|Year : 2015 | Volume
| Issue : 2 | Page : 47-51
The Effect of Education on Administrators and Service Providers' Knowledge of the Family Physician Plan and Referral System in Urban Areas
Hamed Asgari1, Maryam Azarnoosh2, Maryam Kheirmand3, Mansour Shiri4, Mohsen Rohani4, Mehdi Khosravi4, Rasol Hemamy4
1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of English Language Teaching, Semnan Branch, Islamic Azad University, Semnan, Iran
3 Department of Community Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Health, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||27-Nov-2015|
Department of English Language Teaching, Semnan Branch, Islamic Azad University, Fifth Kilometer Damghan Road, Semnan
Source of Support: None, Conflict of Interest: None
Context: As one of the important changes in the health system, family physician plan, and referral system need to be taken into consideration, so as to make the administrators informed of the best ways of its implementation. Aims: This research has been carried out to study the effect of education on the knowledge level of administrators and service providers. Settings and Design: This study was analytical and interventional and conducted in Isfahan in 2012 with a statistical population of 2851 and a sample size of 118 people. Materials and Methods: This quantitative study was an interventional comparison group applying pre- and post-tests. Random sampling was used to select physicians, administrators and service providers in the family physician plan. A researcher-made questionnaire was filled out by the sample before and after the intervention, and the collected data were analyzed descriptively and inferentially. Statistical Analysis Used: The data were analyzed by using the SPSS 16 software and the mean scores of knowledge level, before and after the intervention, were compared. Demographic variables, also, were described and their relationship with the knowledge level scores was determined. A t-test was used, too. Results: The findings showed that the mean scores of knowledge level were 46.18 15.37 before the intervention and 50.14 14.46 after the intervention. Moreover, the t-test result, with 95% certainty, was significant (P = 0.043). Conclusion: Considering the meaningfulness of the results of t-test, it can be concluded that education has a high effect on the knowledge level of administrators and service providers. The results, also, showed that for having a more effective education, face to face education and active and practical teaching methods such as workshops and group discussions as well as different informative materials like brochures and media (radio, television and press) can be used. In addition to these factors, the age and work experience of people receiving education should be considered, too.
Keywords: Family physician, information, referral system, service providers
|How to cite this article:|
Asgari H, Azarnoosh M, Kheirmand M, Shiri M, Rohani M, Khosravi M, Hemamy R. The Effect of Education on Administrators and Service Providers' Knowledge of the Family Physician Plan and Referral System in Urban Areas. J Earth Environ Health Sci 2015;1:47-51
|How to cite this URL:|
Asgari H, Azarnoosh M, Kheirmand M, Shiri M, Rohani M, Khosravi M, Hemamy R. The Effect of Education on Administrators and Service Providers' Knowledge of the Family Physician Plan and Referral System in Urban Areas. J Earth Environ Health Sci [serial online] 2015 [cited 2019 Jul 21];1:47-51. Available from: http://www.ijeehs.org/text.asp?2015/1/2/47/170579
| Introduction|| |
In 1978, all the WHO members unanimously declared that access to basic health services was a fundamental human right, what was known as "Health for All by the Year 2000 (HFA 2000)." Primary health care (PHC), which emphasized community-based preventive services, with substantial community involvement, was advocated as the main strategy to achieve the goals of HFA 2000. PHC entailed universal coverage of basic services such as safe water supply, promotion of food security, vaccination, family planning, education, control of endemic diseases, and the provision of essential drugs. At the core of Iran's PHC plan was decentralization and empowering the rural areas with community health workers. Health houses were opened in 16,000 villages and were run by community health workers. Each health house on average covers four villages, and every few health houses are supervised by a "rural health center." Iran has a total of 2300 rural health centers that are typically staffed by general practitioners, dentists, midwives, pharmacists, nurse assistants, and other health workers. In urban areas, the peripheral governmental health system generally starts from "urban health centers" that are similar in structure to rural health centers. However, in the very poor neighborhoods of larger cities, there are 600 "health posts" each manned by five health workers. 
In recent years, the Ministry of Health and Medical Education (MOHME) implemented family physician and referral system plan as the main strategy in all rural areas and some cities.  Despite the reforms, the organizational structure of PHC system has not changed over the last thirty years.  Organizational structure reform is required to have appropriate performance regarding new goals and strategies. 
In order to implement the family physician plan through a referral system, in 2005, Health Services Insurance Organization with the corporation of Management and Planning Organization and Islamic Consultative Assembly (parliament) was bound to provide a health insurance booklet for all residences in rural and urban areas with populations <20,000 people. 
