Designing a respectful maternity care guideline: a multiphase study.

BACKGROUND: There is no comprehensive guideline for respectful maternity care (RMC) promotion in Iran. This study aimed to design a RMC guideline based on a multiphase study. METHODS: In this multiphase mixed-methods study, recommendations were made for RMC promotion through the data obtained from Phase I (i.e., the quantitative section with a cross-sectional design), Phase II (i.e., the qualitative section with a content analysis method), and Phase III (i.e., focus group discussions with birth attendants as well as opinions of the specialized panel through the Delphi technique). The composed recommendations were then analyzed and finalized by relevant specialists in terms of execution capacity, approvability, and cost-effectiveness within the current context of Iran. Eventually, the resultant guideline were evaluated and approved by two members of the research team specializing in the research area in accordance with the Appraisal of Guideline for Research and Evaluation (AGREE). RESULTS: The results of this multiphase study led to 80 recommendations for RMC promotion. The recommendations were classified as eight areas called recommendations for the pregnancy period, recommendations for the labor period and delivery, recommendations for the neonatal period, occupational recommendations, supervision recommendations, national policy recommendations, recommendations for training students and staff, and general public recommendations. DISCUSSION: Based on the outcomes of disrespect and abuse, it is recommended to provide comprehensive guideline for policymakers and planners to formulate plans through the RMC promotion approach. Healthcare service policymakers can use this guideline to design some interventions to meet women's financial, psychological, and legal needs.

Disrespect and abuse in the delivery room is associated with negative experience of delivery and poor maternal care quality index. Also, disrespect and abuse is the main barrier to achieving maternal health outcomes. In spite of the considerable achievements in maternal and child health, there is still a large number of maternal and neonatal mortality worldwide. It seems that disrespect and abuse is a key potential obstacle hindering access to delivery facilities and skilled care providers. To achieve the sustainable development 2030 goals developed by the World Health Organization (WHO) (Goal 3.1: Ensure health lives and promote well-being for all at all ages: reduce the global maternal mortality ratio to less than 70 per 100,1000 live birth), stakeholders and relevant institutions should consider respectful pregnancy and delivery care services as a key solution to reducing maternal mortality. Nevertheless, there is no comprehensive guideline with regards to respectful maternity care in the WHO or provided by other countries. In this multiphase mixed-methods study, recommendations were made for respectful maternity care promotion through the data obtained from Phase I (i.e., the quantitative section with a cross-sectional design), Phase II (i.e., the qualitative section with a content analysis method), and Phase III (i.e., focus group discussions with birth attendants as well as opinions of the specialized panel through the Delphi technique). The composed recommendations were then analyzed and finalized by relevant specialists in terms of execution capacity, approvability, and cost-effectiveness within the current context of Iran. The results of this multiphase study led to 80 recommendations for RMC promotion. The recommendations were classified as eight areas called recommendations for the pregnancy period, recommendations for the labor period and delivery, recommendations for the neonatal period, occupational recommendations, supervision recommendations, national policy recommendations, recommendations for training students and staff, and general public recommendations.

The effect of ginseng on sexual dysfunction in menopausal women: A double-blind, randomized, controlled trial.

OBJECTIVES: Sexual problems constitute a largely-overlooked problem for women during menopause. The present study was conducted to determine the effect of Ginseng on sexual function (primary outcome), quality of life and menopausal symptoms (secondary outcomes) in postmenopausal women with sexual dysfunction. DESIGN: This randomized controlled trial was conducted on 62 women who were randomly assigned to the intervention/control groups using block randomization. INTERVENTION: The intervention group received 500 mg of Panax Ginseng and the control group received placebo twice daily for four weeks. MAIN OUTCOME MEASURES: Standard questionnaires including the Female Sexual Function Index (FSFI), the Menopause-Specific Quality of Life (MENQOL) and the Greene Menopausal Symptom Scale were completed before and four weeks after the intervention. RESULTS: There were no statistically significant differences between the two groups in terms of demographic characteristics and the baseline scores of sexual function, quality of life and menopausal symptoms (P > 0.05). After the intervention, the mean total score of FSFI (Adjusted Mean Difference = 6.32, 95% CI = 3.48 to 9.16, P < 0.001) was significantly higher in the intervention group compared to the control group. The mean total score of quality of life (AMD=-20.79, 95% CI=-25.83 to -15.75, P < 0.001) and menopausal symptoms (AMD=-8.25, 95% CI=-10.55 to -5.95, P < 0.001) were significantly lower in the treatment group than the control group. CONCLUSION: Ginseng has significant effects in improving sexual function and quality of life and mitigating menopausal symptoms. As a multipotent plant, Ginseng can be a suitable alternative for conventional therapies to promote the health of menopausal women.

