Abstract
Background:
The present study aimed to empower the community to identify and prioritize the needs for the health development of the Eskan neighborhood in Yazd province, Iran.Methods:
This community-based participatory research (CBPR) was conducted in the Eskan neighborhood, Yazd. The project ‘neighborhood health improvement plan (Tabasom)’ was conducted, which included five steps (i.e., area identification, organization, empowerment, needs assessment and prioritization, and intervention and action). In the present paper, two steps, namely empowerment and needs assessment, are described.Results:
The results revealed 10 high-priority problems in the Eskan neighborhood. The first problem with the highest priority was associated with waste management.Conclusions:
According to the findings, empowering and educating individuals to detect the neighborhood problems led to the better identification of the problems, resulting in the further development of the neighborhood and the provision of more effective solutions by the authorities with the community participation.Keywords
Community Participation Empowerment Development Residence Characteristics
1. Background
Although the inclusion of community participation in health programs is not a new phenomenon, it has received worldwide attention after being discussed by the World Health Organization (WHO) at a conference in Almaty (formerly Alma-Ata) in September 2016. Since then, it has spread across the globe and is being considered one of the fundamental principles of primary health care (PHC) (1). In Iran, regarding the problems with informal settlements in metropolises and even the middle cities, different approaches to problem-solving have been considered. In some cases, evacuation and demolition policies have even been observed in some metropolises. The Eskan neighborhood, with a population of above 16,000 persons, is located on the western border of Yazd, Iran. Following the implementation of the Health Transformation Plan by the 11th government, the Comprehensive Health Services Center of the region was founded in 2016 to provide a variety of health services to the residents. Considering the potentials of the neighborhood, including a dynamic and popular non-governmental organization, the place was nominated for the implementation of the neighborhood empowerment and optimal health development program (Tabasom Project). The Neighborhood Health Improvement aimed at organizing the community, empowering the residents, supporting individuals to use their capabilities and potential to identify and solve neighborhood problems, and encouraging community self-reliance.
2. Objectives
This project aimed to provide a model for community organization and empowerment to identify and prioritize needs in line with the development of the Eskan neighborhood in Yazd.
3. Methods
This community-based participatory research (CBPR) aimed at the development of the Eskan neighborhood, Yazd. The neighborhood health improvement plan (Tabasom) was implemented in five steps, including area identification, organization, empowerment, needs assessment and prioritization, intervention and action. This article describes the empowerment and needs assessment steps.
In the area identification and organization steps, according to the censuses and the neighborhood map, the neighborhood population was divided into some clusters to facilitate working. In the concerned clusters, among those who were volunteers, provided more dialogue, justification, and consideration, literate (at least in the first grade of high school), could understand the subject more easily, and transferred information to the cluster members more successfully, were selected as the cluster heads. The population of the region, volunteers, and cluster heads were named as the neighborhood health club. In the empowerment phase, the club was trained. They were first taught about qualitative research, needs assessment, and prioritization. In other words, when they surveyed the problems of a cluster, they adopted the qualitative research method. To this end, some university professors were invited to teach the club, and qualitative research was explained to those individuals using a simple language. Such training meetings were held because they were supposed to refer to their clusters and, with the help of people and other volunteers, find the priorities of each cluster via group discussions. Accordingly, the cluster heads should have been fully prepared to guarantee the success of the needs assessment in the neighborhood.
Another issue was the discussion of prioritization. That is, when we found the needs of a cluster, we had to identify ten priority needs among those needs according to the scientific procedures. This implied that two types of training materials were necessary for the club members: Qualitative research and prioritization.
Since it was not possible to train the whole population of the region, the volunteered cluster heads were trained and empowered in each cluster to train the other members. The following steps were adopted to empower all clubs, including the head clusters, trustees, the health team, and club representatives: (1) Holding a workshop on qualitative research and how to conduct interviews and group discussions for the selected head clusters (diploma holders or individuals with higher levels of education); (2) cascade training for other head clusters in small groups; (3) training on how to identify and prioritize problems; (4) training on negotiation techniques, litigation, and others; (5) organizing orientation and training sessions for interdepartmental authorities; (6) organizing empowerment sessions for the health team members; (7) holding a workshop on empowering needy job seekers (marketing, proposal writing); and (8) holding basic and environmental health education classes for the region residents.
