¹Ph.D. Student of Health Education & Promotion, Public Health Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran

²Professor of Health Education, Safety Promotion and Injury Prevention Research Center (SPIPRC), Public Health Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran

³Professor of Health education, Public Health Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Corresponding author Email: rakshanif@gmail.com

Article Publishing History

Introduction

Advocacy is a process, in which individuals and organizations try to affect the public policy decision-making (Stafford and Mitchell, 2009). The goal of advocacy programs is to increase the ability and willingness of communities to participate actively in determining the health and development issues and application of solutions to meet their health needs (American Public Health Association, 2012).

On the other hand, one of the goals of the people working in the health care system is to establish a change to improve the health of the community.If the changes are reflected in the policy-makings and rules, they will have long-term effects (Bateman, 2000). The enforcement of advocacy will lead to the promotion of community participation, empowerment and development of democratic methods in the systems for providing health services (Moore et al., 2013). Therefore, in the field of health, in addition tothe knowledge and specialized skillssuch as clinical skills and communication skills, the skill for designing and implementing an advocacy program is considered among key skills (Shams
et al., 2013).

In this regard, health educators believe that a comprehensive advocacy is an integral part and an important inseparable strategy for health promotion.So health workers who communicate with people and target groups, and make efforts to create the context and healthy and health supporting environments, should equip themselves with knowledge, skills and methods of planning of comprehensive advocacy programs (Caira et al., 2003). As the understanding of the principles and key concepts of advocacy, and proper use of them in line with health system goals, besides educational measures, and health care provision can increase the effectiveness of measures taken in this regard. To this end, the World Health Organization has published the educational materials about advocacy skills for health workers (International Council of Nurses, 2008; World Health Organization, 2003).

The programs designed based one comprehensive advocacy include components foridentification and analysis of the problems, development general and specialized goals, identification and analysis ofthe stakeholders, fabrication of an advocacy message, selection and implementation of the advocacy strategy, preparation of the advocacy proposal and planning (JHU/CCP; CEDPA, 1999). Investigation of studies in Iran suggests applying a comprehensive advocacy strategy to reduce salt intake at the community level and at-risk groups, and the use of disposable plastic containers (Mohammadifard et al., 2012; Amini et al., 2009). The study of King et al. (2015) with the aim of evaluating the one year results of educational intervention of health advocacy among the youths to gain the advocacy of those health policies promoting the community demonstratedthat advocacy intervention in the future is recommended (King et al., 2015).

Given that the employees employed at the headquarter level should have a proper and effective relationship with clients and partners, moreover, they need to communicate with other organizations and higher officials and key people to convince them to do health care. This study aims at evaluating the advocacy skills among the health workers in Gilan Province. The present study’s main purpose was to assess the advocacy skills of health workers in Gilan Province.

Methodology

This cross-sectional study has been carried out in 2016 on 80 employees of health centers in Gilan province using a random sampling method. Inclusion criteria comprised having a bachelor’s degree and higher, and work experience of more than five years. Data collection tool included a self-made questionnaire with content validity ratio (CVR) of 0.8 and content validity index (CVI) of 0.9. The final questionnaire consisted of six parts, including selection of advocacy topic (7 questions), the stakeholders analysis (5 questions), development of a message (3 questions), encouraging techniques and approaches (13 questions), the proposed plan (1 question), and program assessment (1 question). 1 score and two scores were assigned to the correct answer of the closed questions andopen questions, respectively. Using SPSS 17 software, the data were analyzed and descriptive tests (frequency, mean and standard deviation) were used for data analysis.

Results and Discussion

The mean age of participants

Was 43.8 ±3.8, 56.2% male; the majority had undergraduate education (93.8%), and with work experience of 5 years. According to the results of Table 1, the mean score gained for various parts are as follows: issues and goals with score of 3.4 (maximum 9 score), stakeholders with score of 2.7 (maximum six points), message with score of (maximum four points) 0.5, encouraging techniques and approaches with score of 6.9 (maximum 17 points), action plan with score of 0.2 (maximum two points) and evaluation with score of 0.2 (maximum 2 points). In general, given that the mean score for the advocacy of health workers was14.1, only 35 percent of them had the necessary skills for advocacy. Based on the mean scores of the individuals in each section following results were obtained: the skill level of employees in selecting the topic is equal to 38%, determining the stakeholders is equal to 44 %, development of the message is equal to 14.5%, encouraging techniques and approaches is equal to 41%, action plan is equal to 10%, and evaluation is equal to 11 %. Table 2 presents the values obtained for – mean advocacy score.

