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Authors must send one electronic copy to Cristina Mora (cristina@rtsa.ro) 1 Transylvanian ReviewTransylvanian Review of Administrative Sciencesof Administrative Sciences No. 58 ENo. 58 E / / October / October / 20 201919 Senior Editor: Călin Emilian Hinţea Director: Ciprian Tripon Editor: Cristina Mora Administrative director: Ovidiu Boldor Editorial Board: Balogh Marton, Daniel Buda, Marius Dodu, Dacian Dragoş, Călin Ghiolţan, Veronica Junjan, Dan Lazăr, Elena Minea, Natalia Negrea, Liviu Radu, Sorin Dan Şandor, Bogdana Neamţu, Bianca Radu, Raluca Gârboan, Adrian Hudrea, Cornelia Macarie, Dan Balica, Tudor Ţiclău, Cristina Haruţa, Horia Raboca, Raluca Suciu, Ana Elena Ranta, Octavian Moldovan, Alexandru Pavel ISSN 1842-2845 • Accent Publisher, 2019 Babeş-Bolyai University Faculty of Political, Administrative and Communication Sciences Department of Public Administration and Management INTERNATIONAL ADVISORY BOARD Carole NEVES, Smithsonian Institute, Washington, DC Allan ROSENBAUM, Florida International University Arno LOESSNER, University of Delaware Roger HAMLIN, Michigan State University Laszlo VARADI, Corvinus University of Budapest Eric STRAUSS, Michigan State University Gyorgy JENEI, Corvinus University of Budapest Adriano GIOVANNELLI, Genoa University Bernadine Van GRAMBERG, Victoria University Julian TEICHER, Monash University Geert BOUCKAERT, Catholic University of Leuven Veronica JUNJAN, University of Twente György HAJNAL, Corvinus University of Budapest Taco BRANDSEN, Radboud University Nijmegen, Secretary-General of the European Association for Public Administration Accreditation (EAPAA) Juraj NEMEC, Masaryk University, president of The Network of Institutes and Schools of Public Administration in Central and Eastern Europe (Nispacee) Maria ARISTIGUETA, University of Delaware Yüksel DEMIRKAYA, Marmara University Marian PREDA, University of Bucharest Marius PROFIROIU, Bucharest Academy of Economic Studies Alexander HENDERSON, Long Island University Gregory PORUMBESCU, Northern Illinois University 2 Transylvanian Review of Administrative Sciences has been selected for coverage in Thomson Reuters products and custom information services. Beginning with no. 22E/2008, this publication is indexed and abstracted in the following: 1. Social Sciences Citation index® 2. Social Scisearch® 3. Journal Citation Report/Social Sciences Edition Transylvanian Review of Administrative Sciences is also listed in EBSCO, IBSS – International Bibliography of Social Sciences, Elsevier Bibliographic Databases, PA@BABEL Public Administration’s dataBase for Accessing academic publications in European Languages and DOAJ – Directory of open access journals. 3 5 24 38 52 65 85 100 116 C O N T E N T S Mojca BIŠČAK Jože BENČINA The Impact of HRM Practices on the Performance of Municipalities. The Case of Slovenia Oana Maria BLAGA Răzvan Mircea CHERECHEȘ Cătălin Ovidiu BABA A Community-Based Intervention for Increasing Access to Health Information in Rural Settings Emil BOC The Development of Participatory Budgeting Processes in Cluj-Napoca Andrei CHIRCĂ Dan Tudor LAZĂR Students’s Visitors – Among the Unexplored Types of Local Tourism? Min-Hyu KIM Factors Infl uencing the Propensity to Contract Out Health and Human Services in Response to Government Cutbacks: Evidence from US Counties Mateusz LEWANDOWSKI Organizational Drivers of Performance Information Use: The Perspective of Polish Local Governments Romea MANOJLOVIĆ TOMAN Goranka LALIĆ NOVAK The (Lack Of) Demand for Performance Information by the Croatian Parliament Oleksiy POLUNIN The Case of Ukrainian Corruption: Phenomenology and Psychological Insides 24 Abstract The health information needs of people liv- ing in rural areas are unmet. We aim to report on the results of the IRIS institutional- and pop- ulation-level intervention designed to improve ac- cess to health information in rural settings. The in- tervention consisted of three components: equip local libraries with health-related books, train librarians to refer them to locals, and enhance lo- cals’ health information seeking behavior, self-ef- fi cacy, and health literacy. Data was collected using a mixed-methods strategy of inquiry in 2010 and 2011 from 822 adult inhabitants from four ru- ral communities in Cluj county, Romania, using a nonrandomized control-group pretest-posttest study design. We used the Kruskal-Walis one- way analysis of variance to determine statistical- ly signifi cant diff erences between the two study groups. Results show that individuals from rural com- munities included in the intervention group were more engaged in health information seeking, had higher self-effi cacy in reading and understanding health-related materials, and reported higher fre- quencies of asking about and borrowing books on health themes from the village library as com- pared to respondents in the control group. As the IRIS initiative made use of available community resources and proposed only several incremen- tal changes within the librarian