Emerging New Challenge for Providing Health Education in Iranian Rural Primary Health Care.

Dear Editor-in-Chief

Iranian Primary Health Care (PHC) system was established in response to health care needs in the early 1980s and aligned with its goal, training of community health workers has been undertaken, since then. The health care needs change over time (1), due to variations in population attributes, epidemiological factors, and educational level of the society. However, these changes have not been incorporated in the educational system. Hence, in spite of the fact that Iranian PHC system has been successful in terms of reducing infectious disease, it has been less effective when addressing the current health issues, such as chronic diseases (2–3) or non-communicable diseases which have been the leading cause of death in Iran in recent decades (4). Moreover, one of the most important factors in rural health is health education. It should be the principal role of community health workers, (5) but it seems that there is no adequate training in this regard. Given the importance of this issue and considering the lack of clarification in learning outcomes of community health workers, we aimed at determining the core competencies for Iranian rural community health workers (IRCHWs), from experts’ viewpoints. Meanwhile, we surprisingly found a new challenge, and decided to report it here.

To find a primary list of competencies, we performed a comprehensive literature search. We, also, conducted a qualitative study, in which 10 faculty members in health education and promotion were enrolled as well as 20 health expert in different levels of Iranian health system. Putting together data obtained from literature search and from the qualitative study, we created a questionnaire of all competencies including 17 core competencies and 89 sub-competencies. Then, we conducted a modified Delphi study in three rounds to finalize the list of expected competencies. We distributed the questionnaire to the same 30 participants and to 30 new participants. Moreover, we included a free-comment box at the end of the questionnaire for collecting opinions of participants regarding other competencies.

Surprisingly, participants who were involved in both phases, claimed the list of competencies are unrealistic and beyond capabilities of IRCHWs. Following content analysis on the participants′ comment, we found the probable causes for this finding. Two important themes were extracted from the comments: low educational level of IRCHWs and high workload of them.

Finally, we concluded that the proposed competencies are realistic for Iranian Rural primary health care system, but they are unrealistic for IRCHWs mostly due to their low educational level and their high workload. One study (2) demonstrated health care process in Iranian rural society is rapidly changing and IRCHWs encounter new challenges. In addition, another study (5) showed high workload as one of the most important barriers to effective performance. Thus, we recommend a major revision in recruiting and training next generation of IRCHWs, as well as making an attempt to reduce their workload.