Championing Health Promotion through Group Patient and Family Education Activities in the Outpatient Department of a Tertiary Care Hospital

Background Health education involves not only providing relevant information but also facilitating health-related behavior change. Patient education during the waiting period plays an essential role in promoting health and improving patient satisfaction rates. Objective To promote health by educating patients and their companions during their waiting period at the King Fahad Medical City (KFMC) Hospital, Riyadh, with the help of nurses and assess their satisfaction rate. Methods A cross-sectional study, including patients and their companions in the waiting rooms of the various OPD’s, was conducted. Group teaching sessions were conducted, followed by the assessment of patient and nurse satisfaction rate, and compliance rate using evaluation forms. Pre-implementation surveys were conducted to assess the drawbacks, based on which procedure was modified, and feedback was recorded using an electronic iPad. Data were collected with the help of questionnaires filled at the end of each teaching session and analyzed using descriptive analysis. Results of both the assessment and re-assessment were compared in terms of the number of attendees. Results There was an improvement in number of attendees (4362 vs. 3392), patient satisfaction rate (90% vs. 78%), nurse satisfaction rate (83.09% vs. 33.18%) and compliance rate (100% vs. 65%) post-modifications. Few loopholes in terms of inappropriate environment and time of the lecture were also observed. Conclusion The health educators can assist people in achieving their health goals by organizing structured health education activities, providing appropriate health education materials, and effective training. However, the satisfaction rates of people and health educators should be assessed by conducting routine feedback surveys.


Introduction
According to the World Health Organization, "Health promotion is the process of enabling people to increase control over and to improve their health" 1 . It motivates individuals to take initiatives in health literacy and multisectoral intervention to improve healthy habits 2 .
Hospitals play a critical part in health promotion, advancing wellbeing, anticipating illness, and providing rehabilitation services 3 . Nurses and clinical health educators are in the best place to meet patients and their families' health promotion requirements 4 . Responsibility for health promotion in health facilities is equally distributed between the people, community organizations, healthcare professionals, health organizations, and government 5 .
The patient education approach is an efficient way to improve general patient satisfaction and ultimately enhance general demographic health status 6  Patient education during the waiting period plays an essential role in meeting patients' learning requirements and can influence patient satisfaction rates 8 . Also, assessing patient satisfaction is crucial to health educators, doctors, hospital administrators, and patients themselves to guarantee that healthcare requirements are met and preserved 6 .
According to the General Authority for Statistics, Kingdom of Saudi Arabia, the population of Saudi Arabia was more than 33 million in the year 2018. With the rising trend in population, the burden on healthcare has also increased. The government of Saudi Arabia has made tremendous efforts to improve healthcare through health education 9 . Under King Fahad Medical City (KFMC) 5 Strategic Plans 2015-2020, the KFMC in Riyadh, adopted some key strategies to provide excellence in health management and patient's experience and utilized resources in initiating group teaching activities in the outpatient department (OPD) 10   Compliance with planned educational topics: Data was collected from the questionnaires to determine the compliance of planned educational topics for lectures.

Intervention/ modification
Pre-implementation surveys: Pre-implementation surveys are conducted to achieve an enhanced understanding of the potentials and weaknesses of the study and guide project development 23,24 .
The pre-implementation surveys were conducted by involving 20 staff nurses/ health care assistants and 104 patients to identify the factors, if any, responsible for the low satisfaction rate observed after assessment of patients' and staff experience. Identification of loopholes: Root cause analysis and rigorous brainstorming were performed on the pre-implementation survey results to identify the drawbacks/ challenges. Root cause analysis is a method for analyzing adverse events. It is widely used as an error analysis tool in healthcare 11 .
Modifications: To improve the health educator skills, participants' experience, and their satisfaction rates, the following measures were taken:  Two workshops were conducted for Arabic health educators to increase their competence in the delivery of PFE sessions.
 New health education materials were prepared by the OPD nursing team  Approved new health education materials were uploaded on the KFMC iPad for the accessibility of resources to all staff and participants  Electronic surveys were also uploaded on iPad to expedite and receive prompt feedback from patients in response to the group teaching sessions  Structured group teaching activities were organized  The efficacy of the group teaching activities was monitored through surveys  Monthly meetings were conducted and attended by the multidisciplinary team Besides, the procedure of group teaching was also modified.
The topics with unavailable material were not modified/ replaced with the other. However, approved educational material related to that topic was downloaded from the hospital's intranet.
The session was only conducted if the number of participants was more than four or about 4-10.
The staff introduced themselves, the topic, and the duration of the session to the participants before 9 conducting the session. On completion, the staff instructed the participants on how to fill the feedback forms through the iPad.

Re-assessment
The patients/ staff experience and satisfaction were determined using the same questionnaires but were filled electronically using the hospital's iPad. The results obtained from both the surveys were compared to assess change/ improvement in the experience, satisfaction, and compliance.
Therefore, the study endpoints were to determine the increase in the number of patients and their companions, improvement in patient experience, patient and family satisfaction rate, staff and nurse satisfaction rate, and compliance rate to planned educational topics after modifying the group teaching procedure.