3.1. Community Needs Assessment (Identifying and Prioritizing Problems)
In this step, the following measures were adopted: (1) Conducting at least two group discussions in each cluster and identifying problems (Given the significance of the native culture, women had at least one group discussion with the neighborhood ladies, and men held one session with the neighborhood men); (2) prioritizing and determining ten high priority problems in each cluster; (3) integrating clusters’ priorities; (4) extracting the top ten priorities of the neighborhood; (5) submitting high priority problems to the neighborhood health club; (6) sending high priority problems from the neighborhood health club to the board of directors; and (7) creating workgroups to solve priority problems (10 workgroups).
3.2. Needs Assessment Method
(1) Forming small group discussions by the cluster heads in each clusters; (2) typing down all group discussions; (3) having a quantitative content analysis of the reported problems; (4) identifying the problems; and (5) listing all problems in a form.
3.3. Group Discussion Questions
We intend to hear the region’s health problems from you and the neighborhood community so that, with your participation, we can determined the main ones and plan together.
- In your opinion, what are the problems in your neighborhood?
- What cultural problems are there in your region?
- What health-related problems are there in your region?
- What are the social problems in your region?
- What are the economic problems in your region?
It is essential to obtain the participants’ consent in group discussions (written consent). Moreover, if agreed by the participants, the sessions need to be recorded. This will help transcribe the discussions.
3.4. Prioritizing the Problems
3.4.1. Criteria for a High Priority Problem
(1) Magnitude
(2) Emergency
(3) Feasibility
(4) Consequences
To prioritize the problems, a meeting was held by the cluster heads and the representative of the board of directors of the neighborhood health association, who had been trained in prioritizing problems. The problems were prioritized using the Hanlon method for prioritization. Accordingly, each problem extracted from the community was scored by each participant in terms of magnitude, consequences, feasibility, and emergency in separate tables with scores ranging from 10 (highest) to 1 (lowest). The mean score of each problem was estimated, and finally, the total mean score for each problem was calculated. Given the final scores, the top ten priorities were ranked on an ordinal scale, as reported in the table of problem prioritization. These ten problems must have been proposed and approved by the Neighborhood Health Association as the high-priority problems of the region.
Ethical approval was provided by the Iran Research Ethics Committee of the Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran [Code: Ir.ssu.rec.1396.212]
4. Results
Table 1 shows the demographic information of the cluster heads. One hundred two focus group discussions were conducted, each lasting 30 - 110 minutes, from April to October 2018. In general, 1224 individuals participated in the group discussions. Discussions were recorded and transcribed, and the cluster heads spared their efforts to take important notes during the discussions. Table 2 presents the problems of the Eskan neighborhood in priority (38 clusters). Using the Neighborhood Needs Assessment in a qualitative study (focus group discussions - FGD), the extracted codes were classified into some subcategories, categories, and themes (Table 3), according to which the first ten priority problems of the Eskan neighborhood were extracted (Table 4).
Cluster Heads’ Demographic Information in Eskan Neighborhood
| Variables | No. (%) |
|---|---|
| Gender | |
| Female | 59 (61.46) |
| Male | 37 (38.54) |
| Age (y) | |
| 18 - 29.9 | 19 (25.95) |
| 30 - 50 | 77 (37.08) |
| Level of education | |
| Elementary | 22 (22.91) |
| High school | 23 (23.96) |
| Academic | 51 (53.13) |
| Occupation | |
| Self-employed | 14 (14.58) |
| Retired | 3 (3.13) |
| Officer | 13 (13.54) |
| University student | 8 (8.33) |
| Worker | 7 (7.29) |
| Housewife | 51 (53.13) |
Prioritized Problems of Eskan Neighborhood (48 Clusters)