Effect of counselling on health-promoting lifestyle and the quality of life in Iranian middle-aged women: a randomised controlled clinical trial.

BACKGROUND: Promotion of healthy lifestyle is an important strategy. This study was conducted to determine the effects of counselling on health-promoting lifestyle and quality of life in middle-aged women. METHODS: This randomised, controlled, clinical trial was conducted on 102 middle-aged women presenting to health centers in Tabriz, Iran, in 2016-17. Using stratified blocking based on age (40-50 and 50-60 age groups) with block sizes of four and six, eligible middle-aged women were randomly allocated to the intervention and control groups. The intervention group received health-promoting lifestyle counselling over three 45-min sessions. The control group received the routine care provided by health centers. The Health Promoting Lifestyle Profile- II (HPLP-II) and quality of life survey (SF-36) were completed in both group before and four and eight weeks after completion of the intervention. Data were analyzed using the independent t-test and the repeated measures analysis of variance (ANOVA). RESULTS: After adjustment for the baseline values, the repeated measures ANOVA showed that the mean scores of health-promoting lifestyle (adjusted mean difference = 0.91, 95% confidence interval: 0.83 to 0.99, P < 0.001) and quality of life (18.2, 15.75 to 20.66, P < 0.001) were significantly higher in the intervention compared to the control group after the intervention. CONCLUSION: Counselling can improve health-promoting lifestyle and quality of life in middle-aged women. TRIAL REGISTRATION: IRCT2015122610324N27. Registered 4 February 2016.

A randomized controlled trial on the effect of lifestyle education for Iranian women and their husbands on post-partum anxiety and depression.

This randomized controlled trial was conducted on 189 pregnant women to determine the effect of lifestyle-based training for women and their husbands on post-partum anxiety (PPA) and depression (PPD). Follow-ups were continued up for 6 weeks after childbirth. Participants were allocated to three groups using block randomization. In the first intervention group, both the women and their husbands, and in the second intervention group only the women received the lifestyle-based education. In the control group, women received only routine care. Participants completed the Edinburgh Postnatal Depression Scale and Spielberger State-Trait Anxiety Inventory pre-intervention and 6 weeks after childbirth. When compared with the control group, significant reductions in PPD (adjusted difference: -5.5), state anxiety (-13.6) and trait anxiety (-12.6) scores were observed in the lifestyle education-dyad group, and also significant reductions in PPD (-3.2), state anxiety (-5.8) and trait anxiety (-4.9) scores were observed in the lifestyle education-women only group. Also, significant reductions were observed in PPD (-2.2), state anxiety (-7.8) and trait anxiety (-7.7) scores in the lifestyle education-dyad group compared with the lifestyle education-women only group. Results showed the positive effect of lifestyle training on PPD and PPA, especially if the training is given to the parental dyad.

Religious Practice and Health-Related Quality of Life in Iranian Adolescent Girls.

This study aimed to determine the relationship between religious practice and health-related quality of life in adolescent girls in Tabriz, Iran, 2014-2015. This cross-sectional study was conducted on 520 female students who were selected using the random sampling method. Religious practice and health-related quality of life questionnaires were used for data collection. Multivariate linear regression analysis showed a significant relationship between health-related quality of life and received religious support, religiosity, father's and mother's education, father's occupation, family economic status, and the number of children. It is necessary to find ways to further promote religious practices in adolescents and ultimately their quality of life.

Predictors of Depression in Iranian Women with Polycystic Ovarian Syndrome.

