Providing and promoting health-oriented services by nongovernmental organizations: A qualitative study

Abstract

BACKGROUND:

Benefactors of nongovernmental organizations (NGOs) are the hidden public health promotion systems. These benefactors are the symbol and intermediary of people participation, which is one of the main arms of health promotion and reduction of poverty and injustice in the societies. The present study is aimed to identify the benefactors’ experiences in NGOs in terms of providing and promoting health-oriented services.

MATERIALS AND METHODS:

This study was conducted with a qualitative approach. The total number of participants was 32, which consisted of 25 chief executive officers from active and inactive organizations. Active organizations refer to organizations that submitted their 6-month report at the time of the investigation and whose operating license was renewed and in operation and seven officials of the social deputy of governmental organizations related to NGOs. Data collection was performed by using semi-structured interviews and with purposive sampling and then continued until data saturation. Furthermore, the content analysis method was used for data analysis. MAXQDA software version 2007 was used to manage quality data.

RESULTS:

During the data analysis, the following four subcategories were obtained: “high effort in empathy with fellow human beings,” “role of merit in the success of donors,” “creating a platform for social attention for the client's spontaneity,” and “respect of the client,” which were the results of experience and dimensions. The performance of non-governmental organizations is in line with the confrontation and responsibility of non-governmental organizations with a focus on health-oriented services.

CONCLUSION:

Having benevolent motives, benefactors attempt to provide conditions, in which help seekers have more chance for living through establishing new, sustainable, and future-reassuring conditions.

Introduction

Nongovernmental organizations (NGOs) are the symbol and intermediary of people participation, which is one of the main arms of health promotion and reduction of poverty and injustice in the societies. Experiences of both developed and developing countries during more than half a century have proven the necessity of such organizations more than ever.[1] The importance of the existence of civil society as the missing link of development and environment in which the public participation is formed, was known as a necessity in the 1980s.[2] In the heart of the civil society, NGOs were recognized as the best and most important ways for people's organization and participation.[3] The term “civil society” has received much attention since the classical period. However, this could cover a new class of actors that is different from the government but operates within its capacity within the government.[4,5] The term of “civil organizations” versus government refers to the area of social relations that is free from the political power interference, indicating the extent to which the society defends its demands against the government.[6,7] In the 1990s, the health-related reforms reduced the share of the social values compared to the economic and managerial values of health services, which was accompanied by a reduction in the budget allocated to the public health as well as the quality of health services. Therefore, countries’ tendency toward providing services through civil society and supporting the basic right for health as well as access to the health resources increased consequently.[6] Global public–private partnerships for health have gained traction over the past two decades, enabled by the rising NGO participation.[8] In Iran, the number of NGOs has increased from 2000 in 1997 to 10,250 in 2005 and then reached above 17,000 in 2011. Articles of Fourth Development Plan have emphasized the presence and participation of NGOs in the development plans.[9] According to the biosocial theory, similar individuals would have more altruistic behaviors toward each other and then such a motivation would lead them toward helping others. Regarding this point of view, helping a fellowman is a social norm and individuals help each other based on a social convention.[10,11] In terms of assistance, norms of social responsibility are mainly related to the fact that an unfavorable situation is resulted from the conditions or factors that are out of the help seeker's control and the indigent individuals have not caused the problems consciously and based on their knowledge and awareness.[12,13,14] One of the World Health Day plans, entitled “A Thousand Cities, A Thousand Lives,” is to gather the policymakers, communities, and individuals in order to take into consideration health as a priority in urban policymaking. That plan is aimed to take actions at various levels demonstrating that governments require inter-sectoral interventions as well as social support to overcome health-related challenges in cities. All activities should be planned and implemented with participation of interested NGOs, society's representatives and groups, universities, and research institutes.[15] Furthermore, all the planned activities should be based on the local contexts such as traditional cultures, capacity, available resources, and local needs in each city. While many people are working sporadically in the field of health, some others are interested in being influential on their health status and other people.[16] Understanding global health as a complex system of power relations in which actors use financial capital, expertise, and moral authority to pursue career and professional and organizational interests,[11,17] it is clearly important to delineate the social and political dynamics of civil society engagement within this system. Although the value of civil society and NGO participation is almost ubiquitously endorsed, there is little research about contemporary global health governance mechanisms and participation of NGOs.[18,19,20] Regarding the importance of the role of public participation as NGOs in promoting the society's health and, in particular, concerning the fact that there are only few qualitative and quantitative studies on NGOs and experience of benefactors with various fields of activity, we were motivated to investigate the benefactors’ activities in NGOs and their experiences in these organizations in terms of providing health-oriented services and also achieve a better recognition of help seekers’ problems, solutions for helping them and earning their trust, solutions for obtaining authorities’ trust, and solutions for absorbing the benefactors outside the organization.

