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Analysis of the Elements of Self-Care Training Curriculum for Iranian Red Crescent Society (IRCS) Relief Workers Based on the Akker Model

INTRODUCTION: The present study aimed to investigate the elements of the self-care training curriculum for Iranian Red Crescent relief workers based on the Akker model. Exposure to accidents and disasters causes feelings of stress, anxiety, fatigue, weakness, and hopelessness. Due to the intense activities and the problems they encounter during traumatic episodes, they are endlessly anxious and stressed. However, they can control the pressures inflicted by the environment with the required training and effective scientific methods . METHODS: The present qualitative research study prevails based on the database theory. The statistical population comprises 25 curriculum experts and Red Crescent relief workers selected through purposeful and criterion-based sampling. After clarifying the theoretical founding and expert perspectives regarding designing self-care training curriculum and quality of life (QoL) theory, the basic concepts, and components or the logic of curriculum design were specified . FINDINGS: The results showed that the characteristics of the elements of the self-care training curriculum considering the focus and the characteristics of the quality of life (QoL) theory based on the logic of the curriculum in the form of a model are as follows . Objectives (general and specific), content characteristics (principles of organizing and content selection), teaching-learning methods (priorities of selection and types of teaching methods), teaching-learning activities of relief workers, assessment (consecutive assessment and self-assessment), study materials and resources (physical and non-physical resources), space (virtual and online, real: emergency, accident), time and place (flexible), grouping characteristics (developing relief workers’ sense of duty and belonging to the group in accidents and emergencies) and consequences: improving health literacy, correcting lifestyle, reducing the number of paramedics with contagious non-contagious diseases, diminishing the risky behaviors of paramedics, obtaining a set of skills and achieving individual, group and collective self-care competence. The model was validated and approved by experts and specialists through the Delphi method . CONCLUSION: Presenting and implementing a self-care training curriculum in the in-service programs of the Iranian Red Crescent Society can boost their quality of life (QoL) and contentment, while fully preparing them to withstand and deal with emergencies . QoL:

Introduction elf-care is a practice in which each individual uses their knowledge, skills, and capacities as resources to take care of their health independently (20). "Self-care includes acquired, conscious, and purposeful measures that people take to stay healthy, protect their physical, mental, and social health, fulfill their physical, mental, and social needs, prevent illnesses or accidents, endure their chronic illnesses, and maintain their health after undergoing an acute illness or hospital discharge," says Baker (5).
In this regard, Sezici and Akkaya highlight that we must learn how to take care of ourselves (25). In this respect, self-care training can play an S Original Article incredibly crucial role. Improving the ability to self-care leads to one's self-fulfillment (16). Among the determinants of health, healthpromoting self-care behaviors have been recognized as the most fundamental means to prevent diseases, particularly chronic illnesses. Therefore, health-promoting self-care behaviors should be considered as the primary strategy to maintain and promote health (14). Schafer states that the most notable benefits of self-care are that it replenishes energy, reduces stress, and offers one a new perspective and an optimistic perception of life. Self-care establishes a sense of happiness, peace, and serenity. It develops a feeling of health and well-being in the body, boosts self-confidence and self-esteem, and enhances one's enthusiasm for life and motivation for success (24). A research study by Ray et al. concluded that the domains of self-care include health promotion, lifestyle modification, disease prevention, self-assessment, health care, participation in treatment, and rehabilitation (22). The most significant self-care behaviors include healthy eating habits, physical activity, stress management, interpersonal communication, spiritual growth, and taking responsibility for one's health condition (6). Heeding to these behaviors can enhance the efficiency and independence of rescuers and help them control various complications in accidents (28). Ramirez et al. point out that self-care plays a key role in the clinical consequences associated with disease in old age (23). It can improve quality of life and increase life expectancy (21). Moreover, self-care reflects health maintenance through healthy and beneficial activities and regulating diseases or disorders (3). The concept of quality of life (QoL) includes health, environmental and psychological domains (13). In this regard, Schalock's quality of life (QoL) theory introduces significant aspects of quality of life including physical well-being, material well-being, rights, social inclusion, interpersonal relationships, self-determination, personal growth, and emotional well-being.