Table 1: Distribution of correct answers, average and standard deviation of the subjects on the basis of advocacy components
Questions	Frequency (%)
Subject selection
The definition of advocacy	6(7.5)
The main objective of the advocacy strategy	48(60)
The main difference between advocacy strategy with IEC strategy	59(73.8)
Essential characteristics	69(86.2)
The first step in advocacy	55(68.8)
Prioritization and selection criteria issue	24(30)
Choose a theme framework program	5(6.2)
Mean of subject selection(SD)	3.4(1.6)
Determine stakeholder
The definition of stakeholders	9(11.2)
Categories of stakeholders	49(62.2)
Highlights Stakeholder analysis	65(81.2)
Specify the primary beneficiaries of the high death rate of motorcyclists in accidents	41(51.2)
Specify secondary beneficiaries of the high death rate of motorcyclists in accidents	45(56.2)
Men of Determine stakeholder(SD)	2.7(1.5)
Development message
Write a message to problems Question 11	18(22.5)
Features of an Effective Message	12(15.0)
The first step is to produce messages	4(5.0)
Mean of Development Message	0.5(1.0)
choosing the persuasive approaches
Persuasion techniques suitable for all stakeholders	67(83.8)
To influence the debate on which group is involved?	62(77.5)
The main feature negotiation	55(68.8)
A variety of ways to negotiate	24(30.0)
In the absence of a superior position to negotiate your way	41(51)
Negotiation technique, especially if you are going to their relationships with partner	67(83)
Which potential problems are overcome using the skill via which the negotiator can put himself in the position of opposite side and see the situation from his perspective?	2(2.5)
Stages of Negotiation	11(13.8)
The lack of negotiations	41(51.2)
Measures to negotiate	11(13.8)
Which group involved in bargaining or lobbying for better?	56(70.0)
The main focus on bargaining	59(73.8)
Important to implement effective bargaining	9(11.2)
Mean of Choosing Persuasive approaches	6.9(2.8)
The action plan preparation
Stage of action plan	0.2(0.6)
Mean of the Action Plan Preparation	0.2(0.6)
Evaluation
Evaluation program	0.2(0.6)
Mean of Evaluation(SD)	0.2(0.6)
Mean of Total Score(SD)	14.1(6.3)

With regard to table 2, the mean scoreout of the whole questionnaire was 14.1 out of 40, and the highest score achieved was related to the employees of the Health Education Department, and Network Development.

Table 2: Mean advocacy score based on organizational units, health care workers
Unit	N	Mean	Std. Deviation
health education	5	17.40	8.142
occupational Health	7	12.86	3.338
Environment Health	14	13.14	4.990
Family Health	22	14.14	7.206
School Health	5	8.80	5.675
Disease	11	14.36	7.366
Expand	6	17.17	7.195
Nutrition	5	15.00	5.000
Mental Health	5	16.40	5.273
Total	80	14.17	6.358

As the results indicate, the highest scores are related to selecting topic questions (essential features gaining advocators) and the selecting the encouraging approach and techniques (encouraging techniques appropriate for stakeholders and the negotiating method aiming to establish favorable relationships with the negotiating party) and the lowest scores were related to the selecting the encouraging approach and techniques (the skill with which the negotiator can be in the position of the other party and see through his eyes), the development of the message (the first stage to produce a message for comprehensive advocacy programs) and topic selection (the framework to select the topic of advocacy program) andin general, the scores obtained in parts of topic selection (advocacy definition), while the scores obtained for preparation of an action and evaluation plan were not satisfactory and this could indicate a defect in their knowledge in these fields.The results obtained bySiamin et al. (2014) indicated that the scores of participants among communication skills was such that punishment and reward skill had the highest score, and the feedback skill had the lowest score (Siamian et al., 2014).

Belkowitz et al. (2014) in a study entitled “health advocacy education to medical students at the University of Miami Miller”, concluded that advocacy education to medical students can be beneficial in promoting the knowledge on comprehensive advocacy of students and their skill in addressing the health issues (Belkowitzet al., 2014). The results of the study, entitled “first year medical students’ attitude on advocacy in Medicine” by Press et al. (2015) with a main aim of introducing the advocacy course, proved that adding advocacy to the curriculum makes the students able to perceive their professional role (Press et al., 2015).

According to the results, the departments with health education program and the development department exhibited a better performance. In general, the scores of the departments were less than the half of the expected advocacy score. Therefore, the need for education in all departments, especially school health department with the lowest score seems to be essential. The study of Lang et al. (2014) was done with the aim of bridging the gap in the curriculum of residents and other health workers during the years 2011-2013. The results showed an increase of approximately 1 score in the score of advocacy. It was also suggested that advocacy education and health policy should be considered as an important component in the education of specialists (Long et al., 2014).

In this regard, the Peltzeret al. (2016) showed that defining the periodical assignments for undergraduate and graduate students working with the government was conducive to further learning in the field of advocacy (Peltzer et al., 2016). Also defining an advocacy course and one internship course for medical students in the study of Lang et al. (2011) also represented an increase in empowerment, improved efficacy in advocating their health, and in general showed that the advocacy curriculum based on gaining learning experience community-based services is effective in increasing the empowerment of the students, and tendency to serve the community (Long et al., 2011).

Conclusion

According to the results, it is recommended that increasein the advocacy skills in formal educational and in-service programs is highly required.

Acknowledgment

This paper was part of a research project thesis, entitled “Development of assessment tool of Advocacy skills and study of effectiveness of education for promotion these skills among health workers in Gilan province 2016, approved by Shahid Beheshti University of Medical Sciences in 2016 under the code: Ir. SBMU. Retech.REC. 13950305

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