Data analysis
Data were analyzed descriptively and were presented as number and percentages using SPSS version 21.0 statistical software (IBM Corp., Armonk, NY, USA).

Study population
Overall, a total of 7754 patients and their companions participated in health education activities.

Number of patients and their companions receiving health education
The number of patients and their companions who received education were 3,392. The focus group target was achieved, averaging 2.69% of the total patients and their companions who visited OPD per month.

Patient experience of health education activities
Overall, 63.86% of patients reported positive patient experience to the health education activities conducted. The participants believing that educational sessions influentially affect them, and the society was 82.18% (n=2788). A total of 76.24% (n=2586) patients stated that health practitioners could answer their queries. Also, 86.14% (n=2922) of the participants shared the information received amongst their families and community ( Table 1).

Patient and family satisfaction from health education activities
The patient and their companions reported a 78% satisfaction rate on the conduct of PFE activities.
About 78.21% (n=2653) participants reported getting an answer to their queries. Approximately, 78.30% (n=2656) participants reported being very satisfied with the educational sessions in terms of duration. In terms of clarity of the educational sessions, 78.18% (n=2652) reported being very satisfied. The low satisfaction rates attributed to the unclear objectives, unanswered queries, and improper duration of the lectures ( Table 2).
Staff and nurse satisfaction from health education activities 11 The assessment reported an average staff-satisfaction rate of 33.18%. The factors determining the satisfaction rate were staff experience and educational barriers. One-fourth (25%, n=6) of the staff was satisfied with the process of PFE followed. About 35% (n=8) of the staff observed difficulty in getting the educational materials. Around 30% (n=7) of the staff reported that the patients responded to their call for the educational lectures. Also, 10% (n=2) of the staff reported difficulty in answering the patient's queries. The major barriers observed by the staff included the lecture timings (60%), availability of educational materials (55%), venue (40%), gender preferences of the participants (35%), presentation skills (30%), and language (10%) ( Table 3).

Compliance to planned educational topics
The average compliance rate of the planned educational activities observed was 61.25%.

Loopholes
The pre-implementation surveys conducted after the assessment highlighted the shortcomings prevalent during the group teaching session. The significant shortcomings included viz., The drawbacks are presented in detail as a fishbone diagram (Figure 1) and Pareto chart ( Figure   2).

Re-assessment
After modifying the group teaching procedure and adapting the interventions, the following improvements were observed:

Increase in the number of patients and their companions
The number of patients and their companions who received education increased to 4,362. Though the focus group target was achieved in both the assessments, there was an increase in the number of participants, averaging 3.07% of the total patients and companions.

Patient experience
The re-assessment revealed an improvement in the patient experience (67.24%) with the modified health education activities. The participants believing the educational sessions influence the patient and society increased to 87.50% (n=3817) post-modification. The percentage of health practitioners answering participants' queries also increased to 88.46% (n=3859) About, 92.31% (n=4027) of the participants shared the information received amongst their families and community. Table 1 compares the results of both the assessments for patient experience.

Patient and family satisfaction from health education activities
An increase in the patient and family satisfaction rate (90%) was noted on re-assessment  Table 2).
Staff and nurse satisfaction from health education activities 13 With the improvisation in the PFE methods, the staff experience improved significantly, with 86% satisfaction rate. In terms of answering the participant's queries, 86% (n=19) of the staff members were satisfied. About 81% (n=18) of the staff had positive feedback concerning the participant's attention, and 86% (n=19) reported on the ease in availability of educational materials and being able to answer patient queries. Besides, the improved process and modifications implemented after the pre-implementation surveys also helped overcome the staff barriers related to lecture timings, availability of educational materials, venue, gender, presentation skills, and language previously encountered ( Table 3). The overall staff satisfaction rate post-modifications increased to 83.09% (n=18).

Compliance to planned educational topics
With the availability of patient education materials, the compliance to planned educational topics in the OPD increased by 38.75%, thereby strengthening the project structure.

Loopholes
Despite the modifications made and the increase in satisfaction rate achieved on re-assessment, there were few loopholes observed such as inappropriate environment and prolonged or short duration of PFE lecture. The challenges were identified with the help of pareto charts based on the Pareto principle (Figure 4).

Discussion
Education is a systematic, sequential, logical, scheduled course of action comprising of both teaching and learning 13  would recommend the hospital to others. 16 As per the pre-implementation data collected, many barriers faced by staff educators in delivering quality health education were highlighted. These include language, place, time of the session, The study suggests that through teamwork and maximum utilization of resources, population health management, and patient experience can be enhanced. The study recommends continuous monitoring of patient satisfaction using surveys. Proper coordination among the multidisciplinary team is essential to ensure quality health education.

Conclusion
Effective health education is a collaborative effort made by the participants and health educators to attain satisfaction. Health educators play an essential role in assisting people to achieve their health goals in a way consistent with their lifestyles, values, and beliefs. Patients and health care providers should be surveyed to assess their experience, satisfaction, and drawbacks associated with them. Thereby facilitating improvisation as and when necessary. By incorporating simple modifications in the educational activities, a higher satisfaction rate can be achieved among the participants and the health educators. Moreover, continuous monitoring and evaluation of health education activities provide effective services to the participants and the community.