in both developed and developing countries , healthcare is the fastest growing service , whereas improvement in the population s health is the main goal of every health system , and the quality of delivered health care is a matter of increasing concern to governments , health authorities and users . when individuals interact with the healthcare system , it influences their well - being through improvements in health . surging demands and diminishing resources increasingly rise , and healthcare systems need to be sustainable as well as responsible . the users satisfaction is a way to evaluate a healthcare system and determine its efficacy ; subsequently , an accentuated attention has been designated to the users satisfaction with healthcare system since the last two decades . studies revealed that the potential factors which affected the users satisfaction with healthcare system were classified into three main groups ; the first group was healthcare factors , which included travelling distance , waiting time for an appointment , the clinic s physical environment , healthcare payments , patient s privacy and the interpersonal skills of the staff . the second group was individual factors which included the participants age , sex , job , and education level . the third group was socioeconomic status ( ses ) which has be shown as the main potential factor directly associated with the users satisfaction ; that is , people with higher income were significantly more satisfied with the overall quality of the delivered primary health care . one of the important determinants of access to health care is low ses , and these people seek healthcare less often when it is likely to be for an emergency , because they are more likely to be uninsured and have poor - quality health care . regardless of the differences in the individual s income , age and gender , assurance regarding equitable access to high - quality healthcare for all iranians is the goal of the health policy in iran ; however , in relation to ses , differences are observed in the use of healthcare services . also , iran is a large country with the rankings of ses in various areas . based on our search in validated data banks , there exist limited data regarding the relation between ses and users satisfaction with healthcare system in iran . since this information is pivotal for health - policy makers , the present study was designed to evaluate the association between the users ses and satisfaction with healthcare system in shiraz , iran . between december , 2013 and march , 2014 , this analytic cross - sectional study was conducted in shiraz , the fifth populated city of iran and the capital of fars province . to be eligible for participation in this study , the respondents should be residents of shiraz , at least 18 years of age as well as being thoroughly aware of the household medical problems and expenditure in the last 6 months prior to the study . those who were not willing to participate , unable to talk or had problem in recalling the events which occurred during 6 months prior to interview were excluded from the study . ethical approval for the study was granted by the review board of shiraz university of medical sciences , shiraz , iran . reviewing literature and considering z ( 1.96 ) , sigma or    ( 1.04 ) and precision or d  ( 0.035 ) , a total of 3400 households were included in this study . in order to attain the estimated sample size by multi - stage random sampling method , first the number of the households residing in each of the 9-municipality regions was considered as a sampling unit . then , postal codes were chosen by simple random sampling proportionate to the size of households in each municipality region . after giving appropriate introduction regarding the study and its aim , the respondents were asked to express their verbal consent for participation in the study ; this was followed by a face - to - face interview by trained field workers in the interviewees house , using a structured questionnaire . the questionnaire consisted of three main parts , including demographic , insurance status of the household , and users satisfaction regarding different levels of healthcare services , assuming that at least one of the household had used healthcare services in the last 6 months prior to the investigation . demographic part included age , sex , nationality , ethnicity , the family s bread winner marital status , educational level and occupation , family members , and income . a 5-score likert scale was used to assess the respondent s satisfaction level with healthcare system . the scale ranged from 1 to 5 , with 1=very dissatisfied , 2=dissatisfied , 3=neutral ( neither satisfied nor dissatisfied ) , 4=satisfied and 5=very satisfied . 
