A COMMUNITY-BASED INTERVENTION FOR INCREASING ACCESS TO HEALTH INFORMATION IN RURAL SETTINGS.

• Author: Blaga, Oana Maria

1. Introduction

   Despite their poorer health status and greater health-related needs (Strasser, 2003; Bennett, Olatosi and Probst, 2008), residents of rural and remote settings have limited access to health services (Goodridge and Marciniuk, 2016), healthcare workforce (Steinhaeuser et al., 2014), and health information (Carlson et al., 2006; Smith, Humphreys and Wilson, 2008), especially in low and middle income countries such as Romania (Vladescu et al., 2016). In this context, when facing health risk situations, rural residents commonly rely on family networks and friends for support and advice (Wathen and Harris, 2007). However, recent findings suggest that libraries, through the help of trained librarians, could meet the health information needs of people living in rural and remote settings (McKeehan, Trettin and May, 2008; Morgan et al., 2016; Zager et al., 2016).

   The rationale underpinning this type of initiatives is that, in order to ultimately promote and maintain the health of individuals and communities, providing health information should be complemented by increasing the health information seeking behavior of rural inhabitants. A coping strategy in threatening health-related situations, the health information seeking behavior encompasses purposive activities undertaken by individuals in order to manage their health symptoms and improve their health outcomes (Weaver et al., 2010). By considering this definition, an active health information seeking behavior would be essential to ensure the use of health information available within libraries. In addition, there are at least two other concepts strongly related to health information seeking and conducive to access of health information: one's self-efficacy and health literacy level.

   By significantly affecting people's level of motivation, self-efficacy can determine the choice of engaging in specific behaviors and the amount of effort committed to it (Vancouver, More and Yoder, 2008). Furthermore, understanding health information is just as important as finding the most relevant sources. Thus, an adequate health literacy level enables individuals to interpret and act upon the acquired health-related information (Sorensen et al., 2012). Therefore, self-efficacy and health literacy should be taken into account when assessing health information seeking behavior and its role in strategies designed to promote public libraries as health information resources for rural inhabitants.

   To the best of our knowledge, there is no information available from Eastern Europe on the types of interventions that would prove to be efficient in increasing access to health information and encourage health information seeking behavior in rural populations. In countries such as Romania, with a large rural (Trading Economics, 2016) and aging population (Marinca, 2017), and where resources invested in health promotion are scarce (European Commission, 2017), such evidence is essential to advance population health. Thus, this article aims to describe the evaluation results of exactly such an intervention.

2. Methods

   2.1. Study design

   We employed mixed-methods, nonrandomized control-group pretest-posttest study design to evaluate the efficiency of a participatory-based intervention, which aimed to improve access to health information in four rural settings. The main objectives were to (1) offer an institutional framework to facilitate access to health information (intervention at the institutional level), and to (2) increase community awareness, knowledge and skills to increase accessing of health information (intervention at the population level). Thus, at 6-months post-intervention we assessed its impact on increasing HISB and self-efficacy in searching for health information and improving health literacy.

   2.2. Setting, participants, and sample

   The study was implemented in four rural communities in Cluj county, Romania. Two of these communes were included in the intervention group (Sinpaul and Petrestii de Jos) and two in the control group (Tureni and Catina). A short description of the four communes at the time of the study's implementation (years 2010-2011) is presented in Table 1.

   The study population consisted of a convenience sample of 822 community members, 18 and older, who consented to participate in the study after being approached in their courtyards or homes by trained study data collectors. In this paper, we report on the data collected in the post-intervention period only (N=416). We also conducted five semi-structured interviews with local stakeholders (i.e. mayor, librarian, family physician).

   2.3. The Initiative for Health Information Resources in Rural Areas (IRIS)

   The IRIS intervention was designed to improve access to health information in rural areas by facilitating the availability of reliable health information sources, training librarians to manage and refer them to locals, and enhancing rural inhabitants' health information seeking behavior, self-efficacy in searching health information, and health literacy. The intervention was structured on two levels: an institutional level and a population level, each being grounded in comprehensive theoretical frameworks.

   At the institutional level, we developed partnerships with local institutions in the two intervention communes, as well as with four national organizations willing to donate health-related books and pamphlets. The partnership with local stakeholders, such as town halls, libraries, schools, and family physician offices, was designed as a framework for the development of the population arm of the intervention. The collaboration with these institutions was established under the act 'Together for a Healthy Community', signed within the framework of the IRIS initiative, a document stipulating both the general objectives of the agreement, as well as the responsibilities of each partner. The general objectives of the agreement were to (1) increase the number of health-related materials available in the local libraries and to (2) obtain the support of local stakeholders for the implementation of the intervention.

   At the population level, the intervention was theory-driven and developed based on the information collected during a formative research phase, having both a quantitative and a qualitative component and conducted in October-December 2010. A survey was used to evaluate the target population's health information seeking behavior, self-efficacy, attitudes, and barriers and benefits of health information seeking behavior. The qualitative component was developed on the results of the survey and consisted of two focus-groups (n=12). We sought to involve the members of the target audience in the development of the intervention, by determining approaches to reduce the existing barriers in seeking health information and maximize the perceived benefits of this behavior. Also, the project team gathered information about the preferences of the target audience concerning the time and place for the development of intervention activities. Nonetheless, these focus groups were used to pretest the printed intervention materials (brochures) and the visuals elements of IRIS (logo).

   In order to maximize results, the intervention was branded under the name IRIS (The Initiative for Health Information Resources in Rural Areas), and pretested visual elements were designed in order to achieve high recognition among the target population. Local libraries were equipped with more than 300 books on health topics and instruments to manage the collections. Librarians were trained in administering the materials as well as collecting feedback from user for its improvement. Two health workshops were conducted in each of the intervention communities with the scope of increasing health information seeking behavior, build health literacy skills, increase self-efficacy in seeking health information as well as promoting IRIS.

   2.4. Data collection

   Pre- and post-intervention data was collected in all four communities, by trained data collectors, in October-December 2010 and October-November 2011. Data was collected using a structured pre- and posttest survey in the intervention group (n=209 pre- and n=212 post-) and in the control group (n=197 pre- and n=204 post-). A set of 5 individual interviews were also conducted in the post-intervention period with members of the local administration (i.e. mayor, librarian, family physician) in the intervention communes. In this paper, we report the data collected in the evaluation/ post-test phase.

   2.5. Data and measurements

   2.5.1. The quantitative component

   The post-intervention survey consisted of seven sections. However, in this paper, we only report on the questions...