Materials and Methods

Study design and setting

During recent decades, various types of content analysis have emerged attempting to use the principles of this method in combination with the assumptions of various theoretical approaches. Content analysis is used in various fields including communications, sociology, psychology, medicine, and health. Although qualitative research is of special status in health sciences nowadays, it is not a new idea in social and behavioral sciences. The use of qualitative methods for study human phenomena is originated from the social sciences because some aspects such as values, culture, and human relations could not be fully explained by quantitative methods. On the other hand, inefficiency of quantitative methods in responding to some questions and challenges of social environments, in which human's suppositions and interpretations play some roles, has made the qualitative methods to transmit to social environments. In order to properly care for their client, all health teams need to understand their experiences and perspectives and understand the basic processes that illuminate health and disease events.

Sampling

Purposeful sampling was performed initially followed by maximum variation sampling method; choosing the samples out of active NGOs with various fields of activity, inactive NGOs, and authorities of social deputies, within the theoretical sampling, resulted in an increase in data credibility.[21] In the present study, the basis of purposefulness was the homogeneity of the target group with maximum diversity. The initial participants were purposefully selected from among Kerman health donors who were willing to participate in the research and were able to express their experiences. Then, it continued with the snowball method. Sampling was continued according to the inclusion criteria and gradually until data saturation.

Inclusion criteria

Having at least 4 years of experience in NGOs and having at least 4 years of service in governmental organizations related to licensed NGOs, with at least 4 years of executive management experience and expertise in the field of NGOs. Furthermore, analysis of each interview's output was a guideline for selecting the subsequent samples. We continued sampling until obtaining a new idea along with sampling. In other words, the sampling was continued until achieving data saturation so that no new information was obtained from the existing interviews.

Ethical considerations

This article is part of the doctoral thesis on health education and health promotion with ethics code of IR-TUMS.SPH.REC.2016-502. After obtaining the permission from Research Council and Ethics Committee of School of Public Health, Tehran University of Medical Sciences, the recommendation letter was received. Then, by referring to the organizations where the licenses for NGO activity is issued (governorship, social welfare, and youth organization) and obtaining their acceptance, we investigated the names and statutes of NGOs and completed the checklist while considering the confidentiality of their personal information and other details of the statutes. Afterward, by having a phone communication with the chief executive officers (CEOs) of the NGOs initially, the research objective was explained and then in case of agreement, the time and the place of interview would be determined. At the beginning of each interview, the informed consent form for interview and recording the conversations was obtained and then the confidentiality of information was considered through and after interview. In addition, the participants were ensured that, in case of request, they would be provided with a copy of the recorded information as well as the interview transcripts.

Data collection

Data collection was performed from February 2014 to January 2015 using semi-structured interviews which are appropriate for qualitative studies due to their flexible and in-depth nature Primarily, the general questions were presented to NGO's CEOs and then the interviews’ procedure was directed based on the answers to the questions about participants’ experiences on activities in the NGOs and experiences of NGOs in providing health-oriented services. Then more questions were asked about the problems of help seekers, support measures for clients, approaches to gain the trust of help seekers, support from officials and donors. Finally, the data were analyzed with respect to the questions asked.

