Why People Choose to Volunteer? Women Health Volunteers’ Activities, Reasons for Joining and Leaving

Abstract

Introduction: Women health volunteers are the link between people and healthcare workers. They play an important role in health education activities, following up families under coverage, and updating the demographic data to health centers. This study was performed to uncover women health volunteers’ activities, reasons for joining and leaving from the program.

Methods: A qualitative study design was used to conduct the study. Through purposive sampling technique, twenty -four in-depth semi-structured individual interviews and two focused group discussions with women health volunteers and their supervisors were conducted in Tabriz, Iran. Data analysis implemented thematic analysis, using MAXQDA10.

Results: The findings were generally categorized into three major themes, participation in promoting health, perceived benefit, and perceptual- environmental inhibitors. Participation in promoting health consisted of the sub-themes participation in educational programs, participation in health care. The sub-themes of perceived benefit included benefits from health care services and interest in having an active role in the community. The theme perceptual- environmental inhibitors involved the subthemes participation barriers and lack of innovation and inconsistency with social changes.

Conclusion: Culture-building about the role of health volunteers, the valuing on their activities in the community, and informing program supervisors about the health volunteer’s duties would help to retain health volunteers and also sustain their activities at the community level.

Introduction

Women constitute approximately half of the population of Iranian society. Despite their capabilities, scientific, cultural and social competencies, they do not generally have suitable or satisfactory positions in health decision makings.¹ Today, social partnership is considered as the core of development.² The use of active participation of women in health activities leads to improvements in their own and their familys’ knowledge, attitude, behavior.³ and emotional, social and physical well-being, as well as in sustainable development.⁴

Women engaging in health development activities might be done through volunteering or participating in community based activities.⁵ Women health volunteers (WHVs) play an important role in identifying health hazards, helping patients reduce risk behaviors and choosing a healthy lifestyle in community.⁶ The WHVs program, as a government-based voluntary action, is a national initiative that was launched in 1999 in the Islamic republic of Iran.⁷

Health volunteers are considered as interfaces between health centers and marginalized or rural immigrants or people living in the slums.⁸ WHVs may play an effective role in empowering the community for a variety of reasons, for instance through continuous contact with families and sharing cultural, economic, and social similarities with them.^6,9 The evaluation and assessment of the WHVs programs during the years 1995-2002 in Iran showed that the health indicators had improved from 20 to 25 percent mainly due to the activities of health volunteers.¹⁰ additionally, the studies have shown that the activities of health volunteers have been effective in reducing maternal and child mortality, as well as, increasing the rate of contraception in Iran.¹¹

Women health volunteers are generally invited from among those living in the area, being literate, being regarded as socially acceptable, and having the interest and incentive to engage in social activities.¹² each health volunteer is assigned to cover 50 households in her neighborhood as their duties and responsibilities as a health volunteer. The Ministry of Health asserts that health volunteers have the responsibility and duty to participate in health education activities, weekly training sessions, under coverage household members follow-ups and updating demographic information.¹¹ In recent years, extensive urbanization, changes in the political perspective of the Ministry of Health have changed the type of WHVs activities.¹³ At the moment, the main challenge is how to maintain WHVs and how to keep their activities resistant despite the important role of health volunteers in providing health services. Several studies have shown that useful education, respect, family and community appreciation are influential factors on retention and sustainability of health volunteers.^14,15 As well as, experiences throughout the world have shown that reasons for leaving included lack of community support, respect and negative attitude of community members, lack of means of transport.¹⁶

Women health volunteers are the most important communication chain between the healthcare workers and community, failure to pay attention to this will lead to the Wasting of expenditures spent on their training and will have a negative impact on the dissemination of health information and health indicators.¹⁷ despite the success of the WHVs program, the stability of WHVs participation has been reported to be insufficient in the long run.¹⁸

Furthermore, in recent years many health volunteers have broken off their cooperation with health centers in Iran.¹⁹ Nevertheless, during the 24 years of program implementation, research has not been conducted on the analysis of the change of health volunteers’ activities, reasons for joining and leaving the programs. This qualitative study was performed to clarify health volunteers’ and their supervisors’ experiences about their activities, and the reasons for their joining and leaving of women health volunteers program.