Research findings indicate that the quality of life is low. 58% of the elderly over the age of 65 need assistance to perform their daily activities (24). Modifying the lifestyle and attending to its quality can remarkably increase efficiency, independence, and control of various complications in old age (30). Alterations in lifestyle and tending towards a healthy life is only possible with proper nutrition, dietary supplements, regular exercise, weight loss, stress reduction, fat reduction, not smoking, reduction of salt intake, no self-medication, adding fruits and vegetables to the diet, daily supervision of blood pressure and increased water intake (31) and (12). Red Crescent relief and rescue teams are one of the major influential human resources in the development process of the country. They encounter exorbitant pressure. Immense stress is imposed on them during some contacts (29).
According to the checklist of stressful life events, even daily work activities, e.g., routine patient transfers can place the emergency staff of relief groups in a mentally difficult state (8). Exposure of rescue teams to disasters prompts them to feel stressed, anxious, exhausted, vulnerable, and desperate (19). The Red Crescent relief and rescue teams are constantly in a state of anxiety and tension due to the intense activities and problems they encounter in accidents, as well as the multiple hardships they endure during natural and man-made disasters, e.g., earthquakes, floods, fires, wars (27) unless they learn to take control of the pressure inflicted by the environment after getting the required training and learning practical scientific methods of coping (7).Various sorts of accidents affect rescuers. They may witness damage to people's homes and the loss of their loved ones, violence, destruction, and death. Thus, in each incident, they experience a wide range of reactions and emotions such as weakness, error, panic, extreme anxiety, numbness, and apathy, or a relatively vague sense of what is occurring (17). In the Red Crescent, it is very common and probable for rescue teams to be exposed to potentially traumatic episodes or psychological trauma. Therefore, the staff of those departments is at high psychological risk. Moreover, the issues of the social environment and providing basic needs double the anxiety and stress (4).
Research on the mental and physical health of paramedics, as opposed to other occupational groups, has indicated that chronic fatigue, mental disorders, depression, anxiety, and burnout are more common in Red Crescent relief workers than in other occupational groups. Furthermore, it has reduced their quality of life (QoL) [Keesler]. Studies have also shown that Red Crescent relief workers endure high levels of work-related stress among high-risk jobs (11).
Various studies have been conducted on the general health, work-related stress, and burnout of paramedics. Brownell and Smith reported that many paramedics quit their jobs for a variety of reasons, mentioning work-related stress and reduced quality of life (QoL) as the most significant reasons for giving up their jobs (18). A study by Singer concluded that the rate of physical and mental burnout and exhaustion is approximately 10% higher among paramedics (8).
Therefore, considering the importance of selfcare as a foundation for the quality of life (QoL) [9], the present study was conducted to design a self-care training curriculum for rescue teams. The curriculum can be utilized by the Iranian Red Crescent as a constructive step toward self-care training, improving the quality of life, maintaining health, and preparing the Red Crescent rescue teams to manage accidents. The self-care training curriculum can be a critical factor in assisting to coordinate the self-care training activities of Red Crescent relief and rescue teams and a description of supportive and practical response to the individual (30).
The Red Crescent Society of the Islamic Republic of Iran is an Iranian non-profit organization and a member of the International Red Cross and Red Crescent Movement which carries out relief and humanitarian activities inside Iran and in some cases across borders. According to its international responsibilities (the International Committee of the Red Cross (ICRC)), the Red Crescent must assist in rescuing and evacuating the injured and victims of crises, e.g., floods, earthquakes, wars, etc. inside and outside the country. Red Crescent relief workers ought to learn to take care of themselves due to their work-related stress and intense missions. If Red Crescent relief workers can operate under high pressure and receive feedback with no discomfort, they will be trusted and handed out major projects. Moreover, self-care makes Red Crescent relief workers stronger and more successful. Hence, we must pay particular attention to this crucial issue, specifically in the Red Crescent Organization, where the rescue teams are exposed to high levels of psychological and physical hazards and educate relief workers with such characteristics. The results of the existing background studies in the country underline the shortcoming of the self-care training curriculum of the Red Crescent rescue teams.
