In this study, besides method triangulation, data triangulation was also used. Table 1 shows the demographic characteristics of the participants.
Table 1: The demographic characteristics of the healthcare volunteers (n=13)
Volunteer number
|
Role
|
Age
|
Education level
|
Job
|
Marital status
|
Husband’s job
|
Number of children
|
Years of volunteer work
|
1
|
Volunteer
|
50
|
Middle school
|
Housewife
|
Married
|
Freelance
|
2
|
15
|
2
|
Volunteer
|
47
|
Diploma
|
Housewife
|
Married
|
retired
|
4
|
5
|
3
|
Volunteer
|
63
|
Primary school
|
Housewife
|
Widow
|
Freelance (dead)
|
4
|
15
|
4
|
Volunteer
|
46
|
Primary school
|
Housewife
|
Married
|
Freelance
|
4
|
12
|
5
|
Volunteer
|
54
|
Primary school
|
Housewife
|
Single
|
-
|
-
|
15
|
6
|
Volunteer
|
60
|
College degree
|
Retired
|
Married
|
Accountant
|
3
|
8
|
7
|
Volunteer
|
42
|
Middle school
|
Housewife
|
Married
|
Freelance
|
4
|
14
|
8
|
Volunteer
|
46
|
Diploma
|
Housewife
|
Married
|
Teacher
|
2
|
15
|
9
|
Volunteer
|
45
|
Bachelor’s degree
|
Housewife
|
Single
|
-
|
-
|
9
|
10
|
Volunteer
|
46
|
Primary school
|
Housewife
|
Married
|
Freelance
|
4
|
14
|
11
|
Volunteer
|
58
|
Diploma
|
Housewife
|
Married
|
Retired
|
4
|
15
|
12
|
Volunteer
|
48
|
Middle school
|
Housewife
|
Married
|
Freelance
|
3
|
15
|
13
|
Volunteer
|
53
|
Primary school
|
Housewife
|
Married
|
Freelance
|
2
|
12
|
14
|
Volunteer
|
47
|
High school
|
Housewife
|
Married
|
Paramedic
|
3
|
3
|
15
|
Volunteer
|
40
|
Middle school
|
Housewife
|
Single
|
-
|
-
|
5
|
16
|
Volunteer
|
38
|
Middle school
|
Housewife
|
Married
|
Freelance
|
2
|
8
|
17
|
Volunteer
|
40
|
Middle school
|
Carper weaver
|
Single
|
-
|
-
|
7
|
18
|
Volunteer
|
57
|
College degree
|
Retired
|
Married
|
No job
|
5
|
12
|
19
|
Volunteer
|
52
|
Diploma
|
Housewife
|
Married
|
Freelance
|
2
|
15
|
20
|
Volunteer
|
51
|
High school
|
Housewife
|
Married
|
Freelance
|
4
|
15
|
21
|
Volunteer
|
70
|
Primary school
|
Housewife
|
Widow
|
Freelance (dead)
|
3
|
15
|
22
|
Volunteer
|
49
|
Middle school
|
Housewife
|
Married
|
Freelance
|
5
|
10
|
23
|
Volunteer
|
50
|
Middle school
|
Housewife
|
Married
|
Retired
|
4
|
4
|
24
|
Volunteer
|
70
|
Illiterate
|
Housewife
|
Widow
|
Freelance (dead)
|
4
|
10
|
25
|
Volunteer
|
38
|
Diploma
|
Housewife
|
Married
|
Employee
|
1
|
12
|
26
|
Current instructor
|
53
|
Bachelor’s degree
|
Healthcare worker
|
Married
|
Engineer
|
2
|
20
|
27
|
Previous instructor
|
50
|
Bachelor’s degree
|
Expert
|
Married
|
Engineer
|
2
|
18
|
Results of the first cycle
Stage 1: Qualitative data analysis yielded 1000 codes irrespective of repeated codes. After categorizing the codes, four subcategories emerged: role confusion, inadequate volunteer training, deficits in attracting and keeping volunteers, and being unfamiliar to the public. One main theme was also extracted named “unfertilized capacity”. For the quantitative section, questionnaires were completed by the volunteers including questions about different aspects of their performance and problems they faced at the beginning of the study. In the first cycle of the study, 80% of the volunteers thought that their main responsibility was to educate the families under coverage. Moreover, their main problems were as follows: not having a clear plan (100%), disorganization in holding educational plans related to the volunteers (80%), lack of practical skill training alongside theoretic instruction (56%), not benefiting from the volunteers’ abilities (52%), and not having a place for holding the educational sessions (52%). From the volunteers’ perspective most of the problems stemmed from lack of support from authorities (88%) and little interaction between the volunteer and instructor (76%). Public survey was another method for data collection on the healthcare volunteers’ performance. For this reason, 300 forms were completed by people who referred to the center. The results showed that 288 (96%) of the respondents did not know that