system, this inter- vention has a major potential of sustainability and replicability. Keywords: rural, health information, access, library, Cluj county, Romania. A COMMUNITY-BASED INTERVENTION FOR INCREASING ACCESS TO HEALTH INFORMATION IN RURAL SETTINGS*1 Oana Maria BLAGA Răzvan Mircea CHERECHEȘ Cătălin Ovidiu BABA Oana Maria BLAGA (corresponding author) Research Assistant, PhD, Department of Public Health, Center for Health Policy and Public Health, College of Political, Administrative and Communication Sciences, Babeș-Bolyai University, Cluj-Napoca, Romania E-mail: oana.blaga@publichealth.ro Răzvan Mircea CHERECHEȘ Professor, Department of Public Health, Center for Health Policy and Public Health, College of Political, Administrative and Communication Sciences, Babeș-Bolyai University, Cluj-Napoca, Romania E-mail: razvan.chereches@publichealth.ro Cătălin Ovidiu BABA Professor, Department of Public Health, Center for Health Policy and Public Health, College of Political, Administrative and Communication Sciences, Babeș-Bolyai University, Cluj-Napoca, Romania E-mail: baba@fspac.ro * Acknowledgement. This research project was fi nanced through the ‘Access to Health Information in Rural Areas’ Grant, funded by the Romanian Ministry of Education and Research, through the PNII-Idei Program, fi nancing contract 2450/2009. Transylvanian Review of Administrative Sciences, No. 58 E/2019 pp. 24-37 DOI:10.24193/tras.58E.2 Published First Online: 10/15/2019 25 1. Introduction Despite their poorer health status and greater health-related needs (Strasser, 2003; Bennett , Olatosi and Probst, 2008), residents of rural and remote sett ings have limit- ed access to health services (Goodridge and Marciniuk, 2016), healthcare workforce (Steinhaeuser et al., 2014), and health information (Carlson et al., 2006; Smith, Hum- phreys and Wilson, 2008), especially in low and middle income countries such as Romania (Vlădescu 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 fi ndings suggest that libraries, through the help of trained librarians, could meet the health information needs of people liv- ing in rural and remote sett ings (McKeehan, Trett in 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 situa- tions, the health information seeking behavior encompasses purposive activities un- dertaken by individuals in order to manage their health symptoms and improve their health outcomes (Weaver et al., 2010). By considering this defi nition, an active health information seeking behavior would be essential to ensure the use of health infor- mation available within libraries. In addition, there are at least two other concepts strongly related to health information seeking and conducive to access of health in- formation: one’s self-effi cacy and health literacy level. By signifi cantly aff ecting people’s level of motivation, self-effi cacy can determine the choice of engaging in specifi c behaviors and the amount of eff ort committ ed to it (Vancouver, More and Yoder, 2008). Furthermore, understanding health information is just as important as fi nding the most relevant sources. Thus, an adequate health lit- eracy level enables individuals to interpret and act upon the acquired health-related information (Sørensen et al., 2012). Therefore, self-effi cacy 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 Eu- rope on the types of interventions that would prove to be effi cient 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 ad- vance population health. Thus, this article aims to describe the evaluation results of exactly such an intervention. 26 2. Methods 2.1. Study design We employed mixed-methods, nonrandomized control-group pretest-postt est study design to evaluate the effi ciency of a participatory-based intervention, which aimed to improve access to health information in four rural sett ings. The main objec- tives were to (1) off er an institutional framework to facilitate access to health informa- tion (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 in- creasing HISB and self-effi cacy in searching for health information and improving health literacy. 2.2. Sett ing, 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 (Sînpaul and Pe- treștii de Jos) and two in the control group (Tureni and Cătina). A short description of the four communes at the time of the study’s implementation (years 2010-2011) is presented in Table 1. Table 1: Description of the communes included in the study Intervention communes Control communes Commune Sînpaul, Village Sînpaul Commune Tureni, Village Tureni Population of the commune: 2,652 Population of the village: 826 Location: Road E81 Population of the commune: 2,209 Population of the village: 929 Location: Road E60 Commune Petreștii de Jos, Village Petreștii de Jos Commune Cătina, Village Cătina Population of the commune: 1,891 Population of the village: 685 Location: Road 107/L Population of the commune: 2,209 Population of the village: 819 Location: Road 109C The study population consisted of a convenience sample of 822 community mem- bers, 