Effective Components on the Empowerment of Insured Individuals from the Perspective of Employees of Iran Health Insurance Organization in 2018

Article History: Received: 18 Aug 2018 Revised: 29 Oct 2018 Accepted: 9 Dec 2018 Introduction: Empowerment of insured persons has been one of the main programs of Iran health insurance organization. Accordingly, this study was designed and implemented with the aim of determining the status of knowledge, attitude and performance of employees, as one of the factors influencing the implementation of the program. Methods: This descriptive-analytic study was carried out in 2016-2018. The data gathering tool was a researcher-made questionnaire that was organized in four sections including demographic information, knowledge, attitude and performance of the staff. The sample size was 1536 people who were selected by random sampling method. Data were analyzed by descriptive (frequency, mean and standard deviation) and analytical (Mann-Whitney, Kruskal-Wallis and correlation tests) methods. Results: A total of 1536 questionnaires were distributed and 1347 questionnaires were received (response rate = 92%). Respondents obtained moderate knowledge score (0.57), desirable attitude (3.9) and moderate performance (1.9). The distribution of the scores in the three main parts of the study showed that the attitude of the staff toward empowerment is positive (73% desirable and 26% moderate). While in the knowledge section, only 43% of the respondents were in desirable condition and 12% were in undesirable condition. In the performance section, only 10% of the respondents had desirable situation and more than 80% showed moderate performance. Conclusion: Positive attitude toward empowerment and its alignment with organizational goals, and weakness in education, and inadequate participation of staff in the design and implementation of programs, are one of the main points that should be considered in designing improvement interventions.

n recent years, Iran Health Insurance Organization has adopted the strategy of empowering insured individuals as a new functional approach. The organization seeks insured, not only as a customer but as a partner to achieve the goals, in all process of the organization(1). The term empowerment in different social, cultural and political domains has different meanings, including self-esteem, capacity for self-realization, participation in decision making and competency(2). This concept in the field of health insurance and in the context of the empowerment strategy of insured persons is one of the sub-sectors of empowerment of the community, which refers to the development of the role of insured individual by increasing their knowledge and ability to make decisions in the health market(3, 4). The World Health Organization (WHO) has included the possibility of people's contribution to make decisions on health issues as a component of a good health system(5). Accordingly, the strategy of empowerment of insured individuals, as a new functional approach, has led health insurance organizations to look at their insured not only as a client but also as a partner to achieve goals(6). In simple terms, the required information as well as the opportunities for participation in health decisions will be available to the insured through the various departments of the insurance organization(2). In recent years the empowering of insured individuals has been one of the main programs of Iran Health Insurance Organization, as a major insurance company in the country, covering over half of the population(1). It indicates the exact knowledge of organization about its core challenges. Disability and lack of capacity and the possibility of participation of insured patients in decision-making can divert most of the costs allocated to the health sector from the main pathway(7). Experiences show that in the success of community empowerment programs, including insured individuals, certain elements are effective including access to information, acceptance and participation, involvement and accountability of local organizational capacities(8). But the executive arms in the pursuit of these goals and programs are the relevant organizations, and in particular their staffs. Employees are the most valuable source of today's organizations because they formulate organizational decisions, solve organizational problems, and implement the goals of the organization(9). According to the system perspective, man plays a major role in today's organizations as a complex subsystem and of course, works with his own attitude and motivation in the organization(10). Izdadbakhsh et al. (11), investigated the empowerment of insured persons in Iran Health Insurance Organization. They concluded that based on the results of various meetings with health care professionals and reviewing resources, in order to empower insured individuals, several strategies are being adopted that can be implemented in six areas of information and education, accountability, participation, local organizational capacity, financial empowerment (from two perspectives of increasing funding and financial resources control) and delegation. In the meantime, a fundamental question is whether the staffs of an organization, such as the Iran Health Insurance Organization, as the implementers of empowerment programs for insured persons, are prepared to accept and implement these programs? The answer to this question requires a comprehensive picture of the status of the knowledge, attitude and performance of the subjects .Knowledge, attitude and performance are the tools for recognition of the community education. By measuring these three factors, a clear and understandable status of the capabilities of the society as well as its knowledge and attitudes are presented(11). These studies tell us how much the community is considering the topic. How it feels and how it behaves? The ability to implement and measure the factors as well as the ease of interpreting the results is the benefits of this method of study(12). This study was conducted with the aim of determining the status of knowledge, attitude and performance of the staff of Iran Health Insurance Organization regarding the empowerment of insured persons.