  using principal component analysis for socioeconomic variables including education level and occupation of the household s head and partners and household - income , based on percentiles of ses , the studied population was divided into three groups of high ( ses score upper 75 percentile ) , moderate ( ses score between 25 to 75 percentiles ) and low ( ses score under the 25th percentile ) socioeconomic status . monthly household income was categorized into four groups regarding household income distribution in shiraz , iran as follows ; below 625,000 irr ( 250 usd ) , between 625,000 and 1584,999 irr ( 250 and 634 usd ) , between 1585,000 and 2960,000 irr ( 634 and 1184 usd ) , and above 2960,000 irr ( 1184 usd ) . data were managed and analyzed by spss version 21 ( spss inc ; chicago , il , usa ) . descriptive statistics were reported as meanstandard deviation ( sd ) or number ( % ) as appropriate . a comparison of quantitative and qualitative variables was made using independent sample t - test and chi - square test , respectively , between satisfied versus dis - satisfied respondents . the predictors of satisfaction were calculated by using logistic regression . because of low number of subjects in some satisfaction levels , to assess the relationship between satisfaction level with the studied variables and in regression analyses , the respondent s satisfaction level with healthcare system was stated in two levels of dissatisfied ( very dissatisfied or dissatisfied ) and satisfied ( satisfied and very satisfied ) . alpha was set at 5% and all probability tests used were two - tailed . a total of 3376 ( 99.3% ) participants answered all questions asked by the interviewers . the mean age of the studied population was 51.714 years old . of the total respondents , 2427 ( 71.4% ) were female . forty ( 1.2% ) subjects were not from iran , and the most prevalent ethnicity was persian ( 91.1% ) . 2659 respondents ( 78.2% ) were married and the median of household size was four . 456 ( 13.4 ) of the respondents had postgraduate degrees and 3040 households were insured ( table 1 ) .   characteristics of the studied population ( n = 3376 ) 
  monthly household income in iran 2012 in iranian rial ( the equivalent us dollars ) 
 
 table 2 shows the levels of satisfaction with healthcare system and ses of the respondents in this study . overall , 1.6% of the respondents ( 55 ) were very satisfied , while 6% ( 203 ) were very dissatisfied with healthcare system . frequencies of the ses of the participants were as follows : high ses , 26.3% , middle ses , 47.9% , and low ses , 25.8 . as shown in table 2 , most of the respondents who were classified into high or middle ses were neutral when asked to report their satisfaction level regarding the received healthcare during 6 months prior to the study . among dissatisfied respondents , it was discovered that the better the ses , the more frequently were the respondents dissatisfied with healthcare system ; consequently , about half of dissatisfied respondents belonged to high ses ( 369 ; 50.1% ) while 267 ( 36.8% ) were placed in middle ses and 89 ( 12.3% ) in low ses . conversely , satisfied or very satisfied respondents were mostly from low ses ( 479 ; 55.2% ) , when compared with the respondents with middle ( 606 ; 37.4% ) or high ses ( 22 ; 2.5% ) . the differences in the frequency of satisfaction levels between respondents in regard to their ses were statistically significant ( p<0.001 ) . socioeconomic status ( ses ) satisfaction with healthcare system in the studied population 
  p values calculated by chi square 
  the results of the comparison of the respondents characteristics with regard to satisfaction status with the healthcare system ( satisfaction included satisfied and very satisfied respondents , and dissatisfaction included dissatisfied and very dissatisfied respondents ) are shown in table 3 . there were significant differences between satisfied and dissatisfied respondents with regards to age , sex , education level and ses . female respondents were significantly more dissatisfied when compared with their male counterpart ( p=0.005 ) . respondents with low ses were significantly more satisfied when compared with respondents with high or middle ses ( p<0.001 ) . comparison of respondents characteristics in regard to status of satisfaction with the healthcare system p values calculated by independent samples t - test , or chi square . as shown in table 4 , the adjusted odds ratio from logistic regression revealed that age , marital status , insurance status and ses were determinant factors of satisfaction with healthcare system . in fact , when compared with unmarried respondents , the married ones were more likely to be satisfied with healthcare system ( or 1.09 , 95% ci 1.01 - 1.17 ) . also , insured respondents were more likely to be satisfied with the healthcare system when compared with the uninsured respondents ( or 2.79 , 95% ci 2.07 - 3.77 ) . moreover , when compared with interviewees having middle ( or 1.03 , 95% ci 1.01 - 1.42 ) or high ( or 1.64 , 95% ci 1.57 - 1.72 ) ses , those with low ses were more likely to be satisfied with healthcare system . there has been a steady growth in the interest of policymakers in iran concerning the methods in which people could increase their involvement in the planning , delivery and evaluation of healthcare demand for voluntary and social activities . there are several reasons in putting premium on the users perspective , as well as their satisfaction regarding healthcare services . researchers have found satisfaction to be linked to various factors , and ses is one of the important