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 fi ve 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, train- ing librarians to manage and refer them to locals, and enhancing rural inhabitants’ health information seeking behavior, self-effi cacy in searching health information, and health literacy. The intervention was structured on two levels: an institution- 27 al level and a population level, each being grounded in comprehensive theoretical frameworks. Figure 1: The IRIS non-randomized control-group pretest-posttest study design (N=822) 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 stakehold- ers, such as town halls, libraries, schools, and family physician offi ces, 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 responsibili- ties 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 quan- titative and a qualitative component and conducted in October-December 2010. A survey was used to evaluate the target population’s health information seeking be- havior, self-effi cacy, att itudes, and barriers and benefi ts 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 re- duce the existing barriers in seeking health information and maximize the perceived benefi ts of this behavior. Also, the project team gathered information about the pref- erences 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). 28 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 popu- lation. 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-effi cacy 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 postt est 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 described below: (1) Socio-demographics, such as age, gender, ethnicity, education, employment status, and monthly family income. (2) The health information seeking behavior of the respondents, assessed using 9 items measured on a 5-point Liker scale (from 1=always to 5=never) and designed to evaluate the frequency of the respondents’ health information seeking behavior in the last 12 months (i.e. how often they watched a TV show on a health issue, read a bro- chure on a head issue, discussed with friends regarding a health problem, asked their physician for additional information regarding a medical problem). In addition, two dichotomous questions (0=No, 1=Yes) were used to evaluate whether respondents have ever searched for information on a health problem from any source and if some- one else has searched for health information on their behalf. (3) Respondents’ self-effi cacy in searching and fi nding health-related information was assessed using a batt ery of 9 questions, grouped in three sub-scales. First, we evaluated subjects’ self-effi cacy in reading a book on health issues, in asking a friend or a family member to search for health information on their behalf, and in asking the librarian to search for health information on a 4-point Likert scale from 1 (=unsure) to 4 (very sure). Next, we inquired about individuals’ abilities to search for health information when they are concerned, depressed, tired, or busy, or when they have 29 to perform the search for several times until they fi nd what they need, using the same 4-point Likert scale mentioned above. Lastly, we asked participants to rate, on a scale from 1 (=very diffi cult) to 5 (=very easy) how diffi cult it would be for them to search for health information when they need it. (4) We measured health literacy within the sample by using a batt ery of 8 ques- tions initially developed by Chew, Bradley and Boyko (2004). In this paper, we report only 4 of these questions, measured on a scale from 1 (=always) to 5 (=never) and used to assess how often respondents ask someone else to read materials received from their doctor, understand writt en information regarding their medication, and under- stand prospectuses and physician indications. (5) Respondents’ att itudes towards the community library were evaluated by as- sessing the frequency with which the librarian recommended them a book on a health topic, as well as the frequency of intending to borrow, asking about, and borrowing a book on a health topic from the local library in the last year, with responses for these questions ranging from 1 (=always) to 5 (never). Nonetheless, we asked about the importance of the village library in having a well-informed community on health topics, with possible answer alternatives ranging from 1 (=very important) to 5 (=not important at all). 2.5.2. The qualitative component The qualitative component consisted of a semi-structured interview guide slightly adjusted based on the role of the subject in the local administration (i.e. mayor, librar- ian, or family physician). Topics included the capacity of the IRIS intervention to fa- cilitate access of rural communities to health information, recommendations on how to improve future similar initiatives, and sustainability issues. The interview guide was built to explore the specifi c role of the mayor, the librarian and the family physi- cian in the delivery of the IRIS intervention, and the importance of the local library to have a well-informed community on health topics. 