| No. | Priority | Considering Min. Score | |
|---|---|---|---|
| Mean (SD) | Median | ||
| 1 | Waste | 16.2 (5.9) | 19.5 |
| 2 | No asphalt/broken asphalt | 15.6 (5.4) | 17.0 |
| 3 | No parking lot | 15.3 (5.6) | 17.0 |
| 4 | No educational space | 15.0 (5.1) | 16.5 |
| 5 | No green space | 14.7 (5.5) | 16.0 |
| 6 | No middle school and high schools | 14.1 (5.3) | 16.0 |
| 7 | No house deed | 13.9 (5.5) | 13.5 |
| 8 | No bus station, canopy, and seats | 13.9 (5.8) | 14.5 |
| 9 | No bank | 13.9 (5.4) | 15.0 |
| 10 | Unused lands and ruins | 13.7 (5.3) | 15.0 |
| 11 | No urban bus | 13.6 (5.8) | 13.5 |
| 12 | No pharmacy | 13.6 (5.7) | 15.5 |
| 13 | Unpaved sidewalk | 13.5 (5.7) | 13.5 |
| 14 | Lack of primary school | 13.3 (5.4) | 15.5 |
| 15 | Insecurity | 13.3 (6.1) | 10.5 |
| 16 | No library | 12.8 (4.9) | 13.0 |
| 17 | Cats and dogs | 12.7 (5.1) | 8.0 |
| 18 | Afghan nationality | 12.5 (5.0) | 10.0 |
| 19 | No sanitation of alleys | 12.4 (5.4) | 8.0 |
| 20 | No visit by authorities | 12.3 (5.3) | 8.0 |
| 21 | House toll/tax | 11.8 (4.9) | 8.0 |
| 22 | Poor internet network | 11.8 (4.9) | 8.0 |
| 23 | No footbridge | 11.5 (5.2) | 8.0 |
| 24 | Beautification of Eskan entrance | 11.5 (5.2) | 8.0 |
| 25 | No trash cans on streets | 11.5 (5.3) | 8.0 |
| 26 | Addicts | 11.4 (5.2) | 8.0 |
| 27 | Presence of factories in the neighborhood | 11.2 (4.4) | 8.0 |
| 28 | No religious facilities | 11.2 (4.9) | 8.0 |
| 29 | Absence of cell phone coverage | 11.0 (4.7) | 8.0 |
| 30 | Speed breakers | 11.0 (5.0) | 8.0 |
| 31 | Breach of covenant | 10.9 (5.0) | 8.0 |
| 32 | Traffic in Sanaat Sq. | 10.8 (4.8) | 8.0 |
| 33 | Landlords: Renting to refugees and Afghan evacuees | 10.6 (4.5) | 8.0 |
| 34 | Concern about house demolition order | 10.5 (4.5) | 8.0 |
| 35 | No institute for the intellectual development | 10.5 (4.0) | 8.0 |
| 36 | No language institute | 10.3 (4.0) | 8.0 |
| 37 | No laboratory equipment | 10.3 (4.7) | 8.0 |
| 38 | No dentistry | 10.3 (4.1) | 8.0 |
| 39 | Addiction prevention training courses | 10.2 (4.3) | 8.0 |
| 40 | Traffic | 10.0 (4.5) | 8.0 |
| 41 | Dirty walls of alleys and streets | 10.0 (3.6) | 8.0 |
| 42 | No celebration hall | 9.9 (4.1) | 8.0 |
| 43 | No injection services | 9.9 (4.7) | 8.0 |
| 44 | No technical & vocational training institute | 9.9 (3.8) | 8.0 |
| 45 | Poor street lighting | 9.8 (4.2) | 8.0 |
| 46 | Failure to repair hussainiyas | 9.3 (3.2) | 8.0 |
| 47 | Sports club discount | 9.3 (3.8) | 8.0 |
| 48 | No gym | 9.3 (3.5) | 8.0 |
| 49 | Employment | 8.9 (3.3) | 8.0 |
| 50 | No specialized clinic | 8.9 (3.0) | 8.0 |
| 51 | No training institute | 8.8 (2.7) | 8.0 |
| 52 | Construction waste collection | 8.8 (3.0) | 8.0 |
| 53 | Arman underpass bridge | 8.7 (2.9) | 8.0 |
| 54 | No sports space for women | 8.7 (2.9) | 8.0 |
| 55 | Existence of mice and snakes | 8.6 (2.4) | 8.0 |
| 56 | No footbridge | 8.6 (2.3) | 8.0 |
| 57 | Poor individual culture | 8.5 (2.1) | 8.0 |
| 58 | Heavy vehicle traffic | 8.5 (2.0) | 8.0 |
| 59 | Water and power distribution costs | 8.5 (2.3) | 8.0 |
| 60 | Residents’ lack of cooperation | 8.4 (2.2) | 8.0 |
| 61 | No waste collection vehicle | 8.4 (2.3) | 8.0 |
| 62 | No sewerage system | 8.4 (2.1) | 8.0 |
| 63 | No police station | 8.4 (2.0) | 8.0 |
| 64 | Heavy vehicle traffic | 8.4 (1.9) | 8.0 |
| 65 | Shortage of parking space | 8.3 (1.6) | 8.0 |
| 66 | Inappropriate street numbering | 8.3 (1.6) | 8.0 |
| 67 | Poverty | 8.3 (2.0) | 8.0 |
| 68 | No shopping center | 8.3 (1.4) | 8.0 |
| 69 | Pay fines to the municipality for utilities | 8.3 (2.0) | 8.0 |
| 70 | No police station | 8.3 (1.8) | 8.0 |
| 71 | Lack of women’s employment | 8.3 (1.3) | 8.0 |
| 72 | No lending fund | 8.2 (1.7) | 8.0 |
| 73 | No gas station | 8.2 (1.2) | 8.0 |
| 74 | Pigeon keeping | 8.2 (1.7) | 8.0 |
| 75 | No supervision of the real estate agencies | 8.2 (1.7) | 8.0 |
| 76 | High expenses of kindergarten | 8.2 (1.4) | 8.0 |
| 77 | No water dispensers | 8.2 (1.4) | 8.0 |
| 78 | Existence of flies and mosquitoes | 8.2 (1.3) | 8.0 |
| 79 | Costly commuting to schools | 8.2 (1.3) | 8.0 |
| 80 | Lack of skilled teachers at schools | 8.2 (1.3) | 8.0 |
| 81 | No bakery | 8.2 (1.1) | 8.0 |
| 82 | No Basij site | 8.2 (1.1) | 8.0 |
| 83 | Deed fraud | 8.2 (1.1) | 8.0 |
