The study was conducted in the Bore district, East Guji zone, Oromia Region, Southeast Ethiopia. The Bore district is located 389 km southeast of Addis Ababa, the capital city of Ethiopia (Figure 1). The district had a total population of 210,179 according to the 2007 national census, of which 105,726 men and 104,453 women made up the population (15). In the district, there is one public primary hospital, six public health centers, and 33 health posts. The study was conducted in the six public health centers in the district from March 15 to April 16, 2022.

The sample size for the quantitative study was determined using the single population proportion formula by taking the proportion of clients satisfied with the family planning services, 46%, taken from the study conducted in Jimma (16), with a 95% confidence level and a 5% degree of precision. Accordingly, the calculated sample size was 381 and, after adding a 10% non-response rate, the final sample size was 419. Concerning the sample size for the qualitative study, one family planning service provider from each family planning unit of the six health centers (n = 6) was approached, and the sample size was determined by saturation of data.

For the quantitative study, a systematic random sampling technique was employed to recruit clients of family planning users from the six health centers. According to the 2021 and 2022 reports (17), a monthly average of 3,237 clients visited the family planning units of the six health centers. The calculated sample size was proportionally distributed based on the monthly flow of family planning users in each health center. The sampling interval was calculated by taking the assumptions (k = 3,237/419 = 8), and accordingly, every eighth client who visited the family planning unit of the respective health centers was included in the study (Figure 2). For the qualitative study, a purposive sampling technique was used based on the researcher's judgment regarding participants that were representative of the study phenomenon.

For the quantitative study, a pre-tested (among 5% of the sample size outside of the study area), structured, interviewer-administered questionnaire was used to collect the data. The data collection tool was adapted from a previous similar study (16) and contains the socio-demographic characteristics, service provision characteristics, obstetric factors, and status of service. The tool was originally prepared in English, then translated into the local language (Afan-Oromo) and re-translated back to English to maintain its consistency by an independent professional translator.

Six experienced nurses with bachelor's degrees and two experienced public health experts with master's degrees were recruited as data collectors and supervisors, respectively. The correctness of the responses, data collection instruments, and methods were all closely monitored daily. For the qualitative study, to collect pertinent information from the family planning service providers who have been working in the family planning service unit at those six health centers, a semi-structured interview guide was employed. The interviews were audio-recorded, and written notes were also used to record information.

Client satisfaction: To gauge study participants' satisfaction with family planning services, 10 satisfaction-related items on a five-point Likert scale with values ranging from 1 (very unhappy) to 5 (extremely satisfied) were employed. The median score of satisfaction was used to dichotomize each respondent's satisfaction score. Accordingly, those who scored above the median were regarded as satisfied, while those who scored below the median level were judged unsatisfied with the family planning services (16). The amount of time a client had to wait before obtaining their services was referred to as the waiting time. Less than 30 min is considered the appropriate waiting time; any time over this mark is considered inappropriate (18).

Data trustworthiness was appraised by the following criteria: credibility; participants were given enough time during the in-depth interview to express their opinions and experiences; they were interviewed in a welcoming environment; the principal investigator collected the data; and the data collector watched their facial expressions to decipher their nonverbal cues. Dependability, the same data collectors, and the same interview guide were utilized to conduct in-depth interviews to ensure the consistency of the data from all participants.

Following data collection, verbatim transcriptions of the raw or recorded data were made before they were translated into English. To ensure transferability and accurately represent the source population, in-depth interviews were conducted with members of the nominated sample. Conformability: to eliminate researcher bias during data collection, processing, and analysis, the participants' own words rather than the researchers' opinions and expectations were used. To minimize this, the data collectors were not dressed in white gowns, and they were hired from outside the study site.

Every day, the surveys' consistency and completeness were reviewed. The gathered data were input into Epi Data version 4.6 software, and the entered data were exported to SPSS version 25 statistical software for analysis. Descriptive statistics, including frequency distribution, measures of central tendency, and variability, were computed. The dependent variable, which was the sum of the Likert scale questions, was dichotomized using the median as the cut-off point after the Shapiro-Wilk test was used to verify the normality of the data.

The bivariate analysis was done to check the existence of a crude association and to select candidate variables; those variables that are clinically important and have a p-value of less than 0.25 were included in the final model. Confounding was checked, and a percentage change in the regression coefficients of less than 20% reveals an absence of confounding. The interaction for the main effect model was also checked, and the partial likelihood ratio test result with a p-value > 0.05 and a variance inflation factor less than 10 indicated the non-existence of multi-collinearity among the independent variables.

The multivariable binary logistic regression model was used to identify the independent factors associated with clients’ satisfaction with family planning services. The summary measures of estimated crude odds ratios (COR) and adjusted odds ratios (AOR) with a 95% confidence interval were presented, and a P-value less than 0.05 was used to declare statistical significance. The goodness of fit of the model was assessed using the Hosmer and Lemeshow goodness of fit test.

We promptly translated and transcribed the verbatim audio recording and memo into English for preliminary analysis. To get a sense of what each study participant had said, the interview transcript was once again read line by line and listened to. The following questions that contained contradictory information were verified during an interview by the respondent's own words and double-checked with memoranda to ensure the accuracy of the data. Transcribed notes and audio were loaded into ATLAS ti version 8 for coding and classifying codes, and the output was exported into Excel and report form. Finally, the finding was clarified by combining categories and themes with the quantitative findings.