2.6. Data analysis In this paper, we report analyses conducted on the post-intervention data only (N=416 surveys and 5 semi-structured interviews). For the quantitative component, we conducted descriptive statistics on the socio-demographic variables. We also used the Kruskal-Wallis one-way analysis of variance by ranks to evaluate the presence of statistically signifi cant diff erences on the variables of interest between the inter- vention and control communes in the pre-intervention phase (not reported in this paper). In the post-intervention phase, we conducted the same Kruskal-Wallis test specifi cally for the variables for which we did not fi nd any statistically signifi cant diff erences in the pre-intervention phase, in order to identify any possible eff ects of the IRIS intervention. For the quantitative component, we conducted verbatim transcription of the audio recorded semi-structured interviews and performed an inductive thematic analysis at the semantic level to identify codes and themes in the data. 30 3. Results 3.1. Results from the quantitative component The post-intervention sample consisted of participants with a mean age of 52.51 years (SD=17.51, range 18-87), with the respondents in the intervention communes being slightly younger than the respondents in the control communes (mean age of 51.11 vs. 53.34). Most respondents were of Romanian ethnicity (94% in the control communes and 68.6% in the intervention communes), had a high school education (38.7% in the control communes and 32.5% in the intervention communes), and a monthly family income below 700 RON (41.7% in the control communes and 48.5% in the intervention communes). A detailed description of the sample is available in Table 2. Table 2: Post-test data, sample description (%, N=416) Intervention communes (%) Control communes (%) Total (%) Gender Male 49.5 45.1 47.4 Female 50.5 54.9 52.6 Age (mean, SD) Under 30 16.7 11.3 14 31-49 26.7 24 25.4 50-59 16.6 24 20.3 Over 60 40 40.7 40.3 Mean/SD (range) M=51.11 SD=17.31 (18-87) M=53.34 SD=16.98 (18-85) M=52.51 SD=17.15 (18-87) Ethnicity Romanian 94.8 68.6 82 Hungarian 0.5 27.5 13.7 Roma 4.2 3.4 3.8 Missing 0.5 0.5 0.5 Education No education 6.1 13.3 9.6 Primary school 20.3 20.2 20.2 Secondary school 25.0 30 27.5 High school 38.7 32.6 35.8 College or more 9.9 3.5 6.8 Missing 0 0.5 0.2 Employment status (multiple or no answers allowed) Employed 22.6 17.3 20 Student 1.9 0.5 1.2 Retired 46.2 44.3 45.3 Farmer 14.2 10.3 12.3 Freelancer 20.3 17.6 19 Estimated monthly family income 0-700 R0N 41.7 48.5 45.0 701-1,500 RON 37.4 37.1 37.3 1,501-3,000 RON 14.7 8.9 11.8 3,001-5,000 RON 0.9 0 0.5 Missing 5.3 5.5 5.4 31 Regarding the results of the Kruskal-Wallis one-way analysis of variance, these are presented in Tables 3-6; it is apparent from Table 3 that respondents from the inter- vention communes, as opposed to their counterparts living in the control communes, have searched more frequently for health-related information from any source in the last 12 months (χ2=19.735, p=.000, df=1), while the respondents from the control com- munes had someone else searching for this type of information for them (χ2=7.061, p=.008, df=1). On the other hand, participants from the control communes reported a higher frequency of reading the health section of a newspaper or magazine (χ2=8.148, p=.004, df=1) or of watching a TV show on health issues (χ2=7.321, p=.007, df=1) in the last 12 months. These statistically signifi cant diff erences in the favor of the respon- dents in the control communes might be due to the fact that they are relying more on other sources to get access to health-related information, while their counterparts in the intervention communes reply more on the local library to get this information (hypothesis supported by the results presented in Table 6). Table 3: Diff erences in the health information seeking behavior of respondents from the control and intervention communes in the post-intervention phase (results of the Kruskal-Wallis one-way analysis of variance; N=416) Variable Control(Mean rank) Intervention (Mean rank) Kruskal-Wallis test Seeking health information from any source 181.24 220.21 χ2=19.735, p=.000, df=1 Someone else searching for information on their behalf 149.33 131.59 χ2=7.061, p=.008, df=1 Frequency of reading the health section of a newspaper or magazine 38.57 56.64 χ2=8.148, p=.004, df=1 Frequency of watching a TV show on health issues 38.93 55.86 χ2=7.321, p=.007, df=1 Frequency of reading a book (or fragment) on health issues 53.17 50.84 χ2=0.406, p=.524, df=1 Frequency of reading a pamphlet on a health issue 49.02 51.80 χ2=0.072, p=.789, df=1 Frequency of asking friends or relatives about health prob- lems 47.69 53.01 χ2=0.306, p=.580, df=1 Frequency of discussing with friends or relatives about health problems 49.22 52.40 χ2=0.049, p=.825, df=1 Frequency of asking doctors extra information about a dis- ease or medical problem problems 42.95 53.44 χ2=1.815, p=.059, df=1 As Table 4 shows, there is a statistically signifi cant diff erence between the two study groups in terms of respondents’ self-effi cacy on reading a pamphlet with health information or a book/paragraph on health issues, with respondents in the interven- tion communes reporting bett er self-effi cacy (χ2=4.497, p=.034, df=1 and χ2=8.406, p=.004, df=1). Similar results were reported by the subjects in the intervention com- munes when asked if they felt confi dent to research for health information even in sit- uations when they are concerned, depressed, tired or busy. In addition, participants in the intervention communes reported bett er self-effi cacy in searching for health information when they need as opposed to participants in the control communes (χ2=11.676, p=.001, df=1). 