factors . consequently , the present study examined the association between the users ses and satisfaction with healthcare system . the overall satisfaction with healthcare system in the present study was 67.4% which was similar to emadi s et al . and sohrabi s et al . , who reported overall satisfaction rate of 75% in qatar and 80% in tehran , iran , respectively however , the results of our study showed remarkably a higher rate of satisfaction with healthcare systems , compared to the results of the study conducted in nine countries of former soviet union . however , these inconsistencies might be interpreted by the variation in the used questionnaires , differences in pervasive cultures , expectations and some other external factors , such as political context . also , the present results showed that ses was one of the most significant factors which affected the users satisfaction regarding the healthcare services received . those having low ses were significantly more satisfied when compared with those having middle or high ses . in contrast to the present study , other studies demonstrated that people with higher income experienced significantly better overall primary care quality when compared with people of the lowest income . in previous studies , the majority of participants mentioned that they preferred to be visited in a private healthcare center , although they had to pay through out of pocket payment method . moreover , other surveys reported that individuals stated lower satisfaction level if they lived at or below the poverty line and the families income was low . the differences between the results could be explained by taking the type of healthcare center into account , whether private or governmental , from which the users had received healthcare services and the users expectations . most of the respondents in the present study used governmental healthcare system ; however , other studies were conducted in countries with a large for - profit private sectors and high out - of - pocket payments ; consequently , the quality of services tends to vary with the cost . people who were insured and had supplemental insurance were significantly more satisfied than those who were uninsured or lacked supplemental insurance . 
  among the characteristics of respondents , age , gender , educational level , and marital status were proved to be significant factors in enhancing the satisfaction level with the healthcare system . as revealed in the present survey , older people and those who were married were significantly more satisfied with healthcare system . similarly , other studies showed that satisfied participants were older , and they were illiterate or had primary education . some limitations were identified in the study ; data from this study were cross - sectional , which did not allow for demonstration of causality . also , recall and misclassification bias would be possible because all instructive variables were self - reported and unverified . so , there is a need for further studies to better understand the effects of ses on healthcare system satisfaction . however , the large sample size which was selected by cluster random sampling could properly show the relation between ses and satisfaction with the healthcare services . in summary , this study demonstrated that users sex , age , educational level and their ses were related to dissatisfaction regarding healthcare system . meanwhile , the clients age , ses status , insurance status and marital status were recognized as determinant factors of satisfaction regarding healthcare system . therefore , a multidisciplinary approach should be adopted by health policymakers in order to increase the clients satisfaction rate .
abstractbackground : the users satisfaction is a method for evaluating the efficacy of healthcare system . we aimed to evaluate the association between the users socioeconomic status ( ses ) and satisfaction with the healthcare system in shiraz , iran . 
 methods : this cross - sectional study was conducted from december , 2013 to march , 2014 , in shiraz , iran . 
 3400 households were recruited by multi - stage cluster random sampling . 
 information about demographic , insurance status , and users satisfaction was derived from face - to - face interviews . 
 satisfaction with healthcare system was assessed by using 5-point likert scale statements , which ranged from  very dissatisfied  to  very satisfied  . 
 all statistical analyses were performed using spss-21 . 
 results : overall , 1.6% ( 55 ) of the respondents were very satisfied , while 6% ( 203 ) were very dissatisfied with healthcare system . 
 participants were classified into high ses ( 26.3% ) , middle ses ( 47.9% ) and low ses ( 25.8% ) . 
 it was discovered that the better the ses , the more frequent were the respondents dissatisfied with healthcare system ( p<0.001 ) . 
 also , dissatisfied respondents were significantly older ( p=0.036 ) . 
 moreover , women were more dissatisfied with healthcare system ( p=0.005 ) . 
 also , dissatisfied respondents had significantly a higher level of education than satisfied ones ( p<0.001 ) . 
 furthermore , logistic regression revealed that age ( p=0.04 ) , marital status ( p=0.01 ) , insurance status ( p<0.001 ) , ses ( p<0.001 ) , and having supplemental insurance ( p=0.02 ) were determinant factors of satisfaction with healthcare system . 
 conclusion : this study demonstrated that users sex , age , educational level , and ses were related to dissatisfaction with healthcare system . 
 meanwhile , clients age , ses , insurance status and marital status were recognized as determinant factors .