Similarly, the results of the previous foreign studies suggest the significance and development of this program. Given that no such curriculum model has been designed so far, the present study can play a key role in the development and advancement of the self-care training curriculum, especially in the Red Crescent Organization. Therefore, the goal is to investigate the elements of the self-care training curriculum of Red Crescent relief workers based on the Akker model, according to which the logic of the curriculum was determined and the characteristics of curriculum elements were identified.

Methods
The research method in the present study was theoretical to design a self-care training curriculum for Red Crescent rescue teams based on the Akker model. The present theoretical research aimed to design a curriculum that builds and critiques conceptual schemas that comprehend the basic nature and structure of curricular phenomena and processes. Conceptual schema identifies the basic elements of reality and the relationship between them. While creating conceptual schema, two key terms are usually defined: basic concepts and structural concepts. Basic concepts are the elements that we recognize as creating reality and structural concepts are defined as the relationships amongst those elements (1). The sum of these basic and structural concepts formulates language systems or conceptual schemas through which we can imagine and discuss the curriculum. Conceptual schemas are not presumed in any branch of thought and action; they must be created. This principle applies in the theoretical and practical realms of the curriculum as in any other (26). Therefore, according to the theoretical research method and to design the self-care training curriculum based on the Akker model, after studying the theoretical foundations and expert viewpoints regarding the design of the curriculum and the characteristics of self-care training and the Akker model, the logic of the Red Crescent relief workers' self-care curriculum was identified. Then, the basic concepts or characteristics of the curriculum elements were identified. Similarly, the structural concepts, which are the same as identifying the relationships between the elements of the self-care curriculum or the logic of the curriculum, were discerned. Consequently, the model for designing the self-care training curriculum for paramedics was presented based on the Akker model. The Delphi method was employed to ensure the validity of the self-care curriculum design. To validate the model of selfcare training curriculum based on the Akker model, a proposed model was presented to curriculum experts and specialists. Their judgments on each element of the self-care training curriculum and the logical relationship between the elements were obtained. At this stage, a criterion-based purposive sampling method was used [10]. Samples were selected according to the inclusion criteria, e.g., possessing the subject knowledge, practical experience, and familiarity with curriculum design. Essential modifications were carried out based on the impressions of the mentioned individuals in the designed model. Eventually, the model of the self-care training curriculum for the Iranian Red Crescent relief and rescue teams was formulated and designed based on the Akker model.

Findings
According to Akker's model (2), the logic of designing a self-care training curriculum for Red Crescent relief workers is presented by considering the focus of the self-care training approach and the characteristics of quality of life (QoL) theory. Therefore, the design of the curriculum is inevitably based on the focal points of the self-care training approach, which is presented below .  Health literacy promotion, lifestyle modification, cancer prevention, diabetes prevention, cardiovascular disease prevention, respiratory disease prevention, selfassessment, health maintenance, chronic disease management, smoking cessation, obesity prevention, hypertension prevention, Individual Self-Care Self-Care Training Approach Developing positive interpersonal relationships, empathy and emotional support, Social Self-Care/Self-Help Creating a healthy work environment, creating a physical environment and supportive culture, encouraging a healthy life with the cooperation of employees Organizational Self-Care By studying the theoretical foundations and research studies in the field of self-care training, we found out that in addition to the focal points of the self-care training approach in the logic of the curriculum, the characteristics of quality of life (QoL) theory should be taken into account. Next, according to the focal points of the self-care training approach and the characteristics of quality of life (QoL) theory, which are extracted from the research principles, the logic of curriculum design was determined and is presented in the following figure. As demonstrated in Figure 1, self-care training includes learning the set of individual, social, selfhelp, and organizational self-care. In the logic of curriculum design, the focal points of the self-care training approach and the characteristics of quality of life (QoL) theory were regarded. Considering the aforementioned implications in the field of curriculum logic, the characteristics of curriculum elements based on self-care training for Iranian Red Crescent relief workers were extracted.
