Successful recruitment and retention strategies for women health volunteers: viewpoints of the volunteers’ supervisors and relevant researchers

Figures & data

Table 1 The methods and process of implementing the study

Rounds	Aim	Participants	Procedure	Questionnaire	Data analyses
First round	Identifying new solutions to overcome barriers to the active participation of health volunteers	• WHVs program researchers • Health volunteers’ supervisors	• Potential participants were communicated by phone/email and asked to participate in the project • Questionnaires were sent via email • Two reminders were sent on 14 and 28 days after the initial distribution through telephone contact	• Consisted of 10 questions about barriers to the active participation of health volunteers • The questions were formulated exploratory (open end) and based on perceived barriers • Provided a space for additional comments	Opinion was analyzed using conventional content analysis technique
Second round	Determining the achievement of consensus around strategies derived from the first round	• All participants of the first round • Other WHV program experts (identified by snowball sampling)	• Invitees received questionnaires via email • Two reminders were sent on 14 and 28 days after the initial distribution through telephone contact	• The questionnaire included 133 strategies obtained from the first round • Using a seven- point Likert scale, participants were requested to rank the feasibility of each item	• Feasible strategies were defined from the statements as possessing a median score of 6 and above • The degreeof consensus was defined by calculation of IQR • SPSS software was used to analyze the finding
Third round	Reaching a consensus on strategies that had not previously reached a consensus	All participants in the second round were invited to complete the questionnaire	• Questionnaires were sent by email • Two reminder emails were sent to nonresponders within 4 weeks	• Questionnaire (similar to the second round) was designed on a seven-point Likert scale • The median and IQR derived from the second round of each item was presented	Like the second round

Abbreviations: WHV, women health volunteer; IQR, interquartile range.

Table 2 Strategies for inadequate knowledge of volunteers: Q.1. What is needed to increase the knowledge of health volunteers?

Consensus status	Theme	Possible solutions
Consensus	Empowering WHVs/trainers	• The implementation of continuous training by healthcare workers • Developing educational materials about important health issues • Increasing the professional knowledge of experts in the health centers where health volunteers are taught • The use of appropriate educational materials and new educational methods for training volunteers • Holding workshops and giving end-of-course certificates to WHVs • Providing training to low-literate or illiterate health volunteers individually
	Allocating proper resources	• The use of active and empowered health volunteers in training new health volunteers • Providing suitable educational places for training and meetings with volunteers • Allocating enough time to train the health volunteers • Specialist health volunteers tailored to the health problem
	Assessing the needs of people/WHVs	Needs assessment and prioritization to the beginning of the health volunteers’ educational course
	Improving group work	Increasing the participation of health volunteers in the provision of educational materials
No consensus	Implementing problem-based approaches	Organizing question and answer sessions regularly with WHVs
	Using social networks	The use of educational software such as Health Ambassador software
	Appropriate recruitment of WHVs	Engaging health volunteers with a higher educational level
	Allocating proper resources	Employing a health trainer who lacks organizational responsibility
	Empowering WHVs/trainers	Requesting volunteers to attend health centers in order to directly observe service delivery system

Abbreviations: Q, question; WHV, women health volunteer.

Table 3 Strategies for inadequate skills of the volunteers/trainers: Q.2. What do you believe are contributors to the adequate skills of the volunteers/trainers?

Consensus status	Theme	Possible solutions
Consensus	Implementing motivation tactics	The use of encouragement and motivational skills such as verbal encouragement or giving awards
	Allocating proper resource	• The assignment of simple activities to health volunteers • The use of specialist healthcare worker in order to train health volunteers • Using the educational method according to the WHVs’ skills
	Improving group work	• Designing group works to enhance the communication skills of health volunteers • Using techniques such as role play and demonstration in order to enhance the health volunteers’ skills
	Empowering WHVs/trainers	• The use of films and PowerPoint slides, not relying solely on verbal education • The use of new educational methods to enhance the health volunteers’ skills
No consensus	Implementing motivation tactics	The ranking of WHVs in terms of the diverse skills as an incentive to promote rank
	Allocating proper resources	• Dividing responsibilities among WHVs and providing feedback to them • Assigning more time to train the WHVs by trainers
	Empowering WHVs/trainers	• Conducting educational classes for WHVs about the communication skills • Implementing educational courses outside the health education series for WHVs

Abbreviations: Q, question; WHV, women health volunteer.

