Study design and community selection
A community PAR was conducted drawing on theories of community mobilization, participation, and empowerment. The steps included 1) establishing the Steering Committee 2) deciding on methods 3) identifying trusted and interested people to form Executive Committees 4) transferring knowledge 5) collecting and weighting data and 6) interpreting data and prioritizing needs.
A local requirement that stipulates that any community based program should be based on a formal demand by the community made us choose a potentially demanding area, based on the criteria of 'low socio-economic status', 'an abundance of various health problems', and a persistent demand on the part of the residents for improvement. The existence of a non-state health center and a high probability of participation were other criteria for choosing this location. At a meeting with delegates from Health Department of Ardabil Medical University, Mayoralty, and Welfare Organization, an area of about 20000 inhabitants was selected for the study site.
Our research project followed a set of prior activities that were undertaken by some members of the current project with the aim of establishing relationships with the local people and winning their trust. The earlier activities included identifying the trusted individuals, those with philanthropic interests, and those who were interested in local development and trust-building projects. Earlier projects involved repairing small open sewer canals, lighting pathways, holding leisure time classes, building sport teams, allocating library space inside the non-state health center of the region, and providing consultation services. All of the above services were made possible through cooperation between the community representatives and non-state organization agents, who managed to involve and attract the attention of the highest authority of the province in the process.
These successful experiences paved the way for this study. The research committee examined the profiles of the trusted and interested people in voluntary philanthropic activities and outlined the study procedures. Twelve Executive Committees were formed by representatives from 12 Blocks that were selected after considering physical texture and pathways following the blocking system of local community development center.
The most important challenge of this study was to encourage academic researchers and officials of health system to believe in the fact that people can participate in health domain research and be empowered to help conduct health research more effectively.
Involving the community development center and selecting executives
In order to encourage the Community Development Center (CDC) of Ardabil to participate in this study, the general outline was discussed with CDC officials, agents from Farhikhteh non-state organization, and local people, during three 2-hour face to face meetings. Finally, the Executive Team of research project was decided mostly from among the local people and a few number of university colleagues. An attempt was made to select the majority of Executive Team members of the study from among the non-state organizations and local people. The ratio of the university colleagues to other members was 1 to 7. The members of the instruction, documentation, supervision, coordination, interview, and enquiry teams were selected from among the community members of CDC and the Farhikhteh institute. Rigorous care was taken to limit the role of the academic members to instruction and other technical aspects and much of the research task were delegated to the community groups in spite of numerous difficulties.
Knowledge transfer and empowerment
The different methods of community assessment were presented through lectures to all members of the Steering Committee. The group preferred the 'focus group' technique to the other presented methods. The members of the project Executive Team and the representatives of the twelve blocks, who were selected from among interested people based on the documents of the Social Research Center, attended focus group workshops for two months. In addition, a questionnaire designing workshop and the data entering methods were hold for the community members of the project. The instruction prepared members for full participation; in practice, much of the job was delegated to ordinary members of the Executive Committees.
Method of data collection
The trained community agents of the Executive Committees held group discussions in the twelve blocks with an average attendance of 8 to 14 neighborhood residents with the retention rate of about 70%. On the whole, three group discussions were held in every block by agents who were fluent in both Turkish and Persian.1 The invited people included local retailers, state employees, housewives, pensioners, trustees, and active youth from the local blocks. The people attending the discussions were also supposed to act as facilitators of the research and prepare the community for full participation.
A note-taker recorded the details of every discussion. The workshops took place in April through May, 2006. The venues for the workshops were decided based on the convenience of each individual group and included the neighbor's homes, local mosques or CDC rooms. During the workshops, the purpose and process of the research was thoroughly explained.
The research process was started with the following statement: "what is the most important problem in your community's health?". The agents were asked to tell people that "As a member of our community, we want to understand the problems better. It is necessary to know the answer to this question according to your priorities, so that we can suggest an appropriate intervention to health and other officials, and then implement the intervention, and assess the results of our efforts."
From the beginning, it was made clear to the community that health system officials and relevant domains were expected to allocate considerable amounts of time and money on an annual basis to improve health condition. However, the main challenge was to decide on the priorities from the perspectives of the locals.
Each block team was given the mission to discover the most important problems in their community.
After finishing the workshops, the results were reported to the Steering Committee by the representatives of the groups. The final procedure was agreed to by the Steering Committee with the cooperation of agents of Farhikhteh Institute and representatives of twelve local areas.
Subsequently, in order to assess the needs from the perspectives of the households of the blocks, the Steering Committee planned more workshops to empower the community groups to design the questionnaire and conduct interviews. Three 1-day workshops were planned and implemented in July through August, 2006.
The Steering Committee, representatives of twelve blocks and Farhikhteh institute agreed on a questionnaire which included 60 yes-no items. The items were related to the general problems of local people such as health, security, economy, employment, and education. Subsequently, a final orientation session was held for all the local interviewers to practice completing the questionnaire.
The community interviewers of 12 local areas and their supervisors, from among the members of the Executive Committees interviewed 30 households from the 12 blocks and repeated it after a 14-day interval in order to check the reliability of the instrument, which was found to be 0.76.
Six hundred households were interviewed in September 2006. The target households were selected through cluster random sampling using the CDC database. Considering the population (20,000) and the average number of family members (4.3) in Iran [20
], 600 households equaled about 15% of the households. It should be noted that the demographic information of the participants was not systematically gathered. The supervisors examined the daily delivered questionnaires and randomly checked some households for quality assurance purposes.
Method of data analysis
During the Steering Committee's meetings, the necessity of including diverse groups of people was discussed. The best method of implementing community assessment was also discussed. Finally, the Steering Committee decided to apply a mixed model containing surveys and focused group discussion in the local areas.
The first set of data was produced following analysis of the priorities offered by 12 local groups which represented each block. Then, face-to-face interviews were carried out with [almost all] 600 households of the selected area, to create a second dataset. With consistent supervision and training, the community groups entered the data into the computer as planned. They cooperated with a statistician to analyze the data. Finally, the output of the data which comprised five main problems from the perspective of 600 households was produced.
This study was approved in the research committee of Ardabil University of Medical sciences, which considers and verifies the research proposals both academically and ethically. It should also be noted that participation in this project has been voluntary for all the community representatives and the agents of Farhikhteh institute of Ardabil. In the first meeting, their option to leave or continue the study was explained to them formally at the beginning and during the study. The researcher after acknowledging their participation in the project ensured the privacy of the data. Additionally, an attempt was made to employ both female and male colleagues to observe the religious and cultural norms and values.