A total of 414 clients were included in the study, with a response rate of 98.81%, and 355 (85.75%) of the family planning service users were from rural areas. The median age of the respondents was 26 years, with an interquartile range of 22–30 years. One hundred twenty-four (30%) of the service users were unable to read and write and concerning marital status, 365 (88.16%) were married. Regarding the gravidity and parity of the service users, 233 (56.28%) and 258 (62.32%) were 1−3 gravidas and parous, respectively (Table 1).

Two hundred forty (58%) women used Implanon; only 3 (0.7%) were IUCD users, and 330 (79.71%) women were repeat users of family planning. The mean (± standard deviation) of the waiting times for clients before getting service was 30 ± 25 min. The mean (± standard deviation) of the travel time to the facility was 30 ± 40 min. Four hundred nine (98.8%) of the clients reported that there was enough privacy during consultation and examination, and 413 (99.8%) of family planning users believed that the provider kept their client information confidential.

Three hundred seventy-one (89.6%) were told how to use the method. Three hundred forty-two (82.6%) clients talked about other methods; 336 (81.2%) clients were counseled about the side effects of the method, and 310 (74.9%) were told what to do if they experienced any problems with the method before their next visit. Two hundred thirty-five (56.8%) of the clients said that the provider did not show them any printed materials on family planning during the discussion. The majority of the clients (98.6%) were told about their scheduled follow-ups and appointments (Table 2).

57.5% of clients were satisfied with the family planning services. The majority of the respondents were satisfied with the ease of getting to the clinic site (62.4%), waiting time (59.2%), opening hour convenience (62.1%), cleanliness of the clinic area (44.2%), the provider's friendly approach (71.1%), the information given to the client (70%), method availability (62.8%), maintaining privacy (78.8%), the provider's discussion on the client's health condition (73.6%), and the provider's knowledge (82.8%) (Table 3).

The odds of those clients who were married were two times higher than those who were divorced or widowed (AOR = 2.41; 95% CI: 1.13, 5.15). The odds of those who receive the method they want being 2.3 times more satisfied than those who have not received the method they want (AOR = 2.35; 95% CI = 1.163, 4.756) Respondents with an age range of 25–34 were two times more satisfied than those whose ages were 15–24 years (AOR = 1.99; 95% CI: 1.20, 3.29) (Table 4).

A total of six family planning service providers participated in a qualitative study. More than half of the study participants, 4 (66.6%) were males, and 4 (66.6%) of the study participants were aged between 30 and 35 years, with a mean age of 31. Four (66.6%) of the participants had less than 5 years of clinical work experience, and the mean of their work experience was 4.6 (Table 5). After coding and analysis of in-depth interview data, five themes emerged.

The first theme that emerged from the data analysis was training, and the theme was categorized into three categories: those who take in-service training, the adequacy of training, and what kind of training is important to scale up client satisfaction among family planning service users.

The findings from the analysis of in-depth interview data revealed that almost all the participants take in-service training, except for one service provider. The providers respond whether the training was adequate or not Some responses are presented as follows:

The participants were asked which kind of training was important: theoretical or practical Some respondents responded that it is better to give both theoretical and practical family planning training sessions to improve client satisfaction among family planning service users, while others responded that it is better to focus only on practical training, and one provider responded that comprehensive training is good. Their responses are presented as follows:

The participants were asked whether they had updated knowledge to provide the family planning service. The second theme that emerged from the in-depth interview data analysis was up-to-date knowledge. Two categories were established under this theme: yes, I have updated knowledge, and no, I have not updated knowledge.

The majority of the respondents respond as they have updated knowledge and their responses are reported as follows:

Some respondents responded that they don't think they have updated knowledge and their responses were reported as follows:

The third theme that emerged was a choice of method, an appointment, shifting the method, and being told to take care of other health facilities. These findings implied that client satisfaction among family planning service users can be scaled by considering the client's choice of method, a feasible appointment, and having a one-stop center that can deliver all the family planning methods without referring to other health facilities. The participants were asked about their response if there is no choice of method for a client. According to the findings, among the participants who took part in this study, some of them responded as follows:

Three of the family planning service providers responded that they would shift the method, and their responses are presented as follows:

The participants were asked about factors that influence client satisfaction with family planning services. Different factors influence client satisfaction with family planning services from different health provider's perspectives. These are lack of knowledge and understanding about family planning, religious factors, cultural factors that promote having more children, lack of trained health providers, bad attitude of the community, male involvement, lack of short-acting family planning method, and availability and accessibility issues are some factors that affect client satisfaction with family planning service. This finding was revealed by the following sampled responses:

A mixed approach was used, which gives a broader perspective than using a single-study approach. The study gives a clear understanding of the problem from different dimensions. So, the study was internally valid and consistent since the findings were triangulated to validate the quantitative study with a qualitative study. There may be courtesy bias, and as a result, clients may respond positively to positive answers. There may also be a Hawthorne effect, and providers may change their usual working patterns and work accordingly when they know the client is being interviewed about the service.