| 84 | Absence of facilities at the neighborhood’s endpoint | 8.2 (1.1) | 8.0 |
| 85 | No trees in streets | 8.1 (1.0) | 8.0 |
| 86 | No soccer school | 8.1 (1.0) | 8.0 |
| 87 | No hospital | 8.1 (0.8) | 8.0 |
| 88 | Excavated lands | 8.1 (0.8) | 8.0 |
| 89 | Bachelor pads | 8.1 (0.8) | 8.0 |
| 90 | Workshop camera inconvenience | 8.1 (0.8) | 8.0 |
| 91 | Workshop inconvenience | 8.1 (0.8) | 8.0 |
| 92 | Security cameras in alleys | 8.1 (0.7) | 8.0 |
| 93 | The youth’s leisure time | 8.1 (0.4) | 8.0 |
| 94 | Tree planting/lighting/30m St. | 8.0 (0.0) | 8.0 |
| 95 | Asphalt in street No. 8 | 8.0 (0.0) | 8.0 |
| 96 | Absence of police patrol | 8.0 (0.0) | 8.0 |
| 97 | Poor quality bread | 8.0 (0.0) | 8.0 |
| 98 | No telephone landline in the streets | 8.0 (0.0) | 8.0 |
| 99 | High rental costs | 8.0 (0.0) | 8.0 |
| 100 | No summer school | 8.0 (0.0) | 8.0 |
| 101 | Occupational loans | 8.0 (0.0) | 8.0 |
| 102 | Religious mourning group | 8.0 (0.0) | 8.0 |
| 103 | Traffic line/guide sign | 8.0 (0.0) | 8.0 |
| 104 | House number plate | 8.0 (0.0) | 8.0 |
Categories of Problems in Eskan Neighborhood
| Theme | Category | Subcategory |
|---|---|---|
| Social | Culture and education | House rental to Afghan nationals |
| Addicts | ||
| No religious mourning group | ||
| Poor individual culture, lack of cooperation and participation of residents | ||
| Pigeon keeping and causing inconvenience | ||
| Education | Shortage of skilled teachers at schools | |
| No addiction prevention training courses | ||
| Well-being and sport | No celebration hall | |
| Need for sports club discount | ||
| The youth’s leisure time | ||
| Construction and development | Infrastructure | Poor internet network, absence of cell phone coverage, no telephone landline in the streets |
| Arman underpass bridge | ||
| Unpaved alleys and broken asphalt, unpaved sidewalks, asphalt on alley No. 8 | ||
| Well-being and sport | No gas station, lack of facilities at the neighborhood’s endpoint | |
| No bakery, no shopping center | ||
| No Basij site | ||
| No gym, no sports space for women, no soccer school | ||
| Urban space | No park, no green space, no trees in streets, Tree planting and lighting/30m St. | |
| Beautification of Eskan entrance, Dirty walls of alleys and streets | ||
| Culture | No library | |
| No religious facilities, failure to repair hussainiyas | ||
| No middle school and high school, lack of primary schools, no technical & vocational training institute | ||
| No educational space, no language institute, no Institute for intellectual development | ||
| Health and clinical affairs | No laboratory equipment, No injection services | |
| No pharmacy, no dentistry | ||
| No hospital, no specialized clinic | ||
| Transportation | No urban bus, no bus station, canopy, and seats | |
| No footbridge, speed breakers, poor street lighting, traffic line/guide sign | ||
| Traffic, traffic in Sanaat Sq., heavy vehicle traffic | ||
| shortage of parking space | ||
| Management and security | Management | Authorities’ breach of covenant, no visit by authorities, No supervision on the real estate agencies |
| Security | Workshop camera inconvenience, unused lands and ruins, presence of factories in the neighborhood, insecurity, security cameras in alleys | |
| Migrants and nationals problems, Afghan nationals, bachelor pads | ||
| No police station, absence of police patrol | ||
| Housing | Housing | No house deed, deed fraud, concerns about house demolition order, excavated lands |
| Lack of registration plates for houses, inappropriate street numbering | ||
| Health | Environment | Waste collection and disposal, no large trash cans in alleys, no sewerage system, existence of cats and dogs, mice and snakes, flies, and mosquitoes, construction waste collection, no waste collection vehicle, no sanitation of alleys |
| Service | Poor quality of bread | |
| Economic | House tax, pay fines to the municipality for utilities, water and power distribution costs, high rental costs | |
| Employment, lack of women’s employment | ||
| Poverty | ||
| No bank, lending fund, and occupation loan | ||
| High expenses of kindergartens | ||
| Costly commuting to schools |
Ten High Priority Problems of Eskan Neighborhood