32 Table 4: Diff erences in self-effi cacy of respondents from the control and intervention communes in the post-intervention phase (results of the Kruskal-Wallis one-way analysis of variance; N=416) Variable Control(Mean rank) Intervention (Mean rank) Kruskal-Wallis test Self-effi cacy on reading a pamphlet with health info 186.04 208.96 χ2=4.497, p=.034, df=1 Self-effi cacy on reading a book or a paragraph on health issues 180.18 211.90 χ2=8.406, p=.004, df=1 Self-effi cacy in asking a friend of a family member to search health information 195.39 197.61 χ2=0.042, p=.837, df=1 Self-effi cacy in asking the librarian to search for information of health topics 188.49 201.55 χ2=1.184, p=.277, df=1 How diffi cult do you think it would be to search health infor- mation when you need them? 177.36 213.62 χ2=11.676, p=.001, df=1 I can search for health information even when (…) I am concerned 165.79 224.36 χ2=28.789, p=.000, df=1 (…) I am depressed 169.94 217.31 χ2=19.161, p=.000, df=1 (…) I am tired 174.93 216.29 χ2=14.355, p=.000, df=1 (…) I am busy 170.71 219.82 χ2=20.857, p=.000, df=1 (…) If I must try several times until I fi nd what I need 158.19 234.40 χ2=47.749, p=.000, df=1 From the data in Table 5, we can appreciate that respondents in the intervention communes reported statistically signifi cant bett er results for the four questions as- sessing health literacy components as opposed to their counterparts in the control communes. More specifi cally, statistically signifi cant improvements have been ob- served between the control and intervention group in terms of health literacy. Compared to the control group, respondents in the intervention group reported fewer problems in understanding writt en information regarding their medical condi- tions (χ2=6.679, p=.009, df=1) and feeling less unsure when taking their drugs because of diffi culties in understanding prospectuses (χ2=20.823, p=.000, df=1) or physician’s indications (χ2=20.602, p=.000, df=1). Furthermore, they also reported needing less help from family members, neighbors or friends when reading materials received from their physician (χ2=6.679, p=.009, df=1). These results suggest that the IRIS inter- vention had positive eff ects on individuals’ health literacy levels. Table 5: Diff erences in the health literacy level of respondents from the control and intervention communes in the post-intervention phase (results of the Kruskal-Wallis one-way analysis of variance; N=416) Variable Control(Mean rank) Intervention (Mean rank) Kruskal-Wallis test Ask someone to explain written information regarding their medical condition 172.72 216.04 χ2=15.530, p=.000, df=1 Feeling unsure when understanding prospectuses 171.14 220.98 χ2=20.823, p=.000, df=1 Problems understanding physician indications 169.93 218.7 χ2=20.602, p=.000, df=1 Help needed to read materials received from your doctor 184.39 213.68 χ2=6.679, p=.009, df=1 33 Results in Table 6 show that in the intervention group, the village library had a more important role in having a well-informed community on health themes (χ2=5.857, p=.016, df=1) as compared to the control group. Furthermore, respon- dents in the intervention group reported higher frequencies of intending to borrow (χ2=6.361, p=.012, df=1), asking (χ2=10.869, p=.001, df=1) and borrowing (χ2=9.270, p=.002, df=1) a book on a health theme from the village library. The role of the village librarian in encouraging health information seeking through recommending books on health themes was grater in the intervention group (χ2=10.983, p=.001, df=1) as compared to the control group. Table 6: Diff erences in the attitudes of respondents from the control and intervention communes in the post-intervention phase towards the local library (results of the Kruskal-Wallis one-way analysis of variance; N=416) Variable Control(Mean rank) Intervention (Mean rank) Kruskal-Wallis test Importance of a village library to have a well-informed com- munity of health topics 131.51 111.87 χ2=5.857, p=.016, df=1 Frequency of intending to borrow a book on a health theme 126.75 112.51 χ2=6.361, p=.012, df=1 Frequency of asking about a book on health themes 128.59 111.82 χ2=10.869, p=.001, df=1 Frequency of borrowing a book on a health theme 128.95 114.98 χ2=9.270, p=.002, df=1 Frequency with which a librarian