Materials and methods

This qualitative study, using thematic analysis methodology, was conducted in Tabriz health centers, Iran, from January 2017 to March 2017. A purposive sampling technique with a maximum variation in characteristics such as the age, gender, education was applied. Women health volunteers were identified based on their list at the health centers and were invited to participate in the study by telephone. Finally, thirty- four individuals participated in this study. Of these participants, twenty-four individuals attended the semi-structured interviews, including nine active health volunteers, eight inactive volunteers and seven program supervisors. Furthermore, two focused group discussions were conducted with five health volunteers and five program supervisors. The interviews were continued until no new data could be found to develop new categories.²⁰ Data saturation was reached after about 20 interviews, but four additional interviews were completed to make sure that no new themes developed. The participants were included if they had at least one year of ongoing and regular collaboration with the health volunteers program, and were willing to participate in the study. The volunteers under 18 years of age and those living in other cities were excluded from study. According to the protocol of Krueger & Casey, data were gathered through individual semi-structured interviews and focused group discussions.²¹ all interviews were recorded by a voice recorder. Immediately after the completion of each interview, the audios verbatim were transcribed as text. The time for individual interviews was approximately 50 minutes and the focused group discussion lasted for about 70 minutes. At the end of the interviews, the participants were asked to notify us if anything had been missed out, and they were also informed about possible future interviews. The time and place of the interview were determined according to participants' preferences, therefore the interviews were conducted in health centers.

A number of open- ended questions was designed as an interview guide, probing questions was asked based on responses of the interviewees if the answers were not complete. The interview and focused group guide included informants about women health volunteers’ activities, their reasons for joining and leaving the programs. Data analysis was done, using thematic analysis method. A six-stage thematic analysis framework was used for data analysis and theme emergence.²² The researcher conducted the following actions in the six stages of thematic analysis: in the first phase (getting familiar with data), the transcribed the interviews and reading the transcripts were read out with the aim of immersion in the study data so as to form a general ideas of the interview.

In the second phase (Generating initial codes), the units of meaning were extracted from the text of the interviews and organized data into initial codes. The third phase (searching for themes) was carried out with the aim of sorting the initial codes into themes, in other words, similar codes were categorized into a category under the theme. In the fourth phase (reviewing themes) the themes were reviewed and refined. In the fifth phase (defining and naming themes), the researcher involved ‘refining and defining’ the themes and subthemes for a story to emerge from the themes. In the last phase (producing the report), the researcher transformed the analysis into an interpretable part of writing. Management of the textual data was done, using MAXQDA10.

Strategies to ensure the trustworthiness of the finding were taken from the strategies illustrated by authors such as Guba & Lincoln.²³ Dependability was achieved through stepwise replication, code-recode strategy, audit trail, peer examination the use of peer debriefing, prolonged engagement and member checking and negative case analysis contributed to the credibility of the study.

Conformability was also achieved by the researcher keeping all records and transcripts and auditing. A through description of the research methodology was provided for the purposes of conformability. The quality of this paper was evaluated, using Consolidated Criteria for Reporting Qualitative Research.²⁴

This study was approved by the Ethical Review Committee of the Tabriz University of Medical Sciences (IR. TBZMED. REC: 1395–1038) and was supported by the Tabriz University of Medical Sciences (grant number 1001970- 25/01/2017). After explanations about the aims, the method, recording interviews, and keeping responses confidential, written informed consent was obtained from all participants. Participants were permitted to leave the research at any stage.

Results

The mean age of the participants was 40.9(10.6) with the range of 19 to 62 years. About 91.1% were females. A total of 14.7% of the informants had a master's degree, 47% had bachelor's degree, and 38.3% had high school diplomas and lower. The WHVs activities and their reasons for joining and leaving the WHVs program were categorized into three major themes: participation in promoting health, perceived benefit, and perceptual- environmental inhibitors. Each theme contains several sub themes that are listed in (Table 1).

Table 1. Women health volunteers’ activities, reasons to joining and leaving .

