the ultimate aim of all health systems is clients well - being , which is related to the efficiency of the health - care system . in other words since people are considered as customers of a health system , their level of satisfaction could be considered as an indicator for both the quality of care received and efficiency of the health system . indeed , patients satisfaction is a subjective concept influenced by different aspects of health services . satisfaction could be considered as a strength since it reflects the psychological evaluation of the patients regarding received care . on the contrary , it could be simultaneously affected by different factors such as perceived expertise and behavior of care providers , the level of primary and secondary care , traveling distance , and time spent to make an appointment , patient 's privacy when receiving health service , and cost of care . all these factors contribute in improving the quality of health system and are vital for policymakers , stakeholders , and health - care providers . many studies have been carried out to define the determinant factors of achieving the maximum level of patients satisfaction . nevertheless , the contributing factors are diverse and they are based on the study population , region , and health system . results of the reviewed studies are grouped into 13 factors which could be classified under three categories : the medical care setting , the physicians competence , and the relationships between physicians and their patients . some factors have been proved to have a more straightforward relationship to satisfaction ; including , medical care accessibility , having infrastructure for clinics , duration of treatment , perceived competency of physicians , and commitment to bases of medical ethics in treating the patients . this specifically underlines the need of carrying out comparable surveys in each country and geographic regions . this study was designed based on the fact that there are few studies on clients satisfaction on the health - care system in iran , and there are no published documents regarding newly implemented family physician program in the fars province . this survey was carried out to determine the clients satisfaction regarding health - care services and its determinant factors in south - west of iran . this cross - sectional study was carried out in shiraz , one of the most populous cities in iran , from december 2013 to march 2014 . by conducting a pilot study on fifty subjects , the sample size was estimated as 3515 using single population proportion formula based on the following parameters : p = 71% ( the proportion of clients satisfaction in the pilot study ) , z = 1.96 , and d = 0.15% . therefore , 3515 households were selected by utilizing multistage sampling method ; among them , 3400 ( 96.7% ) agreed to participate in the study . at first , we considered the number of households , as a sampling unit , living in each of the nine municipality regions . thereafter , we chose postal codes by simple random sampling proportionate to the size of households in each municipality region . face - to - face interviews were carried out by trained fieldworkers in the interviewees house . inclusion criteria in the study were participant 's age ( at least 18 years old ) being fully aware of the household medical problems and expenditure and living in shiraz for the past 6 months before the interview . first , the interviewers had to provide the respondents a brief history regarding the study , its goal , and objectives , while they were reassured about the confidentiality of the information collected . if the included participant was reluctant to participate , the selected postal code was substituted by another postal code located on the same municipality region . the ethics committee approval was obtained from the shiraz university of medical sciences research ethics board before starting the study . the team included three policy makers , four physicians , four health - care managers , two health economists , three community medicine specialists , two epidemiologists , and a statistician . the team approved the face validity of the checklist while its reliability was checked in a pilot study of fifty participants ( r = 0.82 ) . the checklist is made up of four main parts comprising demographic information , insurance status of the household , enrollment in family physician program and finally , client 's satisfaction with different levels of health services if at least one member of the households had utilized health service(s ) in the last 6 months before the interview . demographic data included nationality , ethnicity , the family 's breadwinner marital status , educational level , and occupation . moreover , we asked some questions regarding the household 's assets , expenditure , monthly salary , and whether the household is registered in the family physician program . regarding the  yes response , the interviewee was asked about the duration of participating in this program and then answered six questions which rated the respondent 's satisfaction level about this program . the last part of the checklist started with the question  have you or other family members attended a medical center ?  