Materials and Methods
This descriptive-analytic study was carried out in 2016-2017. The research populations were employees of the Iran Health Insurance Organization including a headquarters in Tehran and 31 provincial offices. Random stratified sampling method based on the place of work was used so samples were organized in 32 classes (provincial offices and headquarters). The list of employees in each unit was prepared then based on the share of the employees in the total population of the organization, the number of samples of each unit was determined. The samples were selected by systematic random sampling in each unit and the questionnaire was completed by self-assessment. The data gathering tool was a researcher-made questionnaire that was organized in four sections including demographic information, knowledge, attitude and performance of the staff. In the demographic section, factors such as age, gender and work experience were assessed. The questions about knowledge, attitude and performance were designed based on an extensive literature review as well as using experts' opinion, in two rounds of Delphi method in cooperation with experts in the field of health insurance. By experts' approving, 6 questions for assessment of knowledge, 12 questions for assessment of attitude and 7 questions for assessment of performance were selected. In assessment of knowledge, answers included correct (1 score), I do not know (0 score) and incorrect (-1 score). In the attitude section, the five-point Likert scale (from I totally disagree with 1 score to I totally agree with 5 score) was used. In the performance section, responses were presented in the three-point range as yes (3 score) to some extent (2 score) and no (1 score). The average of maximum and minimum of scores in each of the knowledge, attitude and performance sections were evaluated from weak to strong in three categories of undesirable, moderate and desirable condition (Table 3). In order to control the data in the attitude section, two invert points (reverse) were considered.
To assess the reliability of the tool, the initial questionnaire was distributed among 45 members of the target population, then by using internal consistency (Cronbach's alpha α=.78) and stability (split halves s.c=0.79) the reliability was confirmed. To assess the validity, three methods of formal (qualitative and quantity), content (ratio and index) and structural (factor analysis) methods were used. In order to test the formal validity of the tool in qualitative way, the viewpoint of 10 health system experts (in the field of health insurance), regarding the assessment of the level of difficulty, proportionality and ambiguity was investigated and eventually all terms were accepted with some modifications. In the quantitative assessment, the item impact score, with the participation of 10 members of the target community was used. The significance of each item was measured and by considering acceptable score (scores above 1.5), all the statements were approved . To test content validity, content validity ratio was calculated to ensure that the most relevant and correct content (relevance of the question) was selected, and content validity index was used to ensure that the questions were designed to measure the content in best way, the results were checked and approved according to Lawshe table.
In order to test the structural validity, 250 samples (ten times the number of items) were selected based on available sampling from 4 selected provincial units, then exploratory factor analysis method was used. The questionnaire consisted of 25 main items, in communalities all items had a factor load more than 0.5 and more than 62% of the variations were covered in the form of 9 factors. In terms of knowledge, three areas (theoretical concept, operational concept, and specialized knowledge), in terms of attitude four areas (the role of insured, employees' participation, empowerment culture and awareness) and in terms of performance two areas (individual and organizational tasks and performances) were investigated in the final questioner. Data were analyzed by descriptive and inferential methods and by using SPSS software version 19. In the descriptive analysis, the frequency, mean and standard deviation were used and in the analytical part Mann-Whitney and Kruskal-Wallis tests as well as correlation tests were used.

Results
A total of 1536 questionnaires were distributed and 1347 questionnaires were received. By deleting misleading questionnaires, 1293 complete questionnaires were investigated in the study that showed a response rate over 92%. 54% of respondents were male and 63% of them were in the age group of 41 to 50 years old .Nearly 60% of the participants were permanent employees and more than 70% of them had ten to twenty years of work experience. 53% of samples had bachelor degree. 65% of the samples were in the operational (technical) departments and 73% were in the expert positions. Only 40% of samples participated in relevant educational courses. In the final section of the questionnaire, an open question was asked that more than 40% of participants responded to this question (regardless of text and response quality), which could be a good sign of participation in responding to the questioner. These statistics, along with the high rate of accountability, are the strengths of this study.
Knowledge of the employees was assessed in moderate level (0.57 out of 1 point). Theoretical concept (0.76) had the highest and operational concept (0.39) had the lowest score (Table 1).
The attitude level of the employees, with a score of 3.9 out of 5, was assessed in desirable situation. In this section, the role of the insured with 4.2 score had the highest and empowerment culture with 3.6 score had the lowest score (Table  2).
In the performance section, tasks area had 1.2 and performance area had 1.8 score out of a total of 3 scores . This section showed a moderate situation with a score of 1.9 (Table 3).