Due to the good cooperation of Health Services Insurance Organization with Isfahan University of Medical Sciences, the plan started in Isfahan from June 2005 and then, 83% of the population in rural areas, clans were given insurance coverage, and more than 450,000 of the residences in villages received the health insurance booklet. 
Now, in Isfahan province, 220 doctors, 164 midwives, and 150 drugstores are working in 20 health networks and 152 health centers and are providing health services for all the residences in rural areas. 
With respect to the issued health policies and to implement of paragraphs J and D of article 32 and paragraph A of article 35 considering the development, approval, and issuance of instruction of family physician plan and referral system in urban areas (01 copy), this plan was piloted in some cities with 20-50 thousand in population in three provinces of Khuzestan, Chaharmahal Bakhtiari and Sistan Baluchestan. Due to the cooperation of MOHME, Ministry of Cooperation, Labour and Social Welfare, and other experts, the barriers and obstacles were recognized. This very instruction, under the title of 02, is the result of the abovementioned process and is to be implemented in the foresaid provinces and those provinces, which are agreed upon by these two ministries. 
With regard to the aforementioned issues, some of the related studies conducted in Iran are reviewed below.
Ansaripour and colleagues in their study on "the Effects of Acute Respiratory Infection Education by Rural Health Technicians and Behvarz Training Center Instructors on Knowledge and Practice of Behvarzes" came to the conclusion that Behvarzes' scores in Knowledge and practice increased significantly after education in both groups. The mean scores of increased Knowledge were 59.2 ± 9.2 and 67.2 ± 2.2 in the groups trained by instructors and technicians, respectively. Also, the mean scores of increased practice were 72.2 ± 12.12 and 88.2 ± 9.5 in the groups trained by instructors and technicians, respectively. There was no significant relationship between the score of Behvarzes' knowledge and practice with their experience. The increase in knowledge and practice scores of the group trained by instructors was significantly more than the group trained by technicians. 
In the study of Khazaei et al. on the effect of education on the knowledge level and behaviors of mothers in relation to their infants complementary feeding, it was indicated that mothers' scores in knowledge before the education (7.37 ± 1.07) and after the education (17.62 ± 1.49) were significantly different (P = 0.004). Such a difference was also found considering their behavior before and after the education (54.5 ± 1.21 and 18.72 ± 1.96, respectively). 
In another study carried out by Ansaripour et al., the role of education was found to be undeniable. 
Moreover Sinaei in his study showed that the knowledge level and function scores of secretaries before education were 15.22 and 12.02, respectively. However, such scores after the education changed to 24.92 and 18.56. These changes indicated that there was a significant relationship between the education, knowledge and function of the secretaries. 
Yaghobian et al. work are another study in this field. They compared the effect of education using educational booklet with lecture method and educational booklet alone on the knowledge level of nurses about the professional laws and regulations. They found that the scores before and after the education were significantly meaningful, and there was a direct relationship between the scores before and after the education with nurses' experience and age. 
The knowledge level scores before and after education, also, showed a significant change in Kahveci et al.'s study who studied the effect the anaphylaxis guideline presentation on the knowledge level of family physicians assistances and children. 
In still another study focusing on mechanisms of informing and attracting medical tourists in hospitals of Tehran, Tabibi et al. came to this conclusion that among the probable variables, it was only the media which was significantly related to with attracting the tourists. 
Among foreign studies on the same issue, Acton et al. in a study focused on "knowledge, attitudes, and behaviors of Alabama's primary care physicians regarding cancer genetics." The results validated gaps in primary care practices in obtaining a family history of cancer, as well as lack of confidence in explaining genetic test results and in tailoring recommendations based on the tests.  In another study on "the effect on test ordering of informing physicians of the charges for outpatient diagnostic tests," researchers concluded that displaying the charges for diagnostic tests significantly reduced the number and cost of tests ordered, especially for patients with scheduled visits. 
In order to recognize the ambiguous points and to remove them as well as to inform the administrators and service providers of the family physician plan, this research was conducted. It aimed to investigate the effects of education on the knowledge level of administrators and service providers. 
| Materials and Methods|| |
This quantitative study which was analytical and interventional was conducted in Isfahan, Iran, in 2012 with a statistical population of 2851 people and a sample size of 118 people. The randomly selected the sample of physicians, administrators, and service providers in the family physician plan filled out a researcher-made questionnaire before and after the intervention with a 3-month interval. The collected data were then analyzed descriptively and inferentially by applying pre- and post-tests.