Table 4 Strategies for not taking care of the population covered by the program: Q.3. Which intervention approaches are needed to improve people’s cooperation with WHVs program?

Consensus status	Theme	Possible solutions
Consensus	Assessing the needs of people/WHVs	Educating people according to their expressed needs
	Mobilizing the community	• Rationalizing community members by local influential people like religious leaders • Appealing education materials • Informing via media and social networks in order to attract people’s participation • Educating people about the importance and capabilities of health volunteers • The use of WHVs’ collaboration to implement some health programs in the presence of the public
	Improving intersectorial collaboration	Collaborating with the Literacy Movement Organization, the Basij, and other cultural organizations
	Reforming policy	Merging Health Ambassador program with WHVs program
	Information dissemination	Familiarizing households with their WHVs by healthcare workers in various ways such as by text messages
No consensus	Rationalizing WHVs/trainers/people	Putting health information and health-related indicators in the hands of the community members
	Empowering WHVs/trainers	• Family referrals to WHVs by health personnel in some cases • Assigning the delivery of some basic health services to WHVs, such as blood pressure screening

Abbreviations: Q, question; WHV, women health volunteer.

Table 5 Strategies for inefficient communication: Q.4. What strategies may be effective on inefficient communication in WHVs program?

Consensus status	Theme	Possible solutions
Consensus	Using social networks	• Creating a social media channel for WHVs and sharing the channel link to their covered households • Updating work skills using social networks
	Empowering WHVs/trainers	• Empowering WHVs trainers using the participation workshops • Training WHVs in the field of efficient communication
	Rationalizing WHVs/trainers/people	• Updating the knowledge of WHVs and assuring people that most of the educational content in social networks needs to be further explained by WHVs • Rationalizing healthcare workers about using the potential of health volunteers
	Allocating proper resources	• Identifying WHVs with high social interactions and using their potential • Solving the problems of each area using local health volunteers
	Appropriate recruitment of WHVs	• Engaging well-known people in the program • Encouraging all volunteers to identify the norms of communities well
No consensus	Allocating proper resources	Employing the healthcare worker who is more compatible with the roles of WHVs
	Empowering WHVs/trainers	Establishing a sociology workshop (in order to get acquainted with the culture of the community) for WHVs and healthcare workers

Abbreviations: Q, question; WHV, women health volunteer.

Table 6 Strategies for restrictive social norms: Q.5. How could social norms be better to improve the active participation of WHVs?

Consensus status	Theme	Possible solutions
Consensus	Implementing problem-based approaches	• Receiving suggestions and experiences from WHVs about how to overcome the problems and to share their ideas and experiences • Receiving suggestions from communities’ key informants about removing or reducing barriers
	Allocating proper resources	• The use of educational posters and banners • Engaging people who have more social acceptability as WHVs
	Rationalizing WHVs/trainers/people	Holding Q & A sessions about barriers to the active participation of WHVs with the participation of influential people
	Reforming policy	• Providing clear guidelines and regulations for WHVs’ activities regarding social norms • Engaging male health volunteers in order to educate male individuals
	Mobilizing the community	• Appointing appropriate persons in order to create the suitable conditions for solving cultural problems and expressing issues • Improving peoples’ awareness about the role of health volunteers in the health system and the community • Describing the activities of WHVs to their spouses and getting their consent
No consensus	Mobilizing the community	Conducting some meetings with the participation of local community members to express their problems in the presence of other people
	Rationalizing WHVs/trainers/people	Educating influential people with a focus on reducing barriers and supporting them

Abbreviations: Q, question; Q & A, question and answer; WHV, women health volunteer.

Table 7 Strategies for organizational distrust: Q.6. Which interventions are needed to reduce organizational distrust?

Consensus status	Theme	Possible solutions
Consensus	Reforming policy	Strengthening the status of WHVs program in the health system
	Improving intersectorial collaboration	Organizational advocacy to support the efforts of WHVs
	Empowering WHVs/trainers	• Visiting WHVs from healthcare worker activities • Organizing official education courses and giving certification to WHVs
	Allocating proper resources	• Engaging WHVs to help the healthcare worker on specific days of the year • Involving the entire staff in the educational sessions for health volunteers (not using specific trainers)
No consensus	Appropriate recruitment of WHVs	Recruiting people as health volunteers who do not expect any rewards from the health system
	Reforming policy	Efficient implementation of the WHVs program in city centers due to lack of full knowledge of urban health care workers about their community members
	Monitoring and evaluation of WHVs/trainers	Questioning the WHVs about the services that were provided to the households covered

Abbreviations: Q, question; WHV, women health volunteer.