recommended a book on health issues 130.91 115.12 χ2=10.983, p=.001, df=1 3.2. Results from the qualitative component Five broad themes emerged from the qualitative data analysis. These are summa- rized below. Theme 1: the perception of the local public administration representatives regard- ing the IRIS strategy. A variety of perspectives were expressed by interviewees, who saw the IRIS intervention as: (1) a means of health education for individuals living in rural areas – ‘it is an educative initiative (…) and it fi ts into the specifi c of the activities de- signed to increase the awareness of the population in rural areas regarding what they need to do to maintain a good health, both from the perspective of prevention and treatment’ (mayor, intervention commune). (2) A support program for family physicians – ‘for me [the IRIS intervention] represents a support’ (family physician, intervention commune), but also (3) as a means to reduce disparities in the access to health information between rural and urban areas – ‘of course that the rural population is generally less informed, there is a gap between the city and the countryside (…) this project is very useful in this sense’ (mayor, intervention commune). Theme 2: the capacity of the IRIS intervention to facilitate access of rural com- munities to health information. The analysis revealed that the IRIS intervention was eff ective in facilitating the access of rural inhabitants to health information. Yet, two main discourses emerged from the data explaining the lack of interest and involve- ment of some villagers for the IRIS intervention: (1) that only some population groups are interested in such initiatives – ‘I believe that no program can have benefi ts for 100% 34 of the population, because not everyone participates’ (mayor, intervention commune) and (2) that individuals living rural sett ings prioritize working the land over their health – ‘people in the countryside do not postpone working their land for anything in the world. So this is more important for them than their health’ (librarian, intervention commune). Theme 3: the involvement of the local institutional actors in the IRIS intervention. The direct and active involvement of the institutional actors in this initiative has been done by promoting the lending of health-related books from the local library and by recommending the participation in the IRIS health workshops: ‘we tried to be an active partner in this project. Personally, even when I left the church on Sundays, when it is fairly common to inform citizens, I promoted these activities (…) so we encouraged participation’ (mayor, intervention commune). Theme 4: the sustainability of the project. The analysis revealed that there was a sense of support for the IRIS initiative even after the offi cial end of the project, but the need to continue the initiative has emerged from the discourse of the interviewees. As one of the interviewee said: ‘I hope you can continue this activity because they [people living in rural areas] have a constant need of support and motivation to access health-related information’ (family physician, intervention commune). Theme 5: suggestions for future initiatives designed to increase access of rural populations to health information. In this respect, some interviewees argued that more should be done to involve the villagers in such activities by fi nding new dis- semination and promotion strategies: ‘we have to fi nd some new ideas (…) something to att ract them (…) even if they don’t realize the importance [of participating in these activities]. It is diffi cult to gather people just by telling them you can off er them health-related infor- mation, because people don’t always appreciate gett ing information’ (mayor, intervention commune); others expressed the need for a bett er involvement of the local authorities in such initiatives, because time and eff ort are needed to ‘break down barriers of under- standing and conception’ (family physician, intervention commune). 4. Discussion The proposed Initiative for Health Information Resources in Rural Areas (IRIS), a pilot intervention implemented both at the population and institutional level in two rural communities in Cluj county, has been proven eff ective in enhancing access to health information in rural areas by (1) ensuring the availability of health informa- tion and (2) increasing the health information seeking behavior of rural residents. In terms of the availability of health information, the access to reliable information re- sources was ensured by equipping local libraries with books on health topics and training the librarians activating within the formal frameworks of village libraries to recommend these books. Regarding the health information seeking behavior of the population, the intervention was designed so as to increase individuals’ knowledge and build up their health information seeking skills, with the ultimate purpose to promote the access and utilization of the available health-related resources. To the best of