if any of the households had used health service(s ) , the respondent was asked to mention his / her opinion regarding that . the level of interviewees satisfaction was evaluated utilizing some questions in a 5-score likert scale , ranging from  quite dissatisfied  to  quite satisfied  regarding accessibility of health - care service , waiting time , patient 's privacy when receiving health - care service , and its cost . we also asked if any member of their household had suffered from the chronic disease(s ) . in case of positive response , the next question was on the satisfaction level of the participant with the cost and availability of medications . furthermore , the participants were asked if any member of their household had been hospitalized during the past 6 months before the interview . if the answer was positive , they were to express their level of satisfaction about the hospital facilities and personnel behavior . on completion of the interview , the respondent was asked to rate the whole health system from 5 ( excellent ) to 1 ( very poor ) . statistical analyses were conducted using the spss statistical software , version 18.0 ( spss inc . , chicago , il , usa ) . t - test was carried out to compare quantitative variables in satisfied versus dissatisfied group . all studied variables were entered into the model , and statistically nonsignificant variables were omitted from the final model . when performing the regression analyses , the respondents whose answer on satisfaction was this cross - sectional study was carried out in shiraz , one of the most populous cities in iran , from december 2013 to march 2014 . by conducting a pilot study on fifty subjects , the sample size was estimated as 3515 using single population proportion formula based on the following parameters : p = 71% ( the proportion of clients satisfaction in the pilot study ) , z = 1.96 , and d = 0.15% . therefore , 3515 households were selected by utilizing multistage sampling method ; among them , 3400 ( 96.7% ) agreed to participate in the study . at first , we considered the number of households , as a sampling unit , living in each of the nine municipality regions . thereafter , we chose postal codes by simple random sampling proportionate to the size of households in each municipality region . face - to - face interviews were carried out by trained fieldworkers in the interviewees house . inclusion criteria in the study were participant 's age ( at least 18 years old ) being fully aware of the household medical problems and expenditure and living in shiraz for the past 6 months before the interview . first , the interviewers had to provide the respondents a brief history regarding the study , its goal , and objectives , while they were reassured about the confidentiality of the information collected . if the included participant was reluctant to participate , the selected postal code was substituted by another postal code located on the same municipality region . the ethics committee approval was obtained from the shiraz university of medical sciences research ethics board before starting the study . the team included three policy makers , four physicians , four health - care managers , two health economists , three community medicine specialists , two epidemiologists , and a statistician . the team approved the face validity of the checklist while its reliability was checked in a pilot study of fifty participants ( r = 0.82 ) . the checklist is made up of four main parts comprising demographic information , insurance status of the household , enrollment in family physician program and finally , client 's satisfaction with different levels of health services if at least one member of the households had utilized health service(s ) in the last 6 months before the interview . demographic data included nationality , ethnicity , the family 's breadwinner marital status , educational level , and occupation . moreover , we asked some questions regarding the household 's assets , expenditure , monthly salary , and whether the household is registered in the family physician program . regarding the  yes response , the interviewee was asked about the duration of participating in this program and then answered six questions which rated the respondent 's satisfaction level about this program . the last part of the checklist started with the question  have you or other family members attended a medical center ?  if any of the households had used health service(s ) , the respondent was asked to mention his / her opinion regarding that . the level of interviewees satisfaction was evaluated utilizing some questions in a 5-score likert scale , ranging from  quite dissatisfied  to  quite satisfied  regarding accessibility of health - care service , waiting time , patient 's privacy when receiving health - care service , and its cost . we also asked if any member of their household had suffered from the chronic disease(s ) . in case of positive response , the next question was on the satisfaction level of the participant with the cost and availability of medications . furthermore , the participants were asked if any member of their household had been hospitalized during the past 6 months before the interview . if the answer was positive , they were to express their level of satisfaction about the hospital facilities and personnel behavior . on completion of the interview , the respondent was asked to rate the whole health system from 5 ( excellent ) to 1 ( very poor ) . statistical analyses were conducted using the spss statistical software , version 18.0 ( spss inc . , chicago , il , usa ) . t - test was carried out to compare quantitative variables in satisfied versus dissatisfied group . all studied variables were entered into the model , and statistically nonsignificant variables were omitted from the final model . when performing the regression analyses , the respondents whose answer on satisfaction was the mean age of the interviewees was 51.71 (  14.01 ) years , including 2427 ( 71.4% ) females . the prevailing ethnicity was fars ( 3097 ; 98.8% ) , and 2659 cases ( 78.2% ) were married . the median of family members was four with a minimum and maximum of 1 and 12 , respectively . one hundred and twenty participants ( 3.5% ) refused to report monthly family income , while 3160 cases ( 95.6% ) disclosed monthly family income of $ 730 or less , considering the fact that at the time of the study , one us dollar was equivalent to 26600 iranian rial . among the studied population , 3040 cases ( 89.4% ) sociodemographic characteristics of the interviewees ( 3400 individuals ) the levels of satisfaction with the family physician system based on the measurement of five items are presented in table 2 . the items included waiting period for admission , waiting time at physician 's office , quality of