health volunteers even existed in the system and did not receive any services through them. From the results obtained from the first cycle, we can conclude that the volunteers did not have any plans for teaching the public, were not familiar with some of their roles, and thought that their only role was to teach people, their teaching material was only the pamphlets the center had given them, they received no suitable feedback by authorities, there were some weaknesses in their management, and they did not have suitable solutions for their occupational problems. One of the main duties of the healthcare system is to provide healthcare services actively and effectively. To attain this goal, the culture of public participation should be established and improved in the society. Volunteer empowerment based on their needs as well as the public’s needs is done in a participatory manner.
Stage 2: After identifying the existing condition, the results of the first stage were shared with the participant. Based on the determined problems and prioritizing them, the plan for enhancing their capabilities was designed with their own cooperation.
Stage 3: In this stage, the action plan for each problem was determined by the volunteers based on the problems and strategies. The action plan was designed based on the nine problems identified in the first cycle (lack of planning for volunteers, unsuitable time management for holding educational classes, undefined volunteer responsibility, need for teaching practical skills, lack of educational facilities, not having a suitable place to hold classes, lack of ability to interact with people, deficits in documenting volunteer performance, and lack of motivating and encouraging factors for better volunteer participation.
Stage 4: At the end of the first cycle, the progress in action plans and volunteer empowerment was determined through reflection, observing volunteer performance, interviews with volunteers, and recompletion of the survey forms by people referring to the center (Ghamar BaniHashem Comprehensive Healthcare Center). We found that the volunteers were eager to learn and perform their duties. Recompletion of the public survey forms showed that their unfamiliarity with healthcare volunteers reduced from 96% to 88% and the volunteers put more effort into their work in this stage. Moreover, in the two interviews done, the volunteers emphasized on needing the instructor’s support, repetition of some educational content (such as vital sign measurement skills), and using participatory methods in education.
Results of the second cycle
This cycle began with reflecting on the first stage and then after planning for change, immersion in action and evaluation were done.
Reflection: The second cycle of the action research began with the volunteers’ reflection. They expressed their experiences about the new knowledge and skill they had gained, the changes in their emotions and performance, their effects on their daily lives, and the lessons they had learned.
Action plan: After the reflection sessions, the participants identified the problems and challenges they faced and designed a new plan. A list of problems was prepared concerning issues such as lack of using participatory methods in education, deficits in health volunteer records and completing their performance forms by the instructor, need for repeating practical training, lack of awareness about how to refer people to use healthcare facilities, weaknesses in the teaching role of volunteers, unfamiliarity of the public with healthcare volunteers, and lack of educational facilities. Based on the mentioned problems, the volunteers designed the action plan for the second cycle of the action research.
Immersion in action: Researcher’s reflection is the facilitator of one of the important parts of immersion in action. This reflection was done in the following domains: reflection on the research content, process, and issues.