our knowledge, based on a rapid review of existing health literacy programs 35 implemented in Romania, there are no similar initiatives implemented in Romanian rural or remote sett ings. The IRIS initiative and the results we are reporting are important from at least two perspectives: (1) they add to the body of information and literature on health literacy in Romania, which is currently scarce (Monceanu, 2015), and (2) they respond to the needs of rural inhabitants identifi ed in the only health literacy-based study conduct- ed in Romanian rural sett ings, which highlights low levels of health literacy among rural inhabitants (Pop et al., 2013). While access to health information was also found to be limited in most Transylvanian rural areas due to the lack of community libraries or the lack of health-related resources in the existing libraries (Baba et al., 2010), no in- formation is available on the level of self-effi cacy in searching for health information among the Romanian rural population. In this context, our results have the potential to signifi cantly improve the current situation by enhancing rural inhabitants’ access to health information and ultimately improve their health status. More specifi cally, by employing the proposed population and institutional-level strategy, the intervention was successful in increasing the health information seeking behavior of the rural population, the self-effi cacy of the individuals in searching for health information, and health literacy levels in the rural communities included in the IRIS intervention. Furthermore, as librarians were promoted as lay experts in health information resources, the role of village libraries in having a well-informed commu- nity on health themes was improved. As a result, individuals from rural communities included in the intervention group were more engaged in health information seek- ing and reported higher frequencies of asking about and borrowing books on health themes from the village library as compared to respondents in the control group. These results are similar with the ones obtained by similar programs implemented in the USA and designed to enhance the role of local libraries to improve population health (Morgan et al., 2016; Zager et al., 2016). As the IRIS initiative made use of available community resources and proposed only several incremental changes within the librarian system, this low-cost interven- tion has a major potential of sustainability and replicability in other rural and remote sett ings across Romania. More specifi cally, the IRIS initiative was based on a collab- oration between important community stakeholders (town halls, libraries, schools, and family physicians’ offi ces) in the two intervention communes, established under the act ‘Together for a Health Community’. By signing this act, the stakeholders have agreed to voluntarily support the initiative by off ering their time and access to their facilities in order to support the implementation of the intervention. In addition, the intervention implementation costs were kept to a minimum by developing partner- ships with four national organizations willing to donate the health-related books and pamphlets used to equip the local libraries participating in the IRIS initiative. This strategy made the IRIS initiative a fi nancially viable, easily transferable, and simple intervention that can be implemented by rural communities and stakeholders across Romania to bring positive change in their inhabitants’ health literacy levels. 36 The intervention’s sustainability is ensured by the participation of both formal and informal community leaders, as well as inhabitants of rural areas in the process of de- velopment and implementation, in the formative research phase of the intervention. Future interventions addressing the health information needs of people living in rural and remote sett ings should consider employing a twofold strategy designed to ensure both the access to health information resources, as well as the engagement of rural residents in health information seeking. In terms of the pursued strategy, the framework proposed and implemented at the institutional level within the IRIS in- tervention was successful in supporting the implementation of the intervention at the population level. In conclusion, the access to health information of rural inhabitants with no or poor connections to external health information sources (such as physicians or the inter- net) can be enhanced by making health information resources available, increase in- habitants awareness regarding the availability of health information, as well as by training local librarians to manage and refer health-related materials to people visit- ing community libraries. 5. Limitations This study has several potential weaknesses. Firstly, the proposed intervention ad- dressed only specifi c aspects related to health literacy and failed to provide a compre- hensive strategy designed to include this concept as a whole. 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