Eastern Mediterranean Health Journal | Past issues | Volume 19, 2013 | Volume 19, issue 5 | Determining appropriate strategies for improving women’s health promoting behaviours: using the nominal group technique

Determining appropriate strategies for improving women’s health promoting behaviours: using the nominal group technique


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A. Baheiraei,1,2 M. Mirghafourvand,3 E. Mohammadi,4 S. Mohammad-Alizadeh Charandabi 3 and S. Nedjat 5

تحديد الاستراتيجيات الملائمة لتحسين السلوكيات المعزِّزة للصحة لدى النساء: استخدام طريقة المجموعات الإسمية

أعظم بحيرائي، مزكان ميرغفوروند، عيسى محمدي، سكينة محمد عليزاده، سحرناز نجات

الخلاصـة: تعتبر صحة المرأة من أهم جوانب تنمية المجتمعات، وتُعَدُّ من الأولويات المتعلقة بالصحة. وتهدف هذه الدراسة إلى التعرُّف على الاستراتيجيات الملائمة لتحسين السلوكيات المعزِّزة للصحة لدى النساء في سن الإنجاب في جمهورية إيران الإسلامية. وقد استخدم الباحثون طريقة المجموعات الإسمية، فعقدوا مجموعة مناقشات في 10 تشرين الأول/أكتوبر 2011 ضمت اثني عشر اختصاصياً صحياً تم اختيارهم من خلال عينة قصدية؛ وقد اختار أعضاء المجموعة في الجولة الأولى 81 استراتيجية، وبعد استبعاد العناصر غير ذات العلاقة ودمج العناصر ذات المفاهيم المشتركة، تبقى لديهم 44 استراتيجية. وبعد المناقشة في مجموعات والتصويت، حازت العناصر الأربعة التالية على أعلى الدرجات: تحسين النشاط البدني مع أسلوب للدعم الاجتماعي، وتمكين المرأة، وتعزيز وتحسين دور الرجل في صحة المرأة، وتعزيز الدعم الاجتماعي. ويمكن الاستفادة من الاستراتيجيات المقدَّمة في هذه الدراسة، من قِبَل أصحاب القرار والمديرين والقائمين على إيتاء الرعاية الصحية من أجل تحسين السلوكيات المعزِّزة لصحة النساء، مع ما يتبع ذلك من تحسّن مستوى المعافاة لديهن.

ABSTRACT Women’s health constitutes a major aspect of development in societies and is considered a health-related priority. The aim of the present study was to determine appropriate strategies for improving health promoting behaviours in women of reproductive age in the Islamic Republic of Iran. Using the nominal group technique, a panel discussion was held in October 2011 with 12 health specialists who were selected through purposive sampling. In the first round, panel members generated 81 strategies; after eliminating irrelevant items and merging items with similar concepts, 44 strategies remained. After group discussion and voting, the following 4 items had the highest scores: improving physical activity, with a social support approach; empowering women; promoting and improving men’s role in women’s health; and promoting social support. The strategies presented in this study may be utilized by policy-makers, managers and health care providers to improve women’s health promoting behaviours, and thus contribute to their wellbeing.

Détermination des stratégies appropriées visant à renforcer les comportements bénéfiques pour la santé de la femme par la technique du groupe nominal

RÉSUMÉ La santé de la femme qui est un aspect majeur du développement des sociétés, est considérée comme une priorité sanitaire. La présente étude visait à définir les stratégies appropriées pour renforcer les comportements bénéfiques pour la santé des femmes en âge de procréer en République islamique d'Iran. À l'aide de la technique du groupe nominal, un débat a été organisé en octobre 2011 entre 12 spécialistes de la santé sélectionnés selon un échantillonnage dirigé. Au cours de la première rencontre, les membres du groupe ont compilé 81 stratégies ; après l'élimination des éléments non pertinents et le regroupement des éléments couvrant des concepts similaires, 44 stratégies ont été dégagées. Après une discussion et un vote au sein du groupe, les quatre éléments suivants ont obtenu les scores les plus élevés : l'augmentation de l'activité physique, avec une approche apportant un soutien social ; l'autonomisation des femmes ; l'encouragement et l'amélioration du rôle des hommes dans la santé de la femme ; et la promotion du soutien social. Les stratégies présentées dans cette étude peuvent être utilisées par les responsables de l'élaboration des politiques, les gestionnaires et prestataires de soins de santé afin de renforcer les comportements bénéfiques pour la santé des femmes et de contribuer ainsi à leur bien-être.