As demonstrated in Figure 1, self-care training includes a set of individual, organizational, social, and self-help self-care that was reckoned in the logic of curriculum design at the focus of self-care training and the characteristics of quality of life (QoL) theory. Furthermore, to answer the research questions, the collected qualitative data from the process of conducting semi-structured interviews with the study sample were analyzed through open coding. Implementing the open coding process on the collected qualitative data, first led to the extraction of a large number of features and concepts, which were reduced through reexaminations and revisions. Based on the similarities and correspondences, these concepts and features were classified. Subsequently, these extracted features and concepts were renovated  workers to the curriculum and study of self-care training content, 9.1. Developing a sense of duty on the part of rescuers towards themselves and others, group loyalty and a sense of belonging to the group during disasters and accidents, correct judgment in the group, determining the size of the group to specialize in relief and its set goals into 29 sub-categories. Ultimately, 10 main categories were developed from these subcategories. The findings obtained from the coding process are offered in Table (2). The research findings after the open coding process are illustrated in the form of axial coding pattern dimensions ( Figure 1) including: causal conditions: viewed as the primary cause of the phenomenon, pivotal category: viewed as the primary event to which a series of interactions exist and relate ,strategies: specific actions that result from the primary phenomenon and provide methods to handle the target phenomenon , background: a series of specific features in which interaction is conducted to control management and respond to the phenomenon , intervenor conditions: General contextual conditions that affect strategies , consequences: the output of hiring strategies that reflect on how to design a curriculum based on care ethics according to the main and sub-categories related to each section. This process is also presented in table (2) titled Axial Coding . All the characteristics defined for the elements of the curriculum, derived from the logic of selfcare curriculum design, were compared with the principles that curriculum experts and specialists defined for the elements of the curriculum. Lastly, their compatibility was evaluated. In all cases, there the features derived from the curriculum logic and the principles that the curriculum experts believed in were consistent with one another. After conducting the open coding, in the pivotal coding step, as demonstrated in Figure (2), the conceptual pattern of the rescuers' self-care training curriculum was drawn, in which the relationships between causal conditions, pivotal phenomena, contextual conditions, strategies, and consequences are evident .
Based on the above model, the technical model of self-care training curriculum design based on the Akker model was proposed. To validate the technical model of the curriculum design, which included the characteristics of the curriculum logic and the nine characteristics of the curriculum based on the Akker model, an openended questionnaire and a closed-ended questionnaire were provided to 30 university specialists. The opinions of the experts were utilized to modify the model based on the common opinions with the frequency of the items mentioned and other items that were added.