Table 8 Strategies for unrealistic expectations and systemic confusion: Q.7. Which intervention approaches to reduce systemic confusion are most likely to succeed?

Consensus status	Theme	Possible solutions
Consensus	Reforming policy	• Providing a stable position for the WHVs program at the Ministry of Health and Medical Education universities • Setting up a regular work program annually in which if the supervisors change, the program will run regularly • Delegation of some authorities and decisions to the health centers on how to use WHVs • Incorporating WHVs program within the operational programs of the Ministry of Health and Medical Education • Incorporating the WHVs program within the strategic programs of the Ministry of Health and Medical Education • Making decisions from bottom to top about the WHVs program • Increasing the number of WHVs and reducing their tasks
	Implementing problem-based approaches	Inviting volunteers to attend some of their related sessions and getting their opinions
	Rationalizing WHVs/trainers/people	Rationalizing the directors of the health centers about the existing potentials of the WHVs
	Information dissemination	Listing the capability of the WHVs by healthcare workers and displaying it on the health center board for public viewing
	Assessing the needs of people/WHVs	Educational needs assessment by health center staff
	Allocating proper resources	Appointing a WHVs program specialist in all health system categories
No consensus	Rationalizing WHVs/trainers/people	To clarify the role of WHVs for all organizational units
	Reforming policy	Establishing NGOs or associations for WHVs
	Allocating proper resources	Creating job stability and not changing the trainers who educate the WHVs

Abbreviations: Q, question; NGO, nongovernmental organization; WHV, women health volunteer.

Table 9 Strategies for escaping and denial of responsibility: Q.8. What can be done to overcome escaping and denial of responsibility problem?

Consensus status	Theme	Possible solutions
Consensus	Rationalizing WHVs/trainers/people	• Introducing the importance of WHVs activities to healthcare workers • To justify the health centers directors about the roles of WHVs, at the beginning of their responsibility
	Reforming policy	• Reducing the number of households covered by WHVs • Prioritization of the WHVs program in health centers
	Using social networks	Setting up an online or telephone system about WHVs problems in order to receive their complaints and comments
	Allocating proper resources	• Providing the necessary facilities for WHVs • Allocating independent budgets to health centers for WHVs training programs • Employing healthcare workers with high responsibility and high commitment as being responsible for health volunteers • Recalculating the health care worker workload and changing the number of employees if necessary
	Improving intersectorial collaboration	The use of facilities of other related organizations for educational programs
No consensus	Reforming policy	Replacing WHVs program with Health Ambassador program
	Implementing problem-based approaches	Referring WHVs’ problems to higher levels
	Assessing the needs of people/WHVs	Educational needs assessment and prioritization of issues in health centers
	Empowering WHVs/trainers	Teaching the main principles of management to health center directors

Abbreviations: Q, question; WHV, women health volunteer.

Table 10 Strategies for lack of motivation and organizational support: Q.9. Which intervention approaches are needed to improve the motivation of health volunteers and their supervisors?

Consensus status	Theme	Possible solutions
Consensus	Implementing motivation tactics	• Developing material and spiritual support programs to encourage trainers • Free visits for WHVs and their family members by the health center physicians • Holding recreational competitions among WHVs • Developing material and spiritual support programs for the WHVs • Showing appreciation to WHVs in the workplaces • Promoting the motivation of WHVs and employees based on Maslow’s hierarchy of needs • Providing pilgrimage and recreational tours for WHVs
	Implementing problem-based approaches	• Applying problem-solving approach • Prioritizing the health problems of WHVs by the health centers and supporting them
	Improving intersectorial collaboration	Using the community potential such as collaboration of WHVs with Basij to support-deprived areas
No consensus	Rationalizing WHVs/trainers/people	Implementing an educational course for directors of health centers about how to motivate healthcare workers and WHVs
	Implementing motivation tactics	Providing a monthly fee as an allowance to volunteers

Abbreviations: Q, question; WHV, women health volunteer.

Table 11 Strategies for educational failure: Q.10. How can we overcome educational failure?