This study was a descriptive-analytical type and was conducted in two stages. At first, before receiving any information, the target group was given a questionnaire. After a multi-dimensional intervention including awareness through training workshops, lectures, group discussions, seminars, providing educational pamphlets, radio and multimedia, newspapers and magazines, the participants filled out another questionnaire.
The population, with the total number of 2851, consisted of all health, midwifery, and nursing staff, specialist experts, and doctors working in both governmental institutions (i.e., health centers, Health Services Insurance Organization, Social Services Organization, Relief Committee, Armed Forces) and private ones (offices) in 2012, in Isfahan.
The sample size formula was used to calculate the sample size which was 118. The sampling procedure was a multistage sampling including stratified sampling (considering the differences in the target group) and simple random sampling in every unit (considering the quota). The inclusion criteria were working in the family physician plan as a doctor, expert, instructor, administrator, or supporter; whereas, those whose working time had ended, who had resigned, or had changed their working place were excluded from the study.
To collect the data, a researcher-made questionnaire was used. This questionnaire consisted of two parts; six demographic questions and 35 multiple-choice questions extracted from debates guidelines, family physician, and referral system in urban areas edition 02. The construct, face, and content validity of the questionnaire were verified by the experts on the family physician information committee. By employing SPSS Version 16.0 for windows (IBM SPSS, 2007 Microsoft Corp, Birstol, UK), its reliability by calculating Coronbach' Alpha was confirmed and turned to be 0.089 for the 20 questionnaires completed in the pilot study.
At first, the questionnaires were distributed among the target group. Then, they received information and education through educational CDs, brochures, brainstorming sessions, orientation classes, and lectures. In the second stage, the same questionnaire was given to the participants to complete.
The data were analyzed by using the SPSS software version 16 and the mean scores of knowledge level, before and after the intervention, were compared. Demographic variables, also, were described and their relationship with the knowledge level scores was determined. T-test was also used to check the differences in participants' knowledge after the intervention (through comparing the means and checking the differences when the variances of two normal distributions are unknown and when the sample size is small). 
| Results|| |
The 69% of the participants were organizationally associated with the Health Ministry (University of Medical Sciences), and 31% of them were related to Social Security Organization [Figure 1].
The most frequent age range was 41-46 (21.4%) while 70% of participants were under 45 years old. 82.2% of them were doctors and the rest were educated in different fields (health, nursing, midwifery…). The majority of the participants' had <5 years of work experience, while only a small number of them had more than 30 years of experience. Based on the effectiveness of the materials used to inform participants, educational sessions and workshops (31.4%), multi-media (28.8%), radio and television (14.4%) were the top three instructional methods, respectively.
[Figure 2] indicates that correct answers and the knowledge level of participants increased (mean = 14.4) after the intervention.
|Figure 2: The comparison of frequency distribution of answers of knowledge level before and after the intervention|
Click here to view
Considering question 3 that is "who is responsible to recognize the emergency patients, except those cases which are obviously emergency like heart attack…," the number of correct answers before and after education did not change and was not considerable (between 8.5% and 9.2%).
The same cannot be said for question 6 which was about the work hours in the family physician plan. More than 95% of the answers before and after the intervention were correct.
To compare the answers before and after the intervention, paired sample T-test was used [Table 1].
As it is shown is in [Table 1], before the intervention, the lowest and the highest scores were more than those after the intervention were and the indexes of dispersion (median, mean, standard deviation) showed a considerable increase. The result of the t-test proved to be significant at 0.05 levels of significance (95% meaningful, P < 0.05).
| Discussion|| |
This research was carried out with the aim of studying the effect of informing administrators and service providers of the instructions of the family physician plan and referral system in urban areas. By comparing the mean scores before and after the intervention, it was concluded that these scores were meaningfully different. This difference can be attributed to the direct effect of notification. Sinaei in his study showed that there was a meaningful difference between the mean score of knowledge level and functions of secretaries before and after the education. Our findings are consistent with her results.  Such consistency was also found in the study of Mazani et al. In his study, he showed that the knowledge level of mothers about infant feeding, teaching methods, and weight and high, after the education meaningfully changed.  Although, the target group of the two studies were not similar, the results emphasized that education had some effects on knowledge and behavior of the target group. Similar results were also found in the studies of Ansaripour et al.,  Farhadi et al.,  Khazaei et al.,  Yaghobian et al.,  and Kahveci et al. ,
In this study, no meaningful relationship was observed between the ways of gaining information and the mean scores; however, based on their effectiveness, educational sessions, and workshops (31.4%) are in the first place and multi-media, radio and television are in the next steps. In a similar study, considering managers and doctors, Tabibi et al. showed that amongst the information mechanisms, only media advertisement (radio, television, press) were significantly and meaningfully was related with attracting tourists. 
