Educational needs assessment of family health providers in Tabriz health care centers in 2015

Introduction Human resources are important asset for any organization, and in this regard their improvement by regular education is considered a key strategy. The need to improve educational programs are commensurate with objectives of each organization.1 Proper educational planning can be a major step in improving knowledge and play an important role in enhancing education quality.2 Educational programmers are well aware of the importance of proper needs assessment as an effective, useful and successful pre-requisite for educational courses design.3 In the field of medicine and health services, curriculum designing, in accordance with the real educational needs of target groups, has been one of the most important priorities in implementing the educational programs. Even systematic and comprehensive needs assessment is a necessity for proper planning of any continuing educational programs and paves way for implementation of successful and satisfying courses.4 Changes in lifestyles and emerging new conditions lead to changes in educational needs and re-


Introduction
Human resources are important asset for any organization, and in this regard their improvement by regular education is considered a key strategy.The need to improve educational programs are commensurate with objectives of each organization. 1Proper educational planning can be a major step in improving knowledge and play an important role in enhancing education quality. 2 Educational programmers are well aware of the importance of proper needs assessment as an effective, useful and successful pre-requisite for educational courses design. 3In the field of medicine and health services, curriculum designing, in accordance with the real educational needs of target groups, has been one of the most important priorities in implementing the educational programs.Even systematic and comprehensive needs assessment is a necessity for proper planning of any continuing educational programs and paves way for implementation of successful and satisfying courses. 4Changes in lifestyles and emerging new conditions lead to changes in educational needs and re-quire revision in current educational courses content.Unfortunately this issue is widely being ignored.In a study conducted at Isfahan University of Medical Sciences many participants at educational courses mentioned that many topics were not related to their field of study and they only gained some general information, and only few attendants reported that 1 or 2 courses satisfied their interest.Others even reported that no single educational session has been held in the field of their task related studies that they really needed. 5In another study, by Hamdi et al on educational needs of environmental health graduates, they have emphasized the need for a revision of current curriculums based on the results gained from needs assessments of target groups. 6Moreover, a study on needs assessment of nurses in intensive care units in Semnan, showed that more than 50% of nurses under study believed that they needed training on specified educational topics, and that in-service continuous education programs were not designed on the basis of their tasks based needs. 7In a study in 2006, in Indonesia, Hennessy et al pointed out to the importance of assessment of educational needs of the midwives, based on their professional duties. 8Mirzaei Karzan et al in a similar work have concluded that in addition to holding courses and workshops in the field of specified requirements, a continuous need assessment system should be established. 9Based on a study on the educational needs of the personnel employed in Isfahan health centers, it was found that there was not much agreement among target population and authorities of educational courses.They believed that their view points and ideas were ignored, and that different organizer's groups had no joint and coordinated activities in this regard, and at the end program managers were not able to create a common sense. 10Based on a study carried out in 2011 on the educational needs assessments of nurses in psychiatric wards in Isfahan, authors emphasized that needs of nurses should seriously be taken into consideration. 11Educational need assessment is an important tool for empowerment of human resources and can fill educational gaps and facilitate rapid and effective decision making. 9To our best knowledge there is no published and documented educational needs assessment conducted on family health care providers in Tabriz Medical Sciences University in 10 years. 12By this study we can fill the gap, and improve the level of educational courses arranged for this group.

Design, setting and participants
This work is a cross-sectional, prospective, and applied study in the field of educational studies.The study population included all 330 employees, all female, in the urban family health units of Tabriz health centers, together with 22 managers and senior officials of the same centers.Inclusion criteria were: having a relevant diploma degree, official or contract employment, having a defined duty in a family health unit, and at least one year job experience.For senior managers at least 10 years job experience as the head of a center as was mandatory.Exclusion criteria were: lack of interest to complete the questionnaire, hesitation to participate in the study, and employment in rural health care units.

Measures and data collection
A researcher-designed questionnaire was data collection tool.Questionnaire was designed through study of family health staff task description documents, as well as the current in-use check lists monitoring ongoing processes.The first questionnaire was a self-assessment of family health staff to evaluate 6 family health task processes.Data included demographic information such as their age, education, type of employment, and professional work experience.The second questionnaire was to determine the viewpoint of managers and authorities on current processes.The validity of the data collection tools was determined and confirmed by 5 experts from health care centers and Medical Education Department.The internal consistency reliability of scales was confirmed by Cronbach alpha coefficient (range between 0.90-0.96).The answers were valued based on a 5-item Likert scale, ranging from very low to very high with the following marks; very high = 5, high = 4, moderate = 3, low = 2 and very low = 1.The scores were calculated by taking averages over items scores, therefore the possible range of scores were 1-5 with a midpoint of 3. Knowledge and skill self-assessment questionnaire completed by family health staff was used for comparison with scores obtained from the annual regular monitoring of staff.