Data analysis

Considering the participants’ informed consent, all the interviews were performed and simultaneously recorded, transcribed, typed, reviewed, encoded, and immediately analyzed. Data collection was performed through face-to-face, semi-structured, and in-depth interviews. The recorded interviews were listened carefully and the transcripts were reviewed for several times and then they were encoded and analyzed [Table 1]. Data analysis was performed using conventional content analysis method because this method helps to clarify the themes and the apparent and hidden patterns from the content of participants’ data.[21] In order to perform the initial encoding, the participants’ words and the implicative codes (researcher's impression of the words) were used and then the next interviews were performed subsequently. After encoding and summarizing the data, the codes were categorized based on the similarities and differences and afterward the categories were compared with each other. Moreover, analysis and interpretation of data resulted in extracting more abstract themes or subjects.[22] To evaluate validity, accuracy, and reliability of the qualitative data, the measures of credibility, conformability, dependability, and transferability were used, and the participants reviewed the accuracy of their own statements in the transcripts. Data credibility was achieved by allocating enough time for data collection, prolonged engagement in the project, good communication with participants, and obtaining their trust. Furthermore, maximum variation sampling method (choosing the participants with various fields of activity) and also sampling from the active and inactive organizations during the research and from the experienced authorities and experts in the social deputies of the governmental organizations led to the improvement of data credibility. The transcripts and also the extracted codes and categories were approved by six faculty members who are experts in conducting qualitative research and then their complementary comments were used to determine the findings’ confirmability. Further, the findings’ dependability was achieved by quick prescribing and providing similar situations for the participants. Accordingly, the data transferability was confirmed. Finally, a rich explication of data was provided by conducting interviews with different participants and by presenting their direct quotations.

Table 1.

An example of inferring codes and categories from semantic units

Row	Semantic units	Summary	Codes
1	We hold regular discussions and sessions on the skills of life for families and children separately. The psychologist regularly talks to children and parents over the phone. For example, there is a child who doesn’t have mother and we frequently contact the family. Thus, we are not only in contact with the help-seekers and they are followed within their family as well	The psychologists have trainings on life skills for families and children and we regularly communicate with children and parents and try to follow-up them within the families	Attempts to empower the help seekers and their families through training the life skills Follow-up the help seekers within their families

Results

In total, 32 participants were interviewed in the present study including 20 CEOs from active NGOs which received their license from one of the social deputies of governorship, welfare organization, or youth and sports department, 7 participants who were responsible for social deputy before or during the research, and 5 participants from registered NGOs which had become inactive during the research. These interviews led to several subcategories including “high ambition in sympathy with help seekers,” “role of competency in the success of benefactors,” “providing social context for help seekers, spontaneity,” and “reverence and respect for help-seekers” [Table 2].

Table 2.

Formation of final theme from other subthemes

Main category	Subcategory	Primary categories
Service oriented in the health	High effort in empathy with fellow human beings	Presence of thoughtful or agonized individuals
		Sense of responsibility for social problems
		Education and training with long and difficult courses
		Dynamic determination for following up help seekers
	Role of merit in the success of benefactors	Use of opportunities
		Deriving ideas from successful projects in other places
		Strategies for absorbing capitals
	Creating a platform for social attention for the client’s spontaneity	Social rehabilitation of help seekers
		Education with the aim of solving the help seeker’s problems
		Considering all-inclusive needs of help seekers
		Concerns about the future of help seekers and follow-up
		Social entrepreneurship
	Respect of the client	Considering minimum citizenship rights
		Respect for help seeker’s privacy

Service oriented in the health

The main theme of the present study was the client-friendly city. In our organization a woman is retired but she wants to work voluntarily. The benefactors who want to work on social pathology provide the solutions themselves and express that they are capable of doing the job This woman, who was an employee of Education Ministry, buys the raw materials for making handicrafts by the disabled women at their homes” (participant no. 2, the CEO of an active NGO). During the new year holidays, I was in the south of Kerman, Iran (Jazmurian and Rudbar; very warm and dry places). Using a preventive approach in Education Organization and Health Network, more than 1000 children under age of 7 years old were selected and underwent fissure sealant and fluoride therapy by dentistry students. Those tasks were so difficult because devices did not work properly in that warm weather conditioned was broken easily. The students worked very hard to finish the job during 2 weeks (participant no. 18, a CEO and responsible authority).