Category	Theme	Subthemes	Codes
Women health volunteers’ activities	Health promotion activities	Participation in educational programs	Participation in the implementation of health campaigns, involvement in providing educational materials, increase inter-sectoral partnerships to carry out health educational activities
		Participation in health care	Census and vital statistics collection, identifying and solving neighborhood problems, identification of patients with certain diseases
Reasons to participate in the WHVs program	Perceived benefit	Interest in having an active role in the community	The desire to community education, communicating with other community members, distinguishing from others
		Benefit from health care	Benefit from rewards, hoping to be hired in the health system, desiring to learn about health, using from side incentives
Reasons for leaving the WHVs program	Perceptual- environmental inhibitors	Participation barriers	Immigration from the area covered by the health center, caring for children, husband's dissatisfaction to continue the partnership
		Lack of innovation and inconsistency with social changes	Wrong beliefs among people, not prioritizing health issues for health system and people, lack of diversity in activities, expanding cyberspace

Participation in Educational programs

The WHVs and their supervisors reported providing educational support to community members, including participation in the implementation of health campaigns, involvement in providing educational materials, public information about health center activities, increasing inter- sectoral partnerships to carry out health educational activities, encouraging people to receive services from health centers, attracting women health volunteers from among people.

Health volunteers’ supervisors organized weekly meetings for the health volunteers, and trained concepts of health and primary health care.

“Instructors in the classroom discuss the necessary HIV/AIDS issues or any other useful current programs and we ask questions at the end of each session”. (P 10)

Health volunteers explained providing individuals and group education through lectures, individual counseling, and face to face education. In other words, they believed in serving as links to health centers and community members. Health volunteers transmitted such education to their families, friends and relatives.

“We talk to people around us about problems such as AIDS, stressing that if they want to stay healthy, they need to pay attention to such matters. We transfer information about the heart, lungs and breast cancer”. (P 8) “I work a lot in the field of volunteers, I keep brochures in my handbag, and when appropriate I distribute them among my family members and relatives”. (P 1) “The breast education curriculum was divided into six- month education. One of the volunteers asked for all of her education topics and instructed in the mosque after prayers and recitation of the Quran”. (P 10)

Participation in health care

According to the participants we interviewed, health volunteers also collaborated with health staff in census and vital statistics collection. Health volunteers stated engaging in health center programs, such as family physician program, identifying and solving neighborhood problems, identification of patients with certain diseases to provide support to community members.

“I took part in the family physician program two yearsago,I’ve designed and invited people to complete the case”. “Recently, at some centers, health volunteers resolved certain problems with each other in some areas such as sewage and waste, and provided a place for women sports”. (P 6)

Perceived benefit

Benefits from health care services

Although the health volunteer program is implemented without paying salary or regular rewards, some participants remarked that incidental incentives (such as free visits) for health volunteers and their family, and benefiting from such rewards further enhances their motivation to work. Some participants believed that health volunteers collaborate with the program, hoping to be ultimately hired in the health system through participation in health center activities.

The majority of respondents mentioned a desire to learn about health as an important motivator to join the health volunteer programs. The respondents believed that health volunteers’ presence in class improves their knowledge and awareness. One of the health volunteers said they had joined the health volunteer program to learn what to do in case a disease broke out.

“They gave us the pool card as a gift and took us to the mountains because my husband didn’t have time, for these I signed up”. (P 7)

The weekly meetings created fun atmosphere for WHVs, the group provided opportunities that women could easily interact with each other. This was one of the reasons for participation.

Interest in having an active role in the community

A number of health volunteers mentioned the desire to train their community members as an incentive for them to get involved in the health volunteer program. There were several reasons for desiring to educate, for example, increasing the awareness of neighbors, an interest in health education activities and the health problems of one of the volunteer’s relatives.

“I chose to come here, because, that way, I both learn what I did not know and teach people, that's why I join”. (P 9)

The health volunteer program provided opportunities for social contact. The participants believed that being in the community would make volunteers feel better mentally, so that one of the health volunteers said that she joined the program because she was depressed at home, and communicated with other community members through this program.