The distribution of the scores in the three main parts of the study showed that the attitude of the staff toward empowerment is positive (73% desirable and 26% moderate). While in the knowledge section, only 43% of the respondents were in desirable condition and 12% were in undesirable condition. In the performance section, only 10% of the respondents had desirable situation and more than 80% showed moderate performance (Table 4).
On the other hand, according to the results of the correlation test there was a positive and significant relationship between the main structures of the study (knowledge, attitude and practice). This finding shows the need for balanced and coordinated attention to these three structures. Table 5 shows the relationship between demographic variables of study and the rating of study structures. The results showed that there was a significant difference between employees' level of knowledge in different groups, except for grouping based on occupation unit (p = .35) and age (p =.15). This difference was particularly evident in terms of educational degree and participation in the training course .In the structure of attitude, except for the gender, other variables showed significant differences among their groupings. However, in the performance structure, only the educational degree, job category, and training course have shown these differences.

Discussion
This study examines the level of knowledge, attitude and performance of Iran Health Insurance staff regarding the empowerment of insured individuals and its relationship with demographic factors . In the present study, the knowledge of employees was evaluated in average level. In this section, the theoretical concept had the highest and operational concept had the lowest score. Bano et al. (13), considered knowledge as an ability to acquire, maintain, and use information and a combination of understanding, experience, recognition, and skill. Bardan also considered it as the ability to search and use information by understanding and learning from experiences and using technology (14).
Attitudinal components as the second pillar of the structure of knowledge, attitude and performance can complement the component of knowledge .Attitude is considered as ways to react and desire toward specific circumstances; to see and interpret events for specific reasons; or to organize views with a coherent and relevant structure (15). Performance can be considered as the sum of knowledge and behavioral habits. Performance is the combining of knowledge and attitude with the rules that leads to action, therefore the best performance as an art, will also be related to the advancement of knowledge and technology along with ethical performance (13,15).
One of the findings of this study is the correlation between knowledge, attitude and performance, however in both of these studies, the relationship between these three main structures and the role of knowledge as the main basis for attitude and performance have been considered.
The overall assessment of the survey reflects the average level of knowledge of respondents in terms of empowerment of insured individuals .12% (155) of respondents had undesirable knowledge level and 45% (582 people) had moderate knowledge. The important point in this regard is the weakness of employees' knowledge in the operational concept due to the lack of understanding of the concept of the empowerment of insured persons with other commonly used organizational concepts, such as informing, educating and client reverence. In the meantime, the item "the most important goal of empowerment is the insured awareness of the insurance regulations" got the lowest correct answer (0.2 out of 1) which shows that respondents, in spite of relative acquaintance with the empowerment concept, consider it as awareness which is one of its subsections. However, according to the study of Izdadbakhsh et al. (11), in order to empower insured individuals, several strategies can be implemented in six areas of information and education, accountability, participation, local organizational capacity, financial empowerment (from two perspectives of increasing funding and financial resources control) and delegation.
Strong correlation between participating in the related educational courses and the level of knowledge, attitude and performance of the staff and on the one hand the participation of only 40% of respondents in these courses shows the importance of these trainings and the need for their quantitative and qualitative development. Rafiefar et al. (16), in their study concluded that education should be recognized as an important part of social development strategies so that by raising the level of knowledge and skills of individuals, they can decide on their own, family and society health. Investigating attitude of respondents showed that this structure was in desirable conditions .Over 70% of the respondents had positive attitude towards the empowerment strategy of insured individuals. Items such as " knowledgeable and demanding insured person is considered as an organization capital", "empowerment of insured people can reduce costs for the organization " and "Promoting the culture of empowering of insured persons is essential to advance the organization's goals ", got the highest score (4.3 of the total 5) among 12 items that investigated respondents' attitude. These items were based on values that lead to the alignment of employee activities with the goals of the organization. On the contrary, item "employees are encouraged by their managers to participate in these programs" got a low score (1.3 out of a total of 5), it can be a warning to the organization and shows that employees 'perception about directors' involvement with this strategy is not desirable and needs to be reviewed. The important thing is that employees' attitudes toward a particular topic is not inflexible and can be changed. Yousefi et al. (17), in a study concluded that education has a strong role in improving the attitudes of the employees along with improving knowledge and performance. The positive attitude of employees is very effective in organizational success, especially in the implementation of change plans, and effective planning is essential to improve the situation. Two domains of employee participation and empowerment culture, which emphasize on practical role of employees, have gotten lower scores than other two areas, which could mean that employees are uncertain about the co-operation with other colleagues in implementing these programs. In the study of Pourreza et al.(18), the findings also showed that employees, despite the rational acceptance of the concept, were uncertain about the co-operation of their colleagues in implementing the programs. According to the results respondents' performance regarding empowerment programs was evaluated in moderate level, of course, this result was expected. In study of Yusefi, performance score has been significantly less than knowledge and attitude scores (17), which can be because the desired performance is the result of aggregation of knowledge and attitude over time (15). In the current study, over 80% of the respondents had moderate performance .The inadequate education along with the planning problems for employee familiarization with their duties in implementing the strategy can be the reasons for this. According to the study of Moeini et al. (19), respondents, in spite of having high knowledge and negative attitudes towards workplace violence, did not report cases because of lack of required implementation mechanisms.