Statistical analyses
The data was analyzed using SPSS 16 and significance level was set at 0.05.Data were presented by mean (SD) for numeric variables and frequency (percent) for categorical variables.To assess the effect of educational needs and prioritization the need, we compare the scores obtained by each item with our criteria (midpoint = 3) by one-sample t test.

Results
Of 330 employees entered study, 282 (85.5%) completed the questionnaire in the second half of 2015.The average age and duration of job experience was 39.7 ± 7.28 and 14.3 ± 7.43 years respectively.Most of the officially employed staff had a bachelor's degree in midwifery (Table 1).Family health staff generally declared their knowledge state and self-assessed skills and attitude in 6 domains at an optimal level, with average mark more than the mean (3).T-score was also higher than the critical value.So according to family health staff their knowledge was satisfactory (Tables 2-7).According to data on Table 8, the officials evaluated the family health staff status satisfactory in all the field under study.They evaluated the professional duties of the staff lower in "common diseases prevention and control" process compared to others, and stated that the staff needed more training in the above-mentioned process.In the attitude domain, the managers declared that the staff were not motivated enough to perform their duties properly.
According to an annual inter-organization monitoring reports on 2015, family health staff status was reported undesirable, especially in "integrated care for pregnant women", "women's general and reproductive health", "common diseases prevention and control", and "teenagers' and young adults' health" processes (Table 9).The high priorities the staff reported in terms of their educational needs included "common diseases prevention and control", "vaccination skills", "teenagers' and young adults' health", "women's general and reproductive health", "integrated care for pregnant women" and, "child health care and breastfeeding" processes, respectively.These are also consistent with managers' views.However, it was not fully compatible with the results of the inter-organization monitoring reports.Despite the staff and managers' report that educational needs in the fields of "integrated care for pregnant women" and "women's general and reproductive health" were the fourth and fifth priorities, but an inter-organization monitoring results showed that the staff obtained undesirable scores in the above-mentioned areas (Table 10).

Discussion
The results of this study showed that generally family health staff evaluated the level of their knowledge, attitudes and skill self-assessment status in 6 studied processes at higher than midpoint criteria level (theoretical average 3).The educational needs stated in 6 studied processes were, in the order of priority, in the following domains; "common diseases prevention and control", "vaccination skills", "teenagers' and young adults' health", "women's general and reproductive health", "integrated care for pregnant women" and "child health care and breastfeeding".In "common diseases prevention and control" domain, average scores obtained in the knowledge of thalassemia couples referral for a genetic counseling and prenatal di-  In "vaccination skills" domain; average scores obtained in knowledge on correct intra-dermal vaccine injection, management of vaccination side effects and prevention of vaccination complications were relatively low.
In "teenagers' and young adults' health", self-care training and parent's education got lower scores, and indicated priority for future education.
In "women's general and reproductive health", principles of family planning counseling, was in the focus of more attention.
In "integrated care for pregnant women" domain, average scores obtained in diagnosis and management of ectopic pregnancy, placenta previa, and placental abruption were relatively low, indicating more educational attention.
In "child health care and breastfeeding" knowledge on guidelines for formula feeding gained priority.
In our study, managers believed that need-assessment should be continuously done and they also agreed that "common diseases prevention and control" process was the most important domain for educational planning in terms of the number and diversity of disease assigned to this process.In a review of training needs of midwifery graduates working in health care centers of Shahrekord University of Medical Sciences, Sereshti et al concluded that the most educational needs in pregnancy and childbirth were related to the fields of genetic counseling, postpartum bleeding and prenatal screening, which are in line with our findings.On the other hand, the least educational needs in their study were related to anatomy and physiology of the reproductive system, minor discomforts during pregnancy and risk factors in development of labor and non-natural delivery.The lowest educational needs of midwives were in the area of maternal and child health, including child routine examination and child growth monitoring, 13 which is in agreement with our findings.
A study conducted by Lotfipur et al, assessing the educational inquiries of midwifes in before, during and postpartum care in Rafsanjan, showed that history taking and physical examinations during pregnancy, proper care during labor for abnormal or at risk cases in labor, and feeding after delivery in the postpartum care were the top educational needs stated. 14This is in contrast with our findings in that our staff had less educational needs in prepartum cares, but sharing in more educational requirements in high risk pregnancies.In another study by Behrouzifar et al, comparing of continuing medical education priorities of midwives employed at health facilities and treatment centers of Kashan, the top 5 educational needs were abnormal genital tract bleeding, diabetes mellitus during pregnancy, breast cancer, anemias and preventing the birth of a premature infants. 15This again shows some similarities with our finding, except that diabetes mellitus and oncologic diseases screening did not come to our staff 's consideration for more education.
In an article by Mokhtary Zanjani et al, they concluded that new medications and modern techniques together with updates in obstetrics and gynecology emergencies were at the top of the list mentioned by participants. 16In our study pharmacologic issues and medications were not detailed in our staff 's tasks list.