“The reason for volunteering is that they like to be in the community and prefer to collaborate in health care with health workers” (P 13). Being distinguished from others and helping to cure diseases were other reasons for some women joining health volunteers.

Perceptual- environmental inhibitor

Participation barriers

The most frequently stated reasons which stopped health volunteers from keeping working included aging, getting married and getting pregnant. “One of the volunteers gave birth to a baby; unfortunately, her child was disabled, so she left the program” (P 3).

Another reason for leaving was that many of the health volunteers were busy studying at Universities/schools, or had a health problem of some kind. Immigration from the area covered by the health center was an issue for most health volunteers. Living in a place away from the health center and heavy traffic were among the problems raised.

“The volunteers who leave the program at our health center were due to immigration from the area” (P 12).

The health volunteer role may be time-consuming; therefore, health volunteers cannot do their other roles, such as caring for children. This was the primary reason of leaving for health volunteers who had children and needed more time to attend to them.

“The problems were the kids; we had to discontinue our attendance because we had a child in the last grade ofhighschoolin the family”. (P 4)

The activities delegated by the health centers could act as a reason for the volunteers discontinuing their attendance if they called for the health volunteers showing up in households for the provision of their services (e.g. health education). Many men would not allow their spouses to do so and, therefore, the women in question had to stop participating in the program. Another reason for discontinuing was marriage, “she left and simply said ‘I got married and my husband does not allow me’”. (FGD 1)

Although lack of monthly salary was not a reason to leave the health volunteers program, some participants chose to leave when they were not encouraged by health centers. Some underlined their lack of incentives, saying that adequate facilities were not being allocated.

Lack of innovation and inconsistency with social changes.

The participants explained that there are multiple reasons why community members do not welcome the training provided by health volunteers, for example, some wrong beliefs among people, not prioritizing health issues for people, people's lack of trust in health volunteers. In other words, the lack of importance of health volunteers in the community disappointed them: “People think that such issues are time consuming and that they already have enough information. For example, they say that everything there is, whether edible or not, ishormonicand that's why they see no reason why anyone should explain such matters to them. In other words, they claim they know what to do”. (P 5)

Inactive health volunteers described health centers they had previously joined, where women health volunteer program was not a priority, nor were they respected. According to the participants, this was the reason for some health volunteers leaving the program. Participants expressed that it is illogical to expect active volunteers, when the health volunteers do not consider their activities to be important.

Lack of diversity in activities and the repeated topics of weekly training was another factor causing the volunteers to withdraw from the program:

“They (WHVs) participate in the class for several months and say that the content is duplicate and repetitive and then rarely can we see them again in the classroom”. (P 4)

Some participants stated that cyberspace has expanded and health issues are easily accessible to the public, therefore health volunteer program was not useful for the community.

“Virtual tutorials are easy and accessible to people. Anytime and anywhere they can access it and they usually prefer virtual tutorials to classroom”. (P 6)

Discussion

This study aimed to explain the activities, and reasons for women health volunteers joining and leaving the WHVs programs in the city of Tabriz, Iran. The findings were categorized into three major themes: participation in promoting health (activities), perceived benefits (reasons for joining) and perceptual- environmental inhibitors (reasons for leaving).

The functions of health volunteers in Iran are fewer compared to other countries. For example, Thailand’s village health volunteer plays a significant role in the community & at organizational levels (e.g. initiating community building activities) and at policy levels. They also cooperate in many activities with the health system, such as empowering communities, and providing social & emotional supports.²⁵ International experiences have shown that health volunteers can be encouraged to participant in Health center activities if they have a greater role in health system. Maybe if collaboration and relationship between health volunteers and health workers were strengthened, we could expect more activity from the WHVs.

As the results showed, health volunteers carried through two out of their three responsibilities and only failed to accomplish “follow-up household members under coverage” task .It may be due to old instructions, because more than two decades have passed since the health volunteers instruction was designed by the Ministry of Health and the community lifestyle, during which many things have changed (such as the expansion of apartment life). Nowadays, because this task requires the presence of health volunteers at households covered, they are not willing to do it, any more.

