Mental health counselling for abused women Attention must be given to the fact that attending a session at the clinic was not convenient for a group of women, and some women suggested that this could even escalate violence. This study does not shed light on the barriers in accessing this service for women who did not come to any sessions. Thus, research needs to be undertaken for understanding what inhibits some women to access such services; other strategies for reaching out these women need to be developed; and working with men to create an enabling situation for women to access services needs to be considered. The fact that most abused women did not come for a second session might be an indicator of how the session was assessed by the women. This is why the reasons for not coming for the second session need to be considered carefully. It seems from the data that there was a communication gap regarding the availability of service, which must be addressed in future programmes. There also was a lack of under- standing of what more consecutive sessions can offer to them. Thus, it is imperative to explain to abused women what mental health counselling aims to achieve and the process through which it attempts to achieve this goal. Means of helping women to manage time and hold sessions at a more convenient time for some women need to be ex- plored. Strategies must be developed for overcom- ing gatekeepers and reaching out to women who are too sick or upset to come to a session. Trans- port also seems to be an issue for some women and needs due attention. Relatively high satisfaction of the abused women with different aspects of mental health counselling service seems reasonable in light of the literature on client satisfaction regarding the quality of health- care in rural Bangaldesh (41). Literature indicates that communication skills of healthcare providers are valued highly by the clients (42). Service pro- viders’ behaviour, especially respect and politeness, is the most powerful predictor of client satisfaction. For the participants of this study, this aspect was much more important than the technical compe- tence of the service provider. These findings might suffer from some biases due to several reasons. First, women may have very low expectations from the service providers. As the literature shows, only 49% of the women reported that a family-plan- ning health worker was usually sympathetic to their needs, and only about 60% were appreciative of their needs for privacy (43). In such a context, active listening skills of the paramedics, their non- judgemental, equal and empathetic treatment of 488 Naved RT et al. the abused women might have contributed to an overtly-positive assessment to the service. Also, it was not known by these women what a standard mental health counselling session consists of. The ability to talk about such private and sensitive is- sues was highly appreciated by the majority and has possibly contributed to their satisfaction with the service. This is not very unusual with women having a high level of distress and inability to share problems with others. Even in Germany where mental health service is quite developed, mature pa- tients with subthreshold depression expected their general practitioners (GPs) to listen to them rather than take specific actions towards symptom relief (44). This underlines the fact that mental health patients have a special need for active listening to their problems, which is a potential contributer to their satisfaction with the service. Second, the long-term relationship between ICDDR,B and the community and between the women and the paramedics who have been work- ing in these communities for years are potential factors that might prompt the women to portray a positive picture of the service. Measuring patient-reported outcomes and behav- iours as close to the targeted exposure as possible has been recommended (45-47) due to several rea- sons. The main reasons are that long-term memory of past experiences does not fully decode details in unbiased ways (48); although recall of memories can produce believable and reasonable results, the results may or may not represent an accurate ac- count of the target situation (49). Delayed assess- ment was found to overestimate the overall posi- tive performance when compared with immediate assessment by exit cards (50). So, an additional limitation of this study is that the evaluation was carried out one to two years af- ter the women attended the counselling session, which might have contributed to an over-estima- tion of positive results. Evaluations of the time-related aspects were prob- ably not accurate, not only due to recall issues but also because rural women do not usually refer to time in terms of hours and mintues. Despite possibilities of some biases in the results, the overwhelmingly-positive feedback from the women in both quantitative and qualitative ex- ploration indicates that the session had some posi- tive impact. In a context where 66% of the women never talk about their experience of violence (19), JHPN