Depression is a major complication of polycystic ovarian syndrome (PCOS). Lifestyle modification can prevent it. This study aimed to determine the predictors of depression in women with PCOS. This cross-sectional study was conducted on 174 women who attended in infertility clinics in Urmia-Iran, 2015. The data were collected through socio-demographic, Beck Depression Inventory-II and Health Promoting Lifestyle Profile-2 questionnaires. The mean (standard deviation) of total score of the depression was obtained 27.4 (10.5) in the range 0-63. The mean (SD) of total score of the health promoting lifestyle was obtained 2.2 (0.3) out of 4. Based on multivariate linear regression, the variables of nutrition, interpersonal relationships, spiritual growth, stress management, BMI, the perceived stress of the disease, the first supporter and menstrual bleeding were predictors of the depression. Given the high prevalence of depression in PCOS patients and its relationship with health-promoting behaviors, lifestyle modification to reduce depression is necessary.

The effect of Vitamin D and calcium plus Vitamin D on leg cramps in pregnant women: A randomized controlled trial.

BACKGROUND: This study intended to determine the effects of Vitamin D and calcium-Vitamin D in treating leg cramps in pregnant women. MATERIALS AND METHODS: This study was conducted as a double-blind randomized controlled clinical trial on 126 participants, 18-35-year-old pregnant women with a minimum of two leg cramps per week who were referred to health-care centers in Tabriz-Iran in 2013. The participants were allocated to three 42 member groups using a randomized block design. For 42 days, the intervention groups took a 1000 unit Vitamin D pill or 300 mg calcium carbonate plus a 1000 unit Vitamin D pill, and the control group received a placebo pill every day. The participants were evaluated with regard to the frequency, length, and pain intensity of leg cramps during the week before and during the 3rd and 6th week of the intervention. The ANCOVA and repeated measurement test were used to analyze the data. RESULTS: Results showed that controlling for the effects before the intervention, calcium-Vitamin D, and Vitamin D supplements had no effect on the frequency, length, and pain intensity of leg cramps. CONCLUSION: The results of this study showed that the calcium-Vitamin D and the Vitamin D supplements have no effect on the frequency, length, and pain intensity of leg cramps during the 6 weeks of the study.

The predictors of quality of life in women with polycystic ovarian syndrome.

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorder that may be effective in reducing the quality of life. This study aimed to determine the predictors of quality of life in women with PCOS. This cross-sectional study was conducted on 174 women with PCOS who attended in public and private fertility clinics in Urmia (West Azerbaijan, Iran), 2015. The data were collected through the questionnaires of sociodemographic and obstetrics characteristics, quality of life and Beck depression inventory-II. Multivariate linear regression was used to estimate the effect rate of the independent variables (depression and sociodemographic characteristics) on the dependent variable (quality of life). In this study, the mean (standard deviation) of total score of the quality of life was obtained, 45.8 (11.3) in the range 0-100. The highest and lowest mean scores were in the subdomains of weight and hirsutism. The variables of depression, body mass index, woman's job, menstrual cycle intervals, and sexual satisfaction were predictors of the quality of life in women with PCOS. Because of various effective factors on quality of life in these women such as depression, necessary strategies must be implemented to control these factors and improve the quality of life.

The Effect of Life Style Based Education on the Fathers' Anxiety and Depression During Pregnancy and Postpartum Periods: A Randomized Controlled Trial.

Due to the harmful effects of prenatal and postnatal anxiety and depression on fathers, the aim of this study was to determine the impact of lifestyle-based training on paternal depression and anxiety (primary outcomes) during the prenatal and postnatal periods. This single-blind randomized controlled clinical trial was conducted on 126 spouses of pregnant women with gestational ages of 24-28 weeks. They were followed up until 6 weeks after childbirth. Using the block randomization method and stratified based on the number of children, the eligible samples were divided into two groups (one receiving two weekly group lifestyle-based training session (lasting 60-90 min) and a control group). Edinburgh Postnatal Depression Scale and Spielberger's State-Trait Anxiety Inventory were filled out by the participants before the intervention, 8 weeks after it, and 6 weeks after childbirth. The general linear model was used to analyze data. Out of 126 fathers, one individual from the intervention group left the study because he was not willing to cooperate. Compared with the control group, there was a significant decrease in depression (adjusted difference: -1.6; 95% CI -2.8 to -0.5), state anxiety (-5.7; -8.6 to -2.9) and trait anxiety (-5.0; -7.8 to -2.2) scores at 8 weeks after intervention as well as postnatal depression (-3.3; -5.0 to -1.5); postnatal state anxiety (-7.5; -11.6 to -3.4), and postnatal trait anxiety (-8.3; -12.2 to -4.4) in the intervention group. The research results indicated the positive impact of training on prenatal and postnatal depression and anxiety in fathers. Given the easy implementation of training interventions during pregnancy, it is suggested that such interventions be paid more attention.