Interestingly, according to the results the highest score (2.7 out of 3) was related to the item "health insurance organization is obligated to protect the rights of its insured" and the lowest score (1.4 out of 3) was related to the item "I am required to provide full advice to clients about health and insurance". This contradiction in individual and organizational behavior can be attributed to the fact that, despite the belief in the usefulness of the programs, people are still not aligned with their individual assignments in this field. On the other hand, the item "I have not been involved in any of the programs for the empowerment of insured persons so far", got a high score (1.2 of 3), which indicates the breakdown of programs in the implementation phase and the lack of expansion and influence of the strategy at the operational levels.
The other strain of this study is the relationship between the demographic variables and knowledge, attitude and performance of the respondents. The findings show the significant relationship between participation in the training course and empowerment in all three structures, which can indicate the importance of these training courses. Lakbala in his study also emphasizes the role of education and awareness in changing attitudes and behavior of respondents (20).
Knowledge, attitude and performance of employees in operational and support units were not significantly different. Official staff had higher level of knowledge and attitude in compare with other employees, although these two groups did not have significant differences in performance area. This situation also was observed in terms of different age groups and work experience. Considering the recent government downsizing policies and the decline in the official recruitment of young employees, generally, formal employees have a higher age and work experience, but their high score can be attributed to their access to training and using them in critical positions .
Respondents have different grades depending on the job category in all three areas, but it is interesting to note that the knowledge and attitude of the employees to the managers had upward trend, but there was a declining trend in performance area. Employees with higher levels of education had a higher degree of knowledge and attitude, but employees with Master and PhDs degrees had lower performance grades.
Unfortunately, similar studies that could explain these findings were not accessible for researchers, but the alignment of these two findings can be attributed to the fact that in this specialized organization, mostly people with higher educational degrees were occupied at higher position. Two variables of age and sex had different behaviors .In the knowledge area, men had higher score and the difference was significant, but there was not a significant relation in the other two parts. In age variable, attitude score indicated a significant difference, and it is interesting to note that the attitude of employees over 50 years old had a better status than others. In general, the least impact of different groupings was related to the performance and most of it was related to the attitude.
One of the serious limitations of this study was the lack of access to previous related studies by researchers in this regard. The main reason for this might be the novelty of the concept at the domestic level and the structural differences between the insurer organizations at the international level. Accordingly, it is attempted to emphasize and expand the results in the discussion for the further understanding of the concepts.

Conclusion
This study aimed to investigate the level of knowledge, attitude and performance of Iran Health Insurance Organization staff regarding the strategy of empowerment of insured individual using a researcher-made tool . According to the results of the study knowledge and performance of the staff was in moderate level and the respondents' attitude was in desirable condition and in general, there was a partial readiness to implement the strategy-related programs. Positive attitude toward empowerment and its usefulness in advancing organizational goals are one of the most important strengths of this strategy .While the weaknesses in theoretical and practical training, employees' uncertainty about the attendance of their managers and colleagues and the inadequacy of employee participation in designing and implementing programs are one of the main weaknesses of the program. Regarding employees' knowledge it seems that the quantity and quality of related training, and in particular its coverage, is important for all staff at different level of the organization . Due to the novelty of the concept and weakness of written literature in this regard, it seems that the organization needs more serious investments. The reported weakness can be attributed to weaknesses in executive planning at the headquarters and operational levels . It seems that, based on the positive public opinion and attitude that exists among the staff structural changes are necessary. The scores vary in different demographic group, which shows the need to change orientations and focus on marginalized groups, including young staff with lower qualifications in organizational empowerment programs to publicize and expand the strategy.