Evaluation: At the end of the second cycle, evaluation was done. For this reason, quantitative methods such as public surveys, assessing volunteer records, volunteer performance monitoring checklist and Kirkpatrick model for assessing the effectiveness of the educational program were used. We also used qualitative methods such as interview, self-report, and focused group discussion for evaluation. In this stage, the volunteers checked the public’s views and opinions. 300 forms were handed to the people referring to the center. We found that 60 (20%) people were familiar with healthcare volunteers and their programs, 48 (16%) had moderate familiarity, and 192 (64%) did not know about such programs. The public’s familiarity with health volunteers had increased from 4% to 36%. The educational program for health volunteers was assessed according to Kirkpatrick’s four evaluation domains of volunteer satisfaction with different aspects of the program, amount of acquired knowledge, amount of acquired skill, and effectiveness of the program. The results showed that most participants (n=19, 76%) were satisfied with different aspects of the program. At the second and third level of Kirkpatrick’s model, the volunteers’ acquired knowledge and skill was compare using paired t test, indicating a significant increase in these domains (P=0.0001). Finally, in the final level of the mentioned model, the effect of the educational program on the volunteers’ work environment was assessed according to their own view point. The scores ranged from 21 to 28 with a mean±SD of 23.8±1.92. We found that all volunteers perceived this course as effective.
Four focused group sessions were held for the volunteers in which they shared the results of the first and second cycles and compared them. The following points were mentioned in these sessions:
- The classes differed from before. We did not understand all the content before, but now we do.
- It is a good experience to work together.
-We must gain more information and skills.
- The program was desirable and satisfactory.
- There are still some problems in transferring health messages to people.
A 60-year-old volunteer with eight years of volunteer work stated: “This program has excellent skills; and everyone, even older volunteers with less literacy level are encouraged to participate. We did many things before, but it is more organized now”.
At the end of the second cycle of the research, six interviews were done with the volunteers. Content analysis was done again on the collected data. In the triangulation of the results obtained from the interviews, focused groups, and daily notes of the volunteers as well as the documents, 300 initial codes were obtained. After categorization, 24 sub-subcategories, four subcategory, and two main themes for the effects of the empowerment program on the volunteers were obtained (table 2). Moreover, table 3 shows the results at the beginning of the first cycle and the end of the action research.
Table 2: The categories and subcategories of the program’s effects on empowering health volunteers
Theme
|
Category
|
Subcategory
|
Improving competence
|
Enhancing knowledge and skill
|
Effective instruction
|
Skill improvement
|
Controlled group performance
|
Facilitating communication and group work
|
Support and mentorship
|
Table 3: Comparing the changes at the beginning of the fist cycle and the end of the action research
Problems and Actions
|
Before the first cycle
|
End of the first cycle
|
End of the second cycle
|
Class order
|
Disorganized classes and constant cancellation without notice
|
Class cancellation without notice for two times
|
Orderly and organized class schedule, in case the instructor could not come (with prior notice) a substitute (an expert or another volunteer) would be introduced
|
Orderly presence of the volunteers in the classes
|
Disorganization, absence or on time presence, absence without prior notice
|
Less disorganization, most absence were without prior notice
|
Limited absence with prior notice
|
Interference in information communication and content transfer
|
Lack of order and access to information, being limited to contents of educational books
|
Creating groups in social media regarding the volunteers’ activities, using the group and educational pamphlets for transferring scientific content
|
Most volunteers had joined the group, they borrowed educational books and copied them, use of other valid sources
|
Location of the class
|
Home of volunteers
|
A room in the healthcare center
|
A room in the healthcare center
|
Content presentation in the class
|
Only by the instructor
|
Participation of both the instructor and the volunteer
|
Participation of both the instructor and the volunteer as well as other invited experts
|
Regular public training program
|
Very limited
|
Monthly sessions at the local center for religious activities, training at religious gatherings, recreational activities with family and friends
|
Qualitative and quantitative increase in public education, volunteers now have plans for public education themselves
|
Organized volunteer record keeping
|
Annually and only by the instructor
|
Every three months but still mostly by the instructor
|
Every three months with the guidance of the instructor
|
Volunteers’ sense of responsibility
|
Only for participating in the classes
|
Increased sense of responsibility for cooperating with the instructor and collecting family statistics
|
Increased sense of responsibility for cooperating with the instructor and collecting family statistics
|
Keeping track of issues with authorities
|
Limited and dispersed
|
Dome with more group participation and follow-up
|
Individual and group follow-up
|