Spiritual Well-Being and Health-Related Quality of Life in Iranian Adolescent Girls.

This study aimed to determine the status of quality of life, spiritual well-being, and their relationship among Iranian adolescent girls. This cross-sectional study was conducted on 520 students using the cluster sampling method. The mean score of quality of life was 59.86 (SD: 12.7) from the possible range of 0-100. The mean score of spiritual well-being was 90.22 (SD: 16.25), ranging from 20 to 120. Multivariate linear regression analysis showed a significant relationship between quality of life and the factors including existential well-being, religious well-being, parents' belief for their children's participation in religious ceremonies, father's education and occupation, father's illness, sufficiency of family income for expenses, and the number of children. Given that spiritual well-being dimensions are among the predictors of quality of life. Thus, it is necessary to find ways to promote spiritual well-being in adolescents and ultimately improve their quality of life.

A population-based study of health-promoting behaviors and their predictors in Iranian women of reproductive age.

Health-promoting behaviors have been recognized as major factors for maintenance and improvement of health. The objective of this study was to determine the status of health-promoting behaviors and their predicting factors in Iranian women of reproductive age. This was a population-based cross-sectional study in which 1359 Iranian women of reproductive age were selected by proportional random multistage cluster sampling in Tehran. Questionnaires including sociodemographic characteristics, Health-Promoting Lifestyle Profile-II (HPLP-II) and Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2) were completed by interview. The association between the dependent variables (HPLP-II and subscales) and the independent variables (social support and sociodemographic characteristics) was analyzed using the multivariable linear regression model. Among the six dimensions of health-promoting behaviors, women scored highest in interpersonal relations (3.08 ± 0.51) and lowest in physical activity (2.04 ± 0.64). The Pearson test indicated perceived social support to be significantly correlated with HPLP-II (r = 0.53; p < 0.001) and all its subscales (r = 0.12-0.60; p < 0.001). Multivariable regression analysis indicated social support to be a predictor of HPLP-II and all its subscales, except for physical activity. Social support and sociodemographic characteristics accounted for 29.8% of the variance in the HPLP-II score and 6.9-39.3 in the six subscales. The findings of the present study confirm the importance of social support and modifiable variables (sociodemographic) in the occurrence of health-promoting behaviors in women and accredit the theoretical relationships among the concepts of the health-promotion model.

Health-promoting behaviors and social support in Iranian women of reproductive age: a sequential explanatory mixed methods study.

OBJECTIVES: The aim of this study was to determine health-promoting behaviors and their determinants including social support and sociodemographic characteristics as well as to explore women's experience of health-promoting behaviors. METHODS: This sequential explanatory mixed methods study was conducted in two phases. The first phase was a cross-sectional study conducted on 1,359 women. Questionnaires, including items on sociodemographic characteristics, the HPLP-II and the PRQ85-Part2, were completed by interview. In the second phase, 15 women who were identified as extreme cases participated in individual in-depth interviews. RESULTS: The results of the quantitative phase showed that women obtained the highest scores on interpersonal relations and the lowest scores on physical activity. Scores on the HPLP-II and all its subscales correlated significantly with the level of social support. In the qualitative phase, factors affecting health-promoting behaviors were explored and grouped into four main categories that included personal and socio-environmental barriers as well as personal and socio-environmental facilitators. CONCLUSIONS: The findings from this study confirm the importance of social support and modifiable variables (sociodemographic) that play a role in the health-promoting behaviours of women. These results will be useful in designing suitable interventions and strategies for the promotion of women's health.

Facilitators and Inhibitors of Health-promoting Behaviors: The Experience of Iranian Women of Reproductive Age.