High ambition in sympathy with help seekers

Benefactors are individuals who feel responsible for various social problems, try to enter different social areas, and do not hesitate in this regard. As soon as the project was started, I traveled to every city and town. You know, at that time, we had many obstacles. For example, Sepah stated, They are going to initiate public forces while we have the same forces. Committee of Promotion of Virtue said, You want to promote virtues while it is our duty. Friday Prayers Imams said, What does Ministry of Justice have to do with people? I mean, there were such obstacles. Further, some foreign networks such as Israel Radio and BBC have announced that they are going to establish a judiciary organization in order to penetrate among the people and obtain information about them, just the same as an intelligencer (participant no. 14, as a former CEO [an inactive NGO]). The benefactors use all of their monetary, spiritual, physical, and mental experience in order to salve other people's injuries and to palliate others’ pains: We have limited facilities, but we try to provide the best services. We wish we could give food to all children, but it is impossible. When we see that there is no meat or chicken in the children's breakfast dishes, we buy it ourselves. We also provide nuts and fruits for children when they are here for two meals. We even buy the clothes. That is all we can provide” (participant no. 4, an active CEO). Each benefactor, regarding his/her capabilities, spiritual knowledge, and interests in a certain and specific context, feels responsible and focuses on a wide range of social problems and harms. We have established a center for cancer researches in order to study the new pathogenic factors and causes of cancer. Are the rumors about the poisonousness of cucumber and tomato really true or not? For example, we sent some cucumbers to Tehran, the capital city, for testing and some of them were showed to be poisonous (participant no. 19, an active CEO). However, they mostly believed that it was very difficult to resolve the social problems and harms. Training the disabled children is not merely sitting in the classroom and teaching similar to normal schools. A deaf is not able to discriminate between the verb and subject, the present and the past tenses and also to recognize tense of sentences. This has been one of the biggest problems that the special needs schools,-specifically the deaf schools have been involved throughout the history. Training and stepwise education should be very slow; it needs a lot of time, and it requires appropriate teaching (participant no. 3, a CEO and responsible authority(. The NGOs have no financial dependence on the governments and they have always made the best use of the opportunities to attract financial supports. My father was admitted in a hospital for chemotherapy. At that time, a Japanese woman who was the representative of the Japanese NGOs headquarters came for a visit in the hospital. I talked to her and requested for a visit in our organization as well. Thereafter, we had a 15-minute meeting on 14^th of March last year. We signed an agreement and opened a bank account. Then, after twenty days, $83,000 was deposited in our joint account on 27^th of March) participant no. 17, an active CEO). There is a carpet-seller who is working with us for almost 5 years. He regularly sends us the carpets that he is not able to sold in the market. Therefore, we have approximately 20–30 carpets per year and we give the carpets to the help-seekers” (participant no. 10, an active CEO). The benefactors seek for the participation of help seekers in social activities and support them within the family and society in order to protect the help seekers against social damages. In our organization, one of the help-seekers has married her cousin. When she encounters a problem with her husband, she always discusses her problem with me and then I usually invite them to my home for dinner in order to solve their problems friendly” (participant no. 1, an active CEO). There was a 12-year-old girl in our organization who had escaped from home despite having parents. During the last year, she was living in the parks and cemetery until she faced one of our colleagues in the park and talked with her. Then, that girl returned to her family and is continuing her education now (participant no. 2, an active CEO). In addition to providing services in the organization and considering all-inclusive requirements and needs of help seekers in the society, the benefactors are worried about their future as well. Somebody called me and I went to see a family which lived in a sheep barn. I learned that the parents were heroine addicted and had three children; a son and two daughters. The boy was physically messed-up with infected intestines. After six months of extensive efforts, we enrolled the elder girl in an orphanage Boarding School in Mahan near to Kerman and sent the boy and little girl to Dilmaghani Orphanage which is a famous school for orphans in Kerman (participant no. 7, an active CEO). Through employment, the benefactors provide the initiatives for improving the lives and increasing the financial power of the help seekers because they face limitations in using social opportunities by themselves. In our organization, we had a female help-seeker who was concerned about her life. Her husband was addicted and we sent him to a drug rehabilitation center and our efforts worked out. Then, she came to me and said her husband was unemployed. After being assured about his request, we sent him to one of the service providing firms. We also sent that woman to work in a kindergarten and both of them are working currently (participant no. 7, an active CEO). Considering entrepreneurship, we introduced some of the referring individuals to the professional and technical centers and then they were trained and received certificates. Thereafter, we introduced them to receive self-employment loans, therefore, they were empowered and obtained the ability to support their lives (participant no. 10, an active CEO). While providing the services for help seekers, the benefactors were seeking to provide the minimum civil rights for them and their families. We prepared a place for one of the assistant educators to stay during nights because the educators and their assistants know how to take care of these children and they are also aware of the risks threatening the children. Moreover, in case of a celebration, prayer, or short trips, we take care of children by the help of the families (participant no. 4, the CEO of NGO for retarded children). In the first sessions with the board of NGO's directors, thirty women from the area started collaboration with us. We analyzed all the shortcomings of a marginal zone and identified the necessary facilities and the minimums of welfare which are the civil rights of any individual. Then, based on these requirements, we prioritized the facilities. After four years of follow-up, we could provide a bus line for the town finally (participant no. 9, an active CEO of NGO for marginal residents). The benefactors also do their best to respect the help seekers’ privacy. This is a home for these children and even a small board on the entrance door have to be removed. The dignity of children should be preserved and they should not walk under such a board to feel that this place is not their home. We receive the financial support from private benefactors and we avoid gathering money through public sources such as charity bazaars) participant no. 6, the active CEO of an NGO for children who are abused by their caregivers).