1Department of Reproductive Health;
2Centre for Community-Based Participatory Research; 
3Midwifery Department, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran (Correspondence to M. Mirghafourvand: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
4Department of Nursing, Tarbiat Modares University, Tehran, Islamic Republic of Iran.
5School of Public Health, Knowledge Utilization Research Centre, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
Received: 17/01/12; accepted: 19/03/12
EMHJ, 2013, 19(5):409-416 


Health care services for women often focus on mother and child care and do not pay due attention to women’s lifestyles [1]. Women have different health issues than men. In addition to obvious differences related to reproductive health, such as diseases related to pregnancy and birth, certain disorders, such as anaemia, depression, anxiety and eating disorders, are more frequent in women than in men [2]. Risk factors related to diseases such as physical inactivity and obesity are more prevalent among women than men [3,4], so too are mental disorders. In a mental health survey of a population sample aged 15 years and over in the Islamic Republic of Iran, 25.9% of the women and 14.9% of the men had mental disorders [5]. In another study, Iranian women reported significantly poorer health-related quality of life compared with men [6]. It has been shown that health promoting behaviours could decrease health problems and improve women’s health [3].

Women assume pivotal roles in families and societies and have the potential to encourage positive changes in behaviour and serve as a model for their children and other family members, for example regarding dietary habits, physical activity and personal hygiene [7,8]. We can consolidate these healthy behaviours in women through health promotion programmes aimed at women [1]. For developing countries, however, women’s health is a more challenging and complicated issue as women have to cope with innumerable obstacles such as discrimination, deprivation of social rights, domestic violence, poverty, hunger and lack of access to medical care, all of which compromise their health [9].

We still lack appropriate strategies to improve women’s health in the Islamic Republic of Iran. The rapid changes in fertility status in the country during recent decades have led to a situation in which the majority of Iranian women (60%) are of reproductive age [10]. This highlights the need to adopt optimal strategies for improving Iranian women’s health promoting behaviours for the benefit of their family and particularly their children. The present study is part of a mixed methods study with a sequential, explanatory design. The protocol of the study has been published previously [11]. The first phase of the study was a quantitative assessment of the status of health promoting behaviours in women of reproductive age. In the second phase, we made a qualitative evaluation of the experiences of women of reproductive age regarding their health promoting behaviours. In the final phase, described here, we used the nominal group technique (NGT) among a group of health specialists with the aim of defining strategies for improving health promoting behaviours in women of reproductive age.



Health specialists were recruited through purposive sampling. We invited 15 professionals who were experts in women’s health issues from different disciplines to participate in the nominal group session. Among these, 12 responded to our invitation. All 12 professionals participating in the nominal group session were experienced in providing health and educational services to women or experts in health issues of women of reproductive age and their background varied from psychology and nursing to sociology and health economics. We selected individuals of different disciplines in order to assess the issue from different aspects and acquire an array of perspectives [12]. Table 1 presents the participants’ characteristics, including age, sex, field of expertise, degree and length of experience in the field of women health.

Data collection

The NGT session was held on 24 October 2011. Prior to the session, each participant received a briefcase containing a letter that elucidated the objectives of the present study and a summary of the preceding quantitative and qualitative phases of the study as well as the strategies obtained through a review of the literature.

The nominal group session was held in a room with a U-shaped table in the Faculty of Nursing and Midwifery of Tehran University of Medical Sciences. A facilitator and a secretary with experience in nominal group sessions helped conduct the NGT session. The facilitator (M.M.) had a PhD in reproductive health and the secretary, a PhD student of reproductive health, was invited to help implement this session.

Steps of the NGT

Step 1: Opening the session

Initially, all the participants were acknowledged for agreeing to take part in the session and the stages of the session were explained to them. We presented the objective of the session as “What are the most appropriate strategies for improving health promoting behaviours in women?”, using the findings of previous studies, the current data and the participants’ experiences.

Step 2: Silent generation of ideas in writing

All participants were asked to use the previously presented findings and data, as well as their own experiences, to write down their ideas over a 10- minute period. This stage was completed in silence and the participants did not share or discuss their ideas with one another.

Step 3: Round-robin recording of ideas

Subsequently, the secretary wrote the ideas presented by the participants on a flip-chart to be visible by other group members. The ideas belonging to each participant were written, followed by ideas from the next participants, and so on, until all the ideas were equally presented to all members. The ideas were numbered sequentially.

Step 4: Serial discussion on the ideas

The collected ideas were then discussed and elucidated. For this purpose, the facilitator started the discussion from the top of the list on the flip-chart. Any previously written idea would be eliminated and ideas with similar concepts were merged. In addition, if any ideas were ambiguous, the owner of the idea or other experts in the session would clarify its meaning. This procedure continued until no ambiguity was left about any of the ideas.

Step 5: Voting to select the most important ideas

Afterwards, the participants were required to select 5 of the most important ideas from the list and write the numbers on an index card. The most important idea would be scored 5; the second most important would be scored 4, and so on, for 5 ideas selected by each participant. Once this task was completed, the index cards were collected and the score of each idea was written next to it on the flip-chart.

Step 6: Discussion of the selected ideas

This step, although not indispensable for NGT, is recommended as it helps the group to organize the findings more effectively. Thus, the strategies were classified as personal or structural, according to the experts’ opinions.