BACKGROUND: There is scant information on the facilitators and inhibitors of health-promoting behaviors among reproductive-aged Iranian women. This study aims to explore the experience of factors influencing health-promoting behaviors among Iranian women of reproductive age from a qualitative perspective. METHODS: This study was performed in Tehran in 2011, over about 8 months. Qualitative methods, specifically in-depth interviews, were used to gather data on 15 women of reproductive age. Data continued to be collected until introduction of new information ceased. The interviews were recorded, transcribed verbatim, and analyzed by conventional content analysis. RESULTS: The reported factors were categorized into four main groups and 12 subgroups: (1) personal barriers (lack of time, school or work duties, lack of preparation or motivation, physical disability); (2) socio-environmental barriers (family responsibilities, environmental pressures, high-costs and financial pressures); (3) personal facilitators (personal interest and motivation, experience of disease); and (4) socio-environmental facilitators (family and social support networks, encouraging and motivating environment, media, and public education). CONCLUSIONS: In these women's experience, factors influencing health-promoting behaviors were either facilitators or inhibitors; most were inhibitors. The findings of this study show that, in addition to personal factors, the pursuit of health-promoting behaviors is affected by socio-environmental factors. These results will be useful in designing interventions and plans for women's health promotion that focus on the improvement of their environment and the modification of social factors.

Social support for women of reproductive age and its predictors: a population-based study.

BACKGROUND: Social support is an exchange of resources between at least two individuals perceived by the provider or recipient to be intended to promote the health of the recipient. Social support is a major determinant of health. The objective of this study was to determine the perceived social support and its associated sociodemographic factors among women of reproductive age. METHODS: This was a population-based cross-sectional study with multistage random cluster sampling of 1359 women of reproductive age. Data were collected using questionnaires on sociodemographic factors and perceived social support (PRQ85-Part 2). The relationship between the dependent variable (perceived social support) and the independent variables (sociodemographic characteristics) was analyzed using the multivariable linear regression model. RESULTS: The mean score of social support was 134.3 ± 17.9. Women scored highest in the "worth" dimension and lowest in the "social integration" dimension. Multivariable linear regression analysis indicated that the variables of education, spouse's occupation, Sufficiency of income for expenses and primary support source were significantly related to the perceived social support. CONCLUSION: Sociodemographic factors affect social support and could be considered in planning interventions to improve social support for Iranian women.

The experiences of women of reproductive age regarding health-promoting behaviours: a qualitative study.

BACKGROUND: Health promotion is critical for community and family health. Health-promoting behaviours provide solutions for maintaining and promoting health. Although several studies have addressed the frequency and different types of health-promoting behaviours in women, little information is available about their experiences. This study aimed to explore the experiences of women of reproductive age regarding health-promoting behaviours. METHODS: In the present study, which was conducted in Tehran, Iran, 15 females, who were selected purposefully, participated in individual in-depth, semi-structured interviews. The interviews were recorded, transcribed verbatim, and analysed using conventional content analysis. RESULTS: Nine main categories were derived from the analysis, including establishing an appropriate eating pattern, establishing a balanced rest/activity pattern, spirituality, stress management, personal sensitivity and responsibility, establishing an appropriate pattern of social interactions, practicing safe and healthy recreations, feeling improvement in physical-functional health, and feeling improvement in emotional and psychological health. The first 7 categories represent the nature and types of real health-promoting behaviours in women of reproductive age, whereas the last 2 constitute feeling and understanding of the implementation of these behaviours. CONCLUSION: The study findings show that the women experience improvement in physical-functional, emotional, and psychological health by implementing health-promoting behaviours. It is therefore necessary to introduce strategies in the context of the community culture for improving different aspects of health-promoting behaviours in women of reproductive age to maintain and improve their overall health.

Health-promoting behaviors and social support of women of reproductive age, and strategies for advancing their health: protocol for a mixed methods study.

BACKGROUND: Determining the health-promoting behaviors of women during the important period of reproduction provides valuable information for designing appropriate intervention programs for advancing women's health. There is no study on the health-promoting behaviors of women of reproductive age in Iran. Thus, the aim of this study is to explore these health-promoting behaviors for the purpose of developing comprehensive and culturally sensitive health advancement strategies for Iranian women. METHODS/DESIGN: This study has a sequential explanatory mixed methods design. The follow-up explanation model is used to elaborate the quantitative results by collecting qualitative data from participants who could best assist in elucidating the results. The study is conducted in two sequential phases. The first phase is a population-based cross-sectional survey in which 1350 Iranian women of reproductive age are selected by proportional random multistage cluster sampling of the 22 main municipal sectors of Tehran, Iran. Questionnaires are completed through a face-to-face interview. The second phase is a qualitative study in which participants are selected using purposive sampling in the form of extreme case sampling on the basis of health-promoting behavior scores. The qualitative phase is based on data collected from focus group discussions or individual in-depth interviews. A conventional qualitative content analysis approach is used, and the data are managed with a computer-assisted program. Women's health-promoting strategies are developed using the qualitative and quantitative results, a review of the related literature, and the nominal group technique among experts. DISCUSSION: The findings of this mixed methods sequential explanatory study, obtained using a culturally sensitive approach, provide insights into the health behavioral factors that need to be considered if preventive strategies and intervention programs are to be designed to promote women's health in the community.