Attitude domain
The staff feel responsible inaccurate doing the mentioned processes

3.59±0.854
The staff are committed to respect the rights of family health clients

3.82±0.795
The staff feel responsible to adhere to the instructions of the mentioned processes

3.77±0.813
The staff are motivated enough to carry out the processes 3.59±0.008 The average of attitude domain 3.44

Total average
3.50 ± 0.662 Each item was compared with criteria = 3 by one sample t test.a P < 0.001.A similar assessment in east of Gilan province, conducted by Yaghobi and Najafi, disclosed that complications of cesarean section procedures, and ways to facilitate normal vaginal delivery were the main concern of midwifes and nurses employed in 5 hospitals in that region. 17They were not mentioned by our staff as top educational priority.
Regarding "teenagers' and young adults' health", Asadi Malek Abadi and Abolghasemi found that besides life skills education, sex education and common infectious diseases in this age group, drug abuse and its prevention were main priorities mentioned by their target population. 18In our study in this domain, substance abuses were not appreciated, so this topic needs more attention.Findings of this study showed that knowledge, skill self-assessment and attitude of family health staff in 6 studied processes were in line with managers' views.Sereshti et al also showed that there was no statistically significant difference in the mean scores of the educational needs from the viewpoints of managers and midwives in specialized and non-specialized areas. 13In this study, the results of an inter-organization monitoring at the same period showed that in some processes ("integrated care for pregnant women", "women's general and reproductive health", "teenagers' and young adults' health" and "common diseases prevention and control") were not in as a desirable level as mentioned by staff and managers.This is in sharp contrast with some parts of our results.

Limitations
We acknowledge some limitations in this study; first all the participants were females and this limits the external validity and generalizability of the results to the male pop-ulation, hence a study comprising both males and females in assessing the educational needs.Second, the needs were assessed by self-descriptive methods may induce bias in the responses, however this is the nature of such evaluations in this area of study.The cross sectional design of the study is another limitation of the study that limits our judgment about the relationship and can be improve by longitudinal study to assess the relationship.

Conclusion
It can be concluded that training program of family health staff requires a revision in some areas.Regular and comprehensive educational needs assessments are required to revise staff training programs, in order to give quality services to general population.Needs assessment detects educational priorities and could be utilized for improvements of education level.

Table 1 .
Demographic information of population under study

Table 2 .
Evaluation of family health staff status in the "integrated care for pregnant mothers" process from their own point of view a Each item was compared with criteria = 3 by one sample t test.a P < 0.001.

Table 3 .
Evaluation of family health staff status in the "women's general and reproductive health" process from their point of view a a P < 0.001.

Table 4 .
Evaluation of family health staff status in the "child health care and breastfeeding" process from their point of view a a P < 0.001.agnosis (PND) testing, mental health counseling, care of thalassemia carrier couples based on available flowchart, and mental health awareness, were relatively low, hence indicating more emphasis on these topics in educational planning.

Table 5 .
Evaluation of family health staff status in the "vaccination skills" process from their point of view a Each item was compared with criteria = 3 by one sample t test.a P < 0.001.

Table 7 .
Evaluation of family health staff status in the "common diseases prevention and control" process from their point of view a a P < 0.001.

Table 6 .
Evaluation of family health staff status in the "teenagers' and young adults' health" process from their point of view a

Table 8 .
Viewpoint of managers, senior officials and experts on the educational needs of the staff a

Table 9 .
Results obtained by family health staff, based on inter-organization monitoring

Table 10 .
Comparison of the educational needs in accordance with the results of the staff self-assessment and the viewpoint of health care centers staff and the scores obtained from inter-organization monitoring by family health workers