service , cleanliness of the clinic , and quality of referral to a specialist . moreover , the participants were asked to rate their overall satisfaction regarding the family physician system . more than half of studied populations were either satisfied or very satisfied with waiting time for admission , waiting time at physicians clinic , quality of service , and quality of referral to a specialist . in addition , 1238 ( 53.1% ) interviewees stated that they were generally satisfied with their family physician . nevertheless , 1603 cases ( 67.5% ) were either unsatisfied or very unsatisfied with the cleanliness of the clinic . satisfaction level of the participants regarding their family physician based on five measurement items 6 months before the study the participants were also asked to state their opinion about different parts of the health - care system to which they had referred during the last 6 months before the survey . as shown in table 3 , the highest dissatisfaction rate was reported about the cost of specialists clinic , followed by the cost of admission in private hospital . levels of satisfaction based on the measurement of five items among studied population 6 months before the study table 4 presents the levels of satisfaction among studied population for hospitalization during the last 6 months before the study based on the measurement of 11 items . the items included reception desk , behavior of security guards , cost , insurance , air conditioning systems , food , nursing services , physicians visits , diagnostic tools , and privacy . most subjects with a history of hospitalization in the given period were  satisfied  or  very satisfied  with all foregoing items , except for the cost ; 104 cases ( 31.5% ) were either levels of satisfaction among studied population regarding hospitalization 6 months before the study overall satisfaction with the health - care system and family physician system is presented in figure 1 . as illustrated in figure 1 , most subjects were satisfied or very satisfied with the health - care system and family physician system . in other words , 2015 ( 61.9% ) and 2088 ( 61.4% ) cases were satisfied with the health - care system and family physician system , respectively . in addition , 187 ( 5.5% ) and 211 ( 6.2% ) of interviewees had very satisfied views regarding the health - care system and family physician , respectively . nevertheless , 660 ( 19.4% ) and 442 ( 13% ) cases were dissatisfied with health - care and family physician systems , respectively , and the frequencies of very dissatisfied subjects were 187 ( 5.5% ) and 218 ( 6.4% ) , respectively . overall satisfaction with healthcare system and family physician system the determinant factors of dissatisfaction with health - care system in studied population were calculated utilizing binary logistic model . among studied variables , inhabitation region , satisfaction with family physician , drug availability , cost of drug , and presence of chronic disease in the household were significantly associated with dissatisfaction with the health - care system . living in high socioeconomic regions ( p = 0.001 , odds ratio [ or ] = 2.2 ) and middle socioeconomic regions ( or = 1.4 ) were determinant variables in comparison to low socioeconomic regions for predicting dissatisfaction with the health - care system . moreover , dissatisfaction with family physician ( p < 0.001 , or = 2.3 ) , unavailability of drug ( p = 0.02 , or = 1.6 ) , high drug prices ( p < 0.001 , or = 1.9 ) , and presence of chronic diseases in the household ( p = 0.03 , or = 1.4 ) were significant predictor factors associated with dissatisfaction with the health - care system [ table 5 ] . the aim of this study was to identify clients satisfaction regarding health - care services and define its associated factors in south - west of iran . to achieve these objectives , households were evaluated by a face - to - face interview and data analysis produced three main findings . first , there was a high level of satisfaction with distance , time for admission , time at the clinic , privacy , and cost among subjects regarding different parts of health - care system such as state clinics , midwifery clinics , nutritionists , physiotherapy centers , and state hospitals . moreover , in private clinics , specialists clinic , and private hospital , and for other parts of the health - care system , subjects were more satisfied with distance , time for admission , time at the clinic , and privacy . nevertheless , most individuals were more unsatisfied with the cost of services . the overall satisfaction rate of the health - care system in our study was 67.4% ; of which , 5.5% were very satisfied while 61.9% were satisfied . these findings are consistent with those of al emadi et al . and sohrabi et al . who reported an overall satisfaction of 75% in qatar and 80% in tehran , iran the rate of satisfaction with health - care systems in general population in 2010 reported by some countries were as follows : armenia 53.8% , azerbaijan 56.4% , belarus 52% , georgia 44.1% , kazakhstan 50.8 , kyrgyzstan 47% , moldova 31.6% , russia 23.8% , and ukraine 17.4% . the results above show that the rate of satisfaction with health - care systems varies widely between countries . these inconsistencies may be related to different aspects of satisfaction , different cultures , expectations , and external factors such as political context . nevertheless , regarding satisfaction with family physician system , the studied subjects were more satisfied or very satisfied with some variables such as waiting for admission , and at physician 's clinic , quality of delivered service(s ) , and referral to a specialist . although they were unsatisfied or very unsatisfied with the cleanliness of their family physician 's clinic , as a whole most subjects were satisfied with family physician system . our results are consistent with those of taheri et al . , who reported that participants were satisfied with the family physician program in iran . furthermore , 67.2% of the respondents in this study rated items of the questionnaire excellent or good . in this context , the high rate of satisfaction regarding family physicians care was reported in the canadian community health survey in 2006 . waiting time in family physician clinics was a factor of patients dissatisfaction expressed by 25% of studied population in the present study . this finding agrees with the previous studies that reported delays in centers as a determinant factor of patients satisfaction . shortage of time , and particularly inappropriate time management could be stated as one of the most remarkable reasons for crowding and congestion in health - care centers and account for long waiting hours in family physician clinics . cleanliness of clinics , quality of service and referral to a specialist , distance , privacy , and cost were other variables studied in this research and were the reasons for some dissatisfaction with family physician . although more than half of the subjects were satisfied with family physician system , the rate of dissatisfaction from such centers could draw the attention of the authorities . this , in addition to considering patients views , would enable those in charge of health systems to focus on the weak points to offer better and more efficient services for patients . in addition to the characteristics of the respondents , age , gender , education level , conditions that require emergency care , need for special drug , access to prescribed medication(s ) , affordability of drug , and chronic disease in the family were significant factors affecting people 's satisfaction level with the health - care system . our results are in line with studies which revealed that participants who were older , illiterate , or just completed primary education were more satisfied . in the present study , women claimed to be more satisfied as indicated by the study of taheri et al . in contrast to our result , in studies carried out by quintana et al . and al - dawood et al . , men stated higher satisfaction level comparing to women . moreover , in terms of the studied variables , people living in higher socioeconomic status ( ses ) regions expressed more dissatisfaction about the health - care system . in other words , respondents with high ses who were dissatisfied with a family physician system were more likely to express dissatisfaction with the health - care system in shiraz , iran . drug availability and cost of the drug were other variables that impact prediction of dissatisfaction with health - care system in shiraz , iran . first , it comprised urban population ; this calls for further investigations including rural inhabitants . besides , the results would be more reliable if we could carry out the study in other cities located in different provinces . nevertheless , due to large sample size which covers all regions in shiraz , the results of this study can be extrapolated to other cities in the fars province . our findings demonstrated a high level of satisfaction with health - care system and family physician in shiraz , and 67.4% of the satisfaction rate in this study shows the efficiency of iran 's health policy . moreover , dissatisfaction with cost of services in studied subjects can be a source of concern to relevant authorities who are in charge of health - care system in iran to provide better and more suitable services ; nevertheless , recent improvement in the quality and coverage of insurance by iran 's ministry of health can improve satisfaction with the health - care system . the results of this study can be compared to those of similar researches carried out in different regions of iran . this could help health policy makers seek alternative approaches to create satisfaction regarding health - care system in the community . besides , policy makers in different regions of iran could implement different efficient interventions to combat existing deficiencies . further comprehensive studies are required to select criteria associated with organized and rightful access to efficient health care in relation to client 's satisfaction . the vice - chancellor for health of shiraz university of medical sciences .
background : the aim of this study was to evaluate clients satisfaction regarding health - care services and its determinant factors in south - west of iran.methods:totally , 3400 households were randomly selected for this cross - sectional study , carried out in shiraz , iran , from december 2013 to march 2014 . 
 data were collected using a checklist that includes insurance status of the household , enrollment in family physician program , and client 's satisfaction level with received health services . the level of statistical significance was set at p < 0.05.results:the mean age of the interviewees was 51.71 ( 14.01 ) years , including 2427 ( 71.4% ) females . 
 9.4% were insured while 72.3% had registered in family physician program . with respect to the family physician and governmental clinics , 
 most subjects were  satisfied  or  very satisfied  with distance , time for admission , time spent at the clinic , privacy , and cost . 
 as for private clinics , specialist clinics , and private hospitals , the studied subjects were more  dissatisfied  with cost but were more satisfied with other items . living in higher socioeconomic regions ( p = 0.001 ) , dissatisfaction with family physician ( p < 0.001 , odds ratio [ or ] = 2.3 ) , scarcity of prescribed medication ( p = 0.02 , or = 1.6 ) , medication cost ( p < 0.001 , or = 1.9 ) , and existing chronic diseases in the household ( p = 0.03 , or = 1.4 ) had determinant role in dissatisfaction with health system.conclusions:results of the present study demonstrated a high level of satisfaction with the health - care system and family physician in shiraz , iran . 
 moreover , dissatisfaction with family physicians , socioeconomic status , scarcity and cost of drugs , and existing chronic disease(s ) were important predictors for dissatisfaction with the health - care system .