Our analysis revealed “perceived benefit” theme as the main reason for joining the WHVs program, it seems that the level of development of communities is plays a role in shaping the people’s motivation to participate in voluntary activities. For example, in a study conducted in Kenya and Nepal, the use of financial benefits was one of the reasons determining the cooperation of health volunteers,^26,27 while a qualitative research in the UK showed that, the use of financial benefits was not mentioned as a reason for the participation of people in the voluntary activities.¹⁶ In developing countries, the reasons for joining can be guided towards non-financial benefits by the provision of people's basic needs and culture-building through mass media.

Although there are no financial benefits to the health volunteers in the Ministry of Health guidelines, the findings of this study showed that some of the volunteers are joining the WHVs programs in order to use the side benefits of the program (such as free visits or other health care services). Policymakers can incorporate appropriate health services as incentives for health volunteers in the guidelines. Given that some studies have shown that the provision of financial incentives may have a negative impact on the health volunteers,²⁸ providing alternative rewards such as free visits or holding competitions and awarding prizes can draw people's attention to participate and join the health volunteers program.

Many participants expressed an interest in having an active role in the community as the reason for joining. On this basis, it can be said that an individual development bonus may be a substitute for direct financial rewards which would lead to the acquisition of knowledge and skills.²⁹ Studies conducted in the Iranian society show that women have been seeking social mobility and trying to reach higher in the social hierarchy over the recent years; however, the existence of cultural and social barriers in the society and the lack of job opportunities for women have led to a very low level of employment for them. For this reason, women in such societies show their presence in the community by participating in voluntary and community-based programs such as the WHVs program.

Our analysis showed that the perceptual- environmental inhibitors were the main reason for the health volunteers to leave the WHVs program. One of the reasons behind this inhibitor is lacking the importance of the WHVs program in the eyes of health system officials. Furthermore, many perceptual- environmental inhibitors to women's participation in the community might have their roots in the social and cultural structure of Iranian society. These inhibitors can be overcome by reorganizing the WHVs program (according to cultural conditions), identifying and modifying people’s wrong beliefs, and developing the culture of volunteering in society, especially among men.

Based on the findings, one of the main reasons for the people joining the WHVs program was the increase of social interactions. On the other hand, in their attempts to take on the new role of health volunteers, they get disheartened and lose interest when they are faced with cultural and social barriers, alongside disinterested people, and thus they get discouraged from participating in this program and according to theory of role accumulation, they even lose overall status security.²⁵

Individual and family problems are one of the unavoidable issues; this is one of the reasons for the volunteers leaving the WHVs program in current study.

It seems that multiple roles play a major role on the volunteers leaving the WHVs program, because a health volunteer as a married woman is more involved with her responsibilities, and thus she has a role conflict. Additionally, according to a research carried out by the Iran’s Vice Presidency for Women and Family Affairs, women feel more responsible for taking care of their children and treating a husband.³⁰ These factors cause the women to leave the volunteer activities. By diminishing gender stereotypes, it can be expected that women's social participation will not decrease after marriage.

Conclusion

Health volunteers can play an important role in advancing the goals of health programs, for instance, they can help provide educational content in the family physician program. . Only the financial benefits are not the reason for joining or leaving of the people from WHVs program, through measures such as culture-building about the role of health volunteers and valuing their activities in the community, the retention and sustainability of women health volunteers' activities might be more easily managed. It is also necessary to inform program supervisors about the health volunteer’s duties, their importance and their role in the community.

In this case people will choose to be a volunteer with more awareness. This study provided a framework for reviewing the WHVs program guidelines by policymakers. These guidelines should be designed based on the cultural structure and social norms of Iran. Moreover, the motivational factors such as providing health services to health volunteers, transportation facilities for volunteers, new technologies, giving more roles to health volunteers and social change should be equitable. This research was carried out in Tabriz city so it cannot be generalized to other parts of Iran.

In this study, the WHVs program supervisors and health volunteers of Tabriz city participated and WHVs and Their supervisors were not studied in Tabriz villages.

Acknowledgments

We really appreciate deputy of research and technology for their valuable supports. We also are most grateful for the assistance given by the facilitators and participants.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study.