Validity of the NGT

We took the following measures to increase the validity of the method: we recruited participants of different disciplines to broaden the range of responses and opinions on the subject in question. Furthermore, we observed the principles for founding and managing the nominal group sessions.


This study was supported by the ethics committee of Tehran University of Medical Sciences. All participants were informed about the objectives of the study, and they all agreed to participate voluntarily. In order to compensate for a small part of the participants’ time and energy, they were awarded with presents as souvenirs.


Individual writing of ideas in silence generated 81 strategies; once the repeated and irrelevant items were eliminated and items with similar concepts were merged, 44 strategies remained. These strategies and their assigned weights are depicted in Table 2 . Among these, the following 4 strategies had the highest scores: improving physical activity, with a social support approach; empowering women; promoting and improving men’s role in women’s health; and promoting social support. These 4 strategies are described in Table 3 .


This is the first Iranian study to use the NGT to extract the opinions and ideas of health professionals regarding strategies for improving health promoting behaviours. There are a number of group-oriented research methods to determine individuals’ attitudes or perceptions about specific issues [13]. The NGT promotes group decision-making about a specific subject and integrates quantitative and qualitative methodology, as decisions are made through both discussion and voting [14]. NGT has certain advantages over other group techniques, such as the Delphi method, focus groups and brainstorming, which render it one of the most efficient group procedures. One advantage is completion of the process in one session with immediate submission of results to the group, which improves the participants’ satisfaction. Moreover, researcher bias is minimized as a result of the highly structured nature of the process [15]. Although the NGT is one of the best methods to adopt efficient decisions about one subject, it has not been paid due attention in Iranian health care system and its benefits and efficiency remain to be evaluated.

Improving physical activity, with a social support approach, was the highest scoring strategy in the session. Women’s inactivity is a challenge not only for women in the Islamic Republic of Iran, but also in many other countries [16–18]. Considering the important role of physical activity in preventing coronary artery disease, type 2 diabetes and colon cancer, as well as improving mental health, reducing the risk of obesity and osteoporosis [19], this strategy may be beneficial to women’s health. Social support is typically classified as perceived and received support and it includes 3 main aspects: emotional (e.g. feeling loved, valued and appreciated), informational (e.g. advice or guidance) and instrumental (e.g. tangible help) [20]. According to our experts, this strategy could be realized on the structural level in the Islamic Republic of Iran through instrumental support, such as enhancing sport facilities and spaces, human resources, increasing the active hours of sport centres, providing free tickets and spaces and providing outpatient service (health care, therapy, rehabilitation) for treating women’s physical problems. On the personal level, it may be actualized through informational support such as promoting positive attitudes in women, men and legislators towards women’s physical activity.

Empowering women was the second highest scoring strategy presented in the specialist panel. Empowerment is an important aspect of health improvement, and is defined as: “enabling individuals to decide about their own health”. Since this strategy focuses on empowering individuals as well as society as a whole, it is practical and efficient for comprehensive health promotion [21].

The third highest scoring strategy in the nominal group session was promoting and improving men’s role in women’s health. This may be accomplished through educating health promoting behaviours, particularly promoting social support for women and encouraging men to concern themselves with their wives’ health as propagated in media, mosques and workplaces. Men play a pivotal role in women’s health through their encouragement of behaviour modification and reduction of reproductive health problems as well as the problems of domestic violence that women encounter. The United Nations Population Fund has stated that as men play an essential role in empowering women [22]. Thus, any comprehensive approach to women’s health requires a component for improving men’s participation [2].

Promoting social support ranked fourth among the suggested strategies. Numerous studies have indicated the positive impact of social support on health promoting behaviours [16,17]. In fact, social support is necessary for health promotion, as it satisfies individuals’ physical and emotional needs and protects quality of life against stressful events [23]. As our experts agreed, this strategy may be realized through promoting health behaviours in local facilities such as mosques, parks, sport centres, and schools, support health promoting behaviours in workplaces, and providing nurseries and day-care centres to take care of children. The characteristics of a community and its organizations have a direct effect on the level of well-being on the individuals and families that reside in it. Promoting close-knit ties among residents can relieve the effects of crises on community members. Stable communities are characterized by value similarity, mutual assistance, shared trust and concern for members [24].

This study has some limitations that are worth mentioning. First, similar to other qualitative methods, the NGT is limited in sample size. Secondly, participants were selected purposively, and therefore, the representativeness and generalizability of the results are limited. Thirdly, the generation of ideas was limited to the actual time spent at the meeting.


This study using NGT provided useful information regarding strategies for improving health promoting behaviours. Among the strategies discussed, improving physical activity with social support, empowering women, promoting and improving men’s role in women’s health and promoting social support had the highest scores respectively. The strategies presented in this study may be utilized by policy-makers, planners, managers, researchers and health care providers to improve women’s health promoting behaviours, and thus contribute to their well-being.


We wish to express our gratitude to all experts who participated in the nominal group session.

Funding: This work was supported by the Tehran University of Medical Sciences (project number 89-02-28-10802).

Competing interests: None declared.


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