Consensus status	Theme	Possible solutions
Consensus	Empowering WHVs/trainers	Updating educational materials for WHVs
	Monitoring and evaluation of WHVs/trainers	Continuous monitoring of WHVs training programs
	Improving group work	Practicing teamwork on training WHVs
	Reforming policy	Setting the curriculum based on the level of education and the culture of the region
	Mobilizing the community	Supplementing existing educational capacity in the community
	Allocating proper resources	• Providing educational resources for health volunteers (hard and soft copies) • The seriousness of supervisors to implement training programs • Reducing the routine responsibilities of the WHVs’ supervisors in order to assign more time to train WHVs • Providing an appropriate training environment for WHVs and clients • Leveling the WHVs and providing educational content based on different levels of health volunteers • Providing transportation facilities for WHVs
	Assessing the needs of people/WHVs	Educational needs assessment before starting educational programs
	Using social networks	The use of social media such as telegram by center trainers
No consensus	Allocating proper resources	• Provision of necessary educational equipment for training WHVs • Using trainers who create motivation among WHVs
	Reforming policy	Considering a level of education for recruiting WHVs
	Empowering WHVs/trainers	Determining the level of practical skills (after the needs assessment) before starting the training

Abbreviations: Q, question; WHV, women health volunteer.

Table 12 Mann–Whitney U test comparing groups (WHVs’ supervisors and researchers) around no consensus strategies

Questions	Suggested strategies (no consensus)	Median	IQR	U	P-value
Q.1.	Organizing question and answer sessions regularly with WHVs The use of educational software such as Health Ambassador software Demanding from health volunteers to attend health centers in order to directly observe service delivery system Engaging the health volunteers with a higher educational level Employing a health trainer who lacks organizational responsibility	5 5 5 5 5	1.75 2 2 2 2	83.5 87.5 98.5 109 114	0.189 0.254 0.487 0.789 0.951
Q.2.	Conducting educational classes for WHVs about communication skills Dividing responsibilities among WHVs and providing feedback to them Conducting educational courses outside the health education series for WHVs The ranking of WHVs in terms of diverse skills as an incentive to promote rank Assigning more time to train the WHVs by trainers	5 5 5.5 5 5	2 2 3 1.75 1.75	48 110.5 93.5 99.5 100	0.006a 0.838 0.371 0.514 0.525
Q.3.	Putting health information and health-related indicators in the hands of community members Family referrals to WHVs by health personnel in some cases Assigning the delivery of some basic health services to WHVs, such as blood pressure screening	5 5 5.5	1.75 2 2	96.5 34 98.5	0.431 0.001a 0.489
Q.4.	Employing the healthcare worker who is more compatible with the roles of WHVs Establishing a sociology workshop (in order to get acquainted with the culture of the community) for WHVs and healthcare workers	5 5	2 3	79.5 104	0.139 0.638
Q.5.	Educating influential people with a focus on reducing barriers and supporting them Conducting some meetings with the participation of local community members to express their problems in the presence of other people	5.5 5	2.75 2	84 99.5	0.198 0.507
Q.6.	Recruiting people as health volunteers who do not expect any rewards from the health system Efficient implementation of the WHVs program in city centers due to lack of full knowledge of urban healthcare workers about their community members Questioning the WHVs about the services that were provided to the households covered	5 5 5	3.75 2 2	100.5 63 84	0.544 0.032a 0.194
Q.7.	To clarify the role of WHVs for all organizational units Creating job stability and not changing the trainers who educate the WHVs Establishing NGOs or associations for WHVs	5.5 5 5	2 2.75 1.75	95 17 97	0.398 0.000a 0.445
Q.8.	Replacing WHVs program with Health Ambassador program Teaching the main principles of management to health center directors Educational needs assessment and prioritization of issues in health centers Referring WHVs’ problems to higher levels	4.5 5 5 5	2.75 1.75 1.75 2	101.5 83.5 99.5 99	0.572 0.187 0.5 0.489
Q.9.	Providing a monthly fee as an allowance to volunteers Conducting educational courses for directors of health centers about how to motivate healthcare workers and WHVs	5 5	2 2	83.5 96.5	0.187 0.426
Q.10.	Provision of necessary educational equipment for training WHVs Using trainers who create motivation among WHVs Considering a level of education for recruiting WHVs Determining the level of practical skills (after the needs assessment) before starting the training	6 5.5 6 6	2 2 2 2	102 104.5 94 106.5	0.569 0.636 0.343 0.706

Note:

a Statistically significant (P<0.05).

Abbreviations: IQR, interquartile range; NGO, non-governmental organization; Q, question; WHV, women health volunteer.