Because of the ongoing changes and displacement of doctors and other health experts, the study was limited in the number of participants and sample size. However, it can be concluded that having a well-developed instruction and teaching to all those who are involved with the plan would be effective for well implementing the plan and producing successful results.
This study was designed to determine the impact of education on physicians and experts' awareness and knowledge of implementing family physician plan and referral system in cities. It can be concluded that educational meetings alone or combined with other interventions can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviors. 
According to the findings of this study, it can be concluded that the best result would be gained when the education is performed in a more active way such as group discussions, workshops, performing educational sessions, and using different methods such as brochures, booklets, Medias (press, television, radio). It also seems necessary to categorize the learning groups based on their age and work experience.
Financial support and sponsorship
Financially, this plan was supported by Deputy of Research and Technology of Isfahan Medical Sciences University and was approved by Health Management and Economics center.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sheikhattari P, Kamangar F. How can primary health care system and community-based participatory research be complementary? Int J Prev Med 2010;1:1-10.
Majdzadeh R. Family physician implementation and preventive medicine; Opportunities and challenges. Int J Prev Med 2012;3:665-9.
Robbins SP. Organization Theory: Structures, Designs, and Applications. 3 rd
ed. Essex: Pearson Education Ltd: Pearson Education India; 1983.
Naghavi M. Transition in Health Status in the Islamic Republic of Iran. Iran J Epidemiol 2006;2:45-57.
Raeisee P, Motlagh M, Kabir M. Evaluation of the performance of referral system in family physician program in Iran University of Medical Sciences: 2009. Hakim Research Journal 2010;13:19-25.
Development Group Network and Promote Health DHIUoMS. The Table of Implementing Family Physician Approved Staffing and Employed Rural and Urban Areas Centers. Isfahan, Iran: Development Group Network and Promote Health; 2011.
Khazaei T, Amoozeshi Z, Ahmadi S, Safamanesh B, Mahmoodi H. The effect of education on mother′s knowledge and practiceabout supplementary nutrition for children under one year. Mod Care (Sci Q Birjand Nurs Midwifery Fac) 2006;3:10-4.
Ansaripour S, Soleimani B, Sadri GH, Bahonar A. The effect of acute respiratory infection education by rural health technicians and behvarz training center instructors on knowledge and practice of behvarzes. Iran J Med Educ 2005;5:33-9.
Sinaei F, Bahman Ziary F, Yamani N, Naji SA, Ghiasi Esfahani M. The effect of office management principles education on knowledge and performance of receptionists working in specialists′ offices in Isfahan. Iran J Med Educ 2011;10:822-30.
Yaghobian M, Yaghobi T, Salmeh F, Golmohammadi F, Safari H, Savasari R, et al
. Comparing the effect of teaching using educational booklets and lecture along with educational booklets on nurses′ knowledge about professional laws and regulations. Iran J Med Educ 2010;9:372-80.
Kahveci R, Bostanci I, Dallar Y. The effect of an anaphylaxis guideline presentation on the knowledge level of residents. J Pak Med Assoc 2012;62:102-6.
Tabibi SJ, NA, Ayubian A, Mahmoodabadi HB. The relation between information mechanisms and medical tourist attraction in hospitals of Tehran. Iran Health Inf Manage 2012;9:423.
Acton RT, Burst NM, Casebeer L, Ferguson SM, Greene P, Laird BL, et al.
Knowledge, attitudes, and behaviors of Alabama′s primary care physicians regarding cancer genetics. Acad Med 2000;75:850-2.
Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med 1990;322:1499-504.
Exchange FS. Xetra Online Dictionary 2015. Online ed. Frankfurt, Germany: Deutsche Börse; 1997. Available at: http://dictionary.reference.com/browse/extra.
Mazani M, Arbabi YH, Nemati A, Mash′oufi M, Mahdavi R. Comparing the effectiveness of attendance and non attendance education of health workers on knowledge of mothers and anthropometric changes of infants. J Health (Res) 2012;3:74-86.
Farhadi A, Foroughan M, Mohammadi F, Sahranavard M. The effect of healthy lifestyle educational program on rural elderly′s quality of life in Dashti District of Boushehr proavince. Iran J Ageing (Res) 2013;8:35-43.
Forsetlund L, Bjorndal A, Rashidian A, Jamtvedt G, O′Brien MA, Wolf F, et al
. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009; 2.
[Figure 1], [Figure 2]