The current study was participatory action research based on the FOCUS-PDCA model. This model consisted of 9 steps, which were implemented in the form of 2 sub-studies. The first sub-study was conducted with a qualitative approach, and the second was conducted with a quantitative approach in the only center providing pre-marriage training in Bandar Abbas (Figure 1).
The first step (Find): Finding the problem: For this purpose, in-depth individual or couple interviews (19 interviews in total) with couples on the verge of marriage or couples who had participated in this training one year ago were carried out to explain their needs of sexual and reproductive health. The second step (Organize): After preparing a list of individuals involved in the marriage counseling process of Bandar Abbas, the research team was organized to deal with the problem. The third step (Clarify): In order to clarify the problems that were related to explaining the concept of reproductive health literacy and the marriage training process and needed to be changed and improved, a qualitative study was conducted using in-depth interviews with 10 consulting service managers and providers at the province level. The fourth step (Understand): In this step, with the help of the brainstorming technique with service providers and managers regarding reproductive health services and drawing a fishbone diagram (Figure 2), the effective causes of the process inefficiency were determined. The fifth step (Select): After identifying the needs, a list of facilitators that were able to implement was selected based on the brainstorming session, and then, using the decision matrix, it was finally decided to modify the current methods and educational content, develop the human resources knowledge, employ a same-sex teacher for gender-sensitive educational materials in classes, hold classes for men, and flexibility in holding classes. The sixth step (Plan): An action plan was written to implement and evaluate the changes. The seventh step (Do): This step included the implementation of changes in the marriage training process. For this purpose, a quasi-experimental study of before and after type was conducted on the couples on the verge of marriage selected by a convenient sampling method.
The inclusion criteria included having the first marriage experience, living in Bandar Abbas, having at least reading and writing literacy, being willing to participate in the study, attending the marriage counseling center, and filling out the reproductive health literacy questionnaire before attending the classes. Also, if a couple or an individual only attended the class at the end of the training sessions, they were excluded from the study despite completing the questionnaire.
Data Collection Tool
- A researcher-made questionnaire (measuring health literacy in three functional, critical, and communication areas) and individual interviews (with some service providers and recipients) concerning young couples’ reproductive and sexual health needs.
- Due to the lack of a tool to measure the level of reproductive health literacy, at the time of the study, a researcher-made tool was designed in accordance with the research objectives to measure couples’ level of health literacy in the areas required in reproductive health, with an inductive-deductive approach. In designing the items of this tool, in addition to the results of the needs assessment of the first step of the study and the review of related texts in this field, the existing standard scales, such as the Iranian Health Literacy for Adults (HELIA) (12) were used. Finally, a questionnaire was finalized in three parts: The first part was related to the variables of couples’ demographic characteristics, the second part involved 37 items for measuring reproductive health literacy in 4 dimensions: Understanding (9 items), access (12 items), evaluation (6 items), and decision-making and application (10 items), and the third part involved 5 items to measure reproductive health literacy in functional and knowledge of health literacy areas. The reliability of the questionnaire was performed by completing the questionnaire by 20 participants and completing it again 2 weeks later and conducting a test-retest using intra-class correlation coefficient (ICC) and Pearson’s correlation coefficient (ICC = 0.941, 0.81 r, and p>0.05). The measurement scale of the items was a 5-point Likert scale (not at all to always) scored from 1 to 5, and the minimum and maximum scores in this section were 37 and 185, respectively. Also, in this study, based on the main scale, the level of health literacy was divided into four categories: “Excellent”, “adequate”, “not much adequate”, and “inadequate”, which the “inadequate” and “not much adequate” levels were reported as limited reproductive health literacy and the “adequate” and “excellent” levels were reported as the desirable level of reproductive health literacy.
- The level of satisfaction with the services provided by the researcher-made questionnaires to evaluate the satisfaction of customer service based on the Service Quality (SERVQUAL) Questionnaire was investigated. The opinions of 10 midwifery faculty members were used to determine the face and content validity of the tool. The reliability of the questionnaire was performed by its completion by 20 participants and completing it again 2 weeks later, and performing a test-retest using ICC and Pearson’s correlation coefficient (ICC=0.86, r=0.883, and p<0.05). This questionnaire contains two pairs of 22 items (a total of 44 items) designed in two parts of customer expectations of services and perceptions of receiving services in 5 dimensions, including warranty (5 items), accountability (6 items), empathy (3 items), assurance (4 items), and tangibility. A 7-point Likert scale was used, and each item was scored from 1 to 7. Service quality was evaluated by calculating the difference between the value obtained between each pair of identical items (gap score) (13). The negative result of the difference indicates poor quality and satisfaction, and the positive result of the difference indicates acceptable satisfaction.
After the preparation of tools and the arrangements made, amendments were made to the educational content of pre-marriage preparation classes, and based on the new content, the training course plan was prepared. In order to continue the training and respond to the specific needs of the audience as much as possible, a communication channel called the marriage training class was created through WhatsApp software; after each training session, couples who desired to join this channel entered the communication channel after receiving the specifications. Sampling lasted from September to December 2019. The training continued daily through common and accessible platforms until the end of April 2020. The eighth step (Check): The evaluation and review of the process improvement were performed to ensure the improvement of the results due to the changes made. The results were controlled through direct observation of the researcher in implementing process changes, surveys, and reviews from the program’s audience, notes, and reports. The participants were followed up for at least 4-6 months after the training and were again measured in terms of reproductive health literacy level in three dimensions, including the ability to access available services, understanding the concepts, and appropriate performance on the issues raised in the fields of reproductive health by appropriate items in the questionnaire, and their health literacy was measured and compared to before the reforms. For this purpose, the reproductive health literacy questionnaire was again provided to the couples to complete. In addition, the opinions of couples and service providers who were members of the virtual space group were asked once a month, and if practical, their opinions and suggestions were applied. The ninth step (Act): A report of the results of this research and the necessary changes and suggestions to reform the couples’ training at the time of marriage regarding improving reproductive health literacy was prepared and submitted to the Population and Family Health Unit of the Health Vice-Chancellor of Hormozgan University of Medical Sciences so that, according to the results of the program, decisions were made on the continuation of the program with new changes or based on the previous process.
Data analysis was performed in SPSS statistical software version 26 using descriptive statistics (mean, standard deviation, frequency, and percentage) and a chi-square test to compare the frequency distribution of the levels of each variable in both male and female groups. The analysis of covariance (ANCOVA) test was used to investigate the effect of the pre-intervention score and compare the scores in both male and female groups. In all tests, p<0.05 was considered statistically significant.