The effect of acupressure at the Sanyinjiao point (SP6) on primary dysmenorrhea in students resident in dormitories of Tabriz.

BACKGROUND: There are two types of primary dysmenorrhea (spasmodic and congestive) which differ from each other in terms of the occurrence time in menstrual cycle, pain quality and other symptoms. The present study aimed to determine the effect of acupressure at the Sanyinjiao point (SP-6) on severity of menstrual symptoms (primary outcome) and the duration of resting time as well as the number of ibuprofen consumption (secondary outcome) in the two types of primary dysmenorrhea. METHODS: This was a clustered randomized controlled trial on 72 eligible students residing in dormitories of public universities of Tabriz, Iran. Determining the type of primary dysmenorrhea using a Menstrual symptoms questionnaire (MSQ), 36 participants which suffered from each type of dysmenorrhea were enrolled from the four dormitories. The dormitories were randomly divided into intervention and control groups. No intervention was carried out at the first cycle. During the two next cycles, Sanyinjiao point of the subjects in the intervention group was pressed for twenty minutes at the time of pain. The subjects in both groups were allowed to consume ibuprofen, if needed. During these three cycles, the participants recorded and reported menstrual symptoms severity, duration of resting time and the number of the used ibuprofen. RESULTS: The severity of menstrual symptoms and duration of resting time in the 2(nd) and 3(rd) cycles were significantly reduced more than control groups for both spasmodic and congestive types of primary dysmenorrhea. In addition, the aver-age numbers of ibuprofen pills taken by both intervention groups was significantly less than the control groups. There was no significant difference between the two intervention groups in terms of any of the outcomes. CONCLUSIONS: Acupressure is effective on lowering the symptoms of dysmenorrhea and duration of resting time almost equally in both spasmodic and congestive types. Therefore, using this method either alone or along with other methods is recommended to treat dysmenorrhea.

Effect of a peer-educational intervention on provider knowledge and reported performance in family planning services: a cluster randomized trial.

BACKGROUND: Peer education is an interactive method of teaching or learning which is widely used for educating school and college students, in a variety of different forms. However, there are few studies on its effectiveness for in-service education. The aim of this study was to evaluate the effect of an educational programme including peer discussions, based on a needs assessment, on the providers' knowledge and reported performance in family planning services. METHODS: An educational programme was designed and applied in a random selection of half of in-charges of the 74 family health units (intervention group) in Tabriz at a regular monthly meeting. The other half constituted the control group. The programme included eight pages of written material and a two-hour, face-to-face discussion session with emphasis on the weak areas identified through a needs assessment questionnaire. The educated in-charges were requested to carry out a similar kind of programme with all peers at their health facilities within one month. All in-charges received one self-administered questionnaire containing knowledge questions one month after the in-charge education (follow-up I: 61 responses), and another one containing knowledge and self-reported performance questions 26 months later (follow-up II: 61 responses). Also, such tests were done for the peers facilitated by the in-charges one (105 responses) and 27 months (114 responses) after the peer discussions. Multiple linear regression was used for comparing mean total scores, and Chi square for comparing proportions between control and intervention groups, after defining facility as the unit of randomization. RESULTS: The mean total percentage scores of knowledge (percent of maximal possible score) in the intervention group were significantly higher than in the control group, both at follow-up I (63%) and at follow-up II (57%); with a difference of 16 (95% CI: 11, 22) and 5 (95% CI: 0.4, 11) percentage units, respectively. Only two of the nine reported performance items were significantly different among the non in-charges in the intervention group at follow-up II. CONCLUSIONS: The educational programme including peer discussions using existing opportunities with no need for additional absence from the workplace might be a useful complement to formal large group education for the providers.