Population and Setting
In Ardabil city, 12 rural health centers and health houses were selected for performing this study. Thereafter, these centers were randomly divided into two groups as interventional and control. Each rural health center covers 4-5 health houses. One of these health houses was found in the same rural with a health center, thus we selected these 12 rural. Health care recipients were mainly unpaid helpers or health volunteers who are called "health Safier". The number of "health Safier" in each village was limited and variable, thus we selected those who were ready for participation in this study. Of 132 rural health personnel, 108 were recognized as eligible to participate. In this study, convenience sampling was performed and a total of 220 health care recipients and 108 staff were surveyed in both interventional and control groups. All who came to the health houses had a chance to enter the study. The inclusion criteria in this study were as follows: age of 15 years old and older, having a file in health houses and current users of health care services, and willingness to participate in the study. The eligible staff should have at least one year of work experience in rural and participated in the health education program. Finally, the participants who met the inclusion criteria were fully informed about the study's protocol.
The interventional group received the intervention and the control group received no intervention. However, after intervention, the control group received the same intervention due to research ethics considerations.
Data collection was done by project executives in the summer and autumn of 2019. Data were collected using three questionnaires including knowledge and practice about healthy lifestyle, communication skills self-assessment(18), and Wright's job motivation(19). Afterward, these questionnaires were completed by the staff according to a predetermined schedule in both interventional and control groups once before and once after the study.
Several questionnaires were developed and then compared to assess rural healthcare workers' communication skills. Finally, the research team selected the communication skills’ self-assessment questionnaire, which was adapted from the Solang Kurmier (1999) questionnaire(20). Correspondingly, this questionnaire has 20 items measuring communication skills using a 7-point Likert scale. After the final translation and editing by the research team, the face and content validity of the questionnaire was provided by 6 health professionals and 4 health center personnel. Cronbach's alpha was also calculated to determine the reliability of the questionnaire. For this purpose, the mean scores of communication skills were extracted by a 14-member group of health workers who were not part of the case and control group, at two stages with a two-week interval. The value of Cronbach's alpha was calculated as 0.74.
The questionnaire was completed by the staff following previous arrangements. Each communication skills questionnaire took about 7 minutes to be completed, which was completed for each study rural. Staff communication skills scores are ranging from 0 to 140. In this questionnaire, a score of 20 to 50 indicates poor communication skills, a score of 51 to 80 indicates some communication limitations, a score of 81 to 110 indicates an appropriate level of communication, and a score over 110 shows a mastery of communication skills.
The Wright Occupational Motivation Scale (2004) was used to measure rural healthcare workers' job motivation(19). After the final translation and editing by the research team, the minimum face and content validities of the questionnaire were provided by presenting 6 professors in health education and promotion as well as 4 health center personnel, similar to the previous questionnaire. This questionnaire has 6 items, which are measured using a 5-point Likert scale, with scores ranging from 6 to 30, with higher scores indicating higher job motivation and lower scores indicating less job motivation. Health care workers are all employees of rural health centers, including physicians, midwives, experts, supervisors, and Behvarzs.
The data collection tool for measuring clients' knowledge and behavior was a self-made questionnaire with the following three sections: demographic information, knowledge section, and behavioral section. This questionnaire was designed using valid articles published on lifestyle(21, 22). The face and content validities of the questionnaire were provided to 6 professors in health education and 4 staff in the city health center. To calculate the reliability, Cronbach's alpha method was used. Accordingly, its reliability(Cronbach's alpha= 0.72) was extracted using a 14-person group of referrals to a rural health center. The knowledge and behavior sections of the questionnaire had 42 and 25 questions, respectively, which was completed by the referrals according to the predetermined table.
To design an appropriate intervention program, the required information were collected on the knowledge and practice about the lifestyle of rural residents, in order to diagnose the educational needs of residents. Of note, the communication skills of health care workers and their job motivation were also evaluated.
The intervention was designed based on four approaches for capacity building introduced by Crisp et al., which are as follows:(10)
Top-down organizational approach: changing agency policies and practices. In order to realize this approach, some courses were implemented about organizational culture and job motivation, communication skills, and message design for rural health care managers and administrators. The content of the courses was also provided to participants. Moreover, three meetings were held with the deputy health center, technical unit managers, and the university health deputy on appropriate training and motivation programs for rural health care workers.
Bottom-up organizational approach: training members of organizations as well as providing them with skills and knowledge. To implement this approach, lectures on social networks (using existing social networks in villages such as female health volunteers and clients in health houses) were conducted in the selected health houses that lasted for 41h sessions (including at least 6 sessions per each village). The topics were explained, and the participants’ questions were then answered. The discussed topics were about the risk of heart attack, stroke, and cancer-based on an initial need assessment. Other topics were also suggested by the participants during the education sessions, including osteoporosis, knee and joint arthritis, hair loss, hydatistic cysts. Additionally, several workshops were held on communication skills for both health center staff and interventional group providers within two business days for 8 hours.
Partnerships: based on this approach, two interventions were designed and then implemented: A) Villages have fruits solar and groceries and cafes that did not observe health guidelines. Face-to-face training was conducted for these fruits and food business operators in more than 15 cases, in order to create a collaborative network among them and health house workers to deliver healthy fruits and food material. B) Establishment of a telegram channel for the village's health workers in the interventional group, in order to share health information and messages among themselves.
Community organizing approach: three interventions were applied to implement this approach as follows: a) lecturing at the villages mosques for village residents, b) conducting group discussions with men in one of their gathering places (such as village cafes), and c) face-to-face training for homeowners who dumped sewage into passages and alleys.
Environmental health position, weight and client satisfaction, and health workers’ satisfaction were not the goals of this study. The program's outputs were assessed by measuring the following approaches by passing three months from the intervention: 1) residents' knowledge and performance, 2) communication skills of health center staff, and 3) and occupational motivation of health center' staff.
All statistical analyses were fulfilled using IBM SPSS Statistics software (Version 24) (IBM SPSS Statistics, Armonk, USA). The normality of the variables was confirmed using Kolmogorov-Smirnov test. To compare the categorical data between treatment groups at the baseline, Chi-square test was employed. Independent sample t-test and paired sample t-test were applied to compare parametric continuous data between and within the groups, respectively. Mann-Whitney U test and Wilcoxon signed-rank test were also applied to test the differences in asymmetric variables between and within the groups, respectively. A p-value less than 0.05 was considered to be statistically significant.