Discussion and Conclusion
The present study attempted to design a conceptual model of self-care training curriculum for Iranian Red Crescent relief and rescue teams based on the Akker model using the database theory .In this respect, data analysis indicates that the self-care training curriculum is designed based on objectives (general objective and specific objectives), the characteristics of the content of the Red Crescent self-care training curriculum (principles of content selection, principles of content organization), teaching methods (priorities of teaching methods, types of teaching methods), characteristics of rescuers' learning activities, evaluation (principles of evaluation and consecutive evaluation), study materials and resources (physical and non-physical), environment, characteristics of rescuers' grouping and training consequences . Based on the conceptual model presented in the research findings section, the characteristics of the content of the Red Crescent relief self-care training curriculum are influenced by the objectives. Therefore, according to the quality of life (QoL) theory, the lack of a positive view towards selfcare training of Red Crescent rescuers, and also the emphasis of some domestic and international vision documents on constructive and effective interactions with rescue and relief teams, objectives are of great significance in the self-care training curriculum .Findings in this section are consistent with the results of the research studies by Keesler and Troxel (15), Heidari and Shahbazi (13), Sezici et al. (25), and Ray et al. (22). Similarly, content affects the teaching-learning and evaluation methods under the heading of strategies . Moreover, these strategies are influenced by contextual factors, e.g., environment, materials, and resources, and intervening factors, e.g., learning time of the selfcare training curriculum and grouping characteristics of Red Crescent relief workers. The characteristics of Red Crescent relief workers' learning activities and the evaluation of Red Crescent relief workers' have been very influential. Eventually, the mentioned strategies lead to training outcomes such as achieving individual and group self-care skills and competence, promoting health literacy through the empowerment of paramedics, designing individual, social, and organizational self-care systems, developing positive interpersonal relationships, empathy, and emotional support, improving the lifestyle of relief workers, enhancing the quality of life of relief if workers, reducing the number of relief workers with contagious and non-contagious diseases, diminishing risky behaviors of relief workers, boosting the quantity and quality of Red Crescent relief workers' participation in health care, increasing relief workers' satisfaction with health services. Findings in this section are consistent with the results of research studies by Everly (8), Wang et al. (30), and Preston et al. (20) .In the designed model, the role of Red Crescent relief workers in the process of learning health literacy will shift (25). In self-care training, Red Crescent relief workers are aware of the fluidity of their roles in the teaching and learning processes. They understand that shifting their roles to fit various learning activities is quite obvious (16). Self-care training retains a wide range of topics, and this fact implies the different roles and responsibilities of Red Crescent relief and rescue teams. Red Crescent relief workers must be able to process their self-care skills and activities beyond the class and establish a mental connection between their earlier self-care knowledge and their newly found self-care knowledge (20) .In designing a self-care training curriculum model, teachers' training roles and tasks are different. As Baker points out, the role of content instructors in the self-care curriculum has changed to leadership. The role of a teacher in the self-care training curriculum is to guide, learn, and lead rather than lecturing and expressing specialized knowledge of self-care topics (5) .The proposed model of selfcare training curriculum in the Iranian Red Crescent has distinct characteristics resulting in more interaction between relief workers with the content, topics of self-care, and with other Red Crescent relief workers. Moreover, the characteristics increase the rate of self-regulated learning and the enthusiasm and passion for learning the correct self-care topics in the workers. In the last decade, due to the outbreak of contagious diseases such as COVID-19, the selfcare training curriculum has been widely utilized. Therefore, given the advantages and characteristics of the self-care training curriculum, authorities must commence using the training curriculum to promote the health literacy of Iranian Red Crescent relief workers. Finally, according to the research findings, guidelines are provided for executing the self-care training curriculum for Red Crescent relief workers. Firstly, the codes extracted in this study can be a good guide for more in-depth and specialized studies on the lesser aspect of this curriculum. Secondly, the results of the current study can be used as a framework for the self-care training of paramedics. The conceptual model, which is designed based on the experience of the majority of research participants and as the final research model, can act as a decent example for a deeper understanding of the Red Crescent relief workers' self-care training curriculum to modify, develop, and use the curriculum. Thirdly, a wide range of underlying factors is considered which should be allotted particular attention. In this respect, the most vital condition in establishing a self-care training curriculum for the Iranian Red Crescent Society is to explain the goals of this curriculum to policymakers and directors to refine and change their attitudes on the concept and objectives of the self-care training curriculum. However, this matter requires access to accurate and authentic knowledge of the self-care training curriculum. It is suggested that the self-care training topics for Red Crescent relief workers be thoroughly reviewed by developing various and specialized working groups concerning the self-care training curriculum.