Discussion

The benefactors, through NGOs, actively and voluntarily promote responsible citizenship, the restoration of kindness, the development of adaptation, and capital and social construction through responsible citizenship.[23]

Through NGOs, the activists and volunteers who worked individually can express their opinions and exchange their experiences easily and also benefit from communication with their sympathetic colleagues. According to Bienstoke, human beings, as organizational citizens, are expected to work more than their official duties and essential tasks in order to achieve the organizational goals.[24] Smaller NGOs play increasingly bigger roles in partnering with governments during generation of the success of global health agendas, including demonstrating their “impact” through quantitative indexes and indicators.[25] In this regard, evidences have shown that the societies with high correlation have better health status than others. Social correlation refers to the close social relationships and high levels of participation in social activities and public utility actions as well as high frequent membership in social groups, which are often associated with the culture of democracy in national policies.[26] The existing evidence confirms the relationship between health and social correlation. Social correlation could have powerful effects on public health in the society and achievement to this matter is far beyond having just social relationships.[27] Social solidarity is very important in order to develop and improve the health of communities.[27] In fact, a “service oriented in the health” is not only limited to the reinforcement of isolated individuality but also requires strengthening individuality by which one's benefits are achieved through achievement of public's benefits. In addition, social participation and creativity are not merely the decorations of life but they are the requirements of humanization of the world. An organizational citizen's behavior can be varied based on the geographical area, or different cultures. According to Garg and Rastogi, a good citizen might have different definitions in different regions;[28] therefore, based on the biosocial theory, similar individuals would have more altruistic behaviors toward each other.

Benefactors attempt to link charitable efforts with economic activities in order to meet the needs of poor and deprived individuals. Development of social entrepreneurship is considered a social and altruistic mission and also a solution for a number of social problems and harms. According to Trivedi, the most important objective of entrepreneurship is to take into account a social motivation such as improving social cohesion, fighting against poverty, defending human rights, and promoting health services.[29] By making optimal use of limited facilities and resources, NGOs provide considerable productivity and efficiency for their help seekers. During providing the services for help seekers, benefactors should be treated in such a way that it is according to the local customs and personal values without hurting their feelings because of having social problems. If the behavior is consistent with custom and humanity, it will lead to more satisfaction of people seeking help and also more satisfaction of people seeking help and their families. The extent to which individuals prioritize different personal values may be conceptually linked to the perceptions of social stigma associated with seeking help (public stigma), as well as the extent to which they apply that stigma to self-related stigma.[30] Although the features of a polite behavior might vary from one culture to another, those behaviors can be taken into consideration as polite in all cultures and also are associated with respect for individuals’ values. In addition, the help seekers’ privacy, that is, what they have the right to hide, either completely or relatively, and to which others are obliged to respect, should be preserved. Jeffrey Johnson defines privacy as a matter which is protected from others’ judgment.[31]

Conclusion

NGOs and donors in a client-friendly city seek to identify situations that create a balance that controls potential deficiencies and mitigates the shortcomings faced by a particular group, and With benevolent motives, conditions are created that, by creating a new, sustainable and reassuring system, give clients more opportunities to survive and thus lead to a better future for the target group and even society as a whole.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.