| Rank | Priority Title | Mean | Median | S.D. |
|---|---|---|---|---|
| 1 | Waste | 16.2 | 19.5 | 5.9 |
| 2 | Unpaved alleys and broken asphalt | 15.6 | 17.0 | 5.4 |
| 3 | Lack of parking lots | 15.3 | 17.0 | 5.6 |
| 4 | Shortage of educational space | 15.0 | 16.5 | 5.1 |
| 5 | No green space | 14.7 | 16.0 | 5.5 |
| 6 | No middle school and high school | 14.1 | 16.0 | 5.3 |
| 7 | No house deeds | 13.9 | 13.5 | 5.5 |
| 8 | No bus station, canopy, and seats | 13.9 | 14.5 | 5.8 |
| 9 | No bank | 13.9 | 15.0 | 5.4 |
| 10 | Unused lands and ruins | 13.7 | 15.0 | 5.3 |
5. Discussion
The prioritization process by selecting high priority problems leads to implementing an intervention project in the community, resulting in the development of the Eskan neighborhood. This study aimed to promote participation and enhance social interaction to solve the problems in the Eskan neighborhood and ultimately develop the region. In this study, the top 10 priorities were extracted. Focus group discussion is a social research method performed as a structured discussion, which involves sharing and clarifying participants’ views and ideas. The method is mainly used for analyzing issues leading to different opinions or complicated issues requiring careful examination. This method has resulted in sharing different perspectives and experiences on the topics under discussion and allows for a precise assessment of different actors’ positions regarding each problem (2-4). In this study, 104 problems in the community assessment process were identified, which were classified into six dimensions: Social, development and civil, management and security, housing, health, and economics. Comparing the results of this study with similar studies conducted in the Azarbayjan neighborhood in Tehran (5), the Chahestani neighborhood in Bandar Abbas (6) the Mehdi Abad and Bastam neighborhood in Shahroud, (7) Gonabad (8), Alani village in Meshkinshahr, one Rural region in Nigeria (9), Tulsa (USA) (10), and one of the neighborhoods of Buenos Aires (11) indicated that although the problems in these societies are more or less similar in general dimensions (namely social, development and civil, management and security, housing, health, economic, and others), the problems in each field are different in these communities as a result of differences in social, economic and cultural variables of different societies. This evidently justifies the necessity of the needs assessment and the identification of problems in each society by individuals in the same society.
Different analyses by various experts indicate the importance of the prioritization process. In this regard, Kamuzora et al. stated that community participation in prioritization in developing countries, characterized by weak democratic institutions and poor public awareness, requires the effective mobilization of communities and health systems (12). Moreover, this study confirmed that community participation is one of the main factors empowering health systems. The findings also indicated the significance of external support and facilitation in empowering health professionals and community representatives to reach efficiency (12). Developed prioritized decisions improve the quality of service delivery and stakeholders’ satisfaction and reduce complaints leading to increased trust and appropriate allocation of resources (13). Some studies have documented the success of these structures in terms of community participation. For example, they have noted that communities have identified and interpreted their problems and, using the existing administrative structures, have discovered resources to implement what they consider as relevant projects (14). Aristeidou et al. explained that we needed to categorize the levels of engagement across different types of community participation and consider group members in interaction profiles according to their behavior patterns (15). The findings illustrate the need for a different design approach regarding citizens’ participation in community and individual profiles (15).
5.1. Conclusions
The benefits of community participation in the decision-making process vary depending on the type of public services.
Acknowledgements
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