/Democratic%20Governance/Youth/UNDP_Youth-Strategy-2014-17_Web.pdf.

2. Moreland, J. J., Coxe, K. A., and Yang, J. (2018). Collegiate Athletes' mental health services utilization: A systematic review of conceptualizations, operationalizations, facilitators, and barriers. Journal of Sport and Health Science, 7(1), 58-69. Retrieved from https://mchb.hrsa.gov/whusa11/hsu/downloads/pdf/w11hsu.pdf.

3. Holt, K., Lince, N., Hargey, A., Struthers, H., Nkala, B., McIntyre, J and Blanchard, K. (2012). Assessment of service availability and health care workers’ opinions about young women’s sexual and reproductive health in Soweto, South Africa. African Journal of Reproductive Health, 16(2), 283-294. Retrieved from https://www.ajol.info/index.php/ajrh/article/view/77855.

4. Evans, D. B., Hsu, J., and Boerma, T. (2013). Universal Health Coverage and Universal Access, 546-546A. Retrieved from https://www.who.int/gender-equity-rights/understanding/accessibility-definition/en/.

5. Nygren-Krug, H. (2002). 25 questions and answers on health and human rights. World Health Organization, Geneva. Issue No 1, July 2002. Retrieved from http://www.who.int/hhr/information/25%20Questions%20and%20Answers%20on%20Health%20and%20Human%20Rights.pdf.

Received on 28.02.2022 Modified on 30.03.2022

Int. J. of Advances in Nur. Management. 2022; 10(3):171-176.

DOI: 10.52711/2454-2652.2022.00044