1. Background
Iran, a lower-middle-income country, is situated in the Eastern Mediterranean Region or Southwest Asia. More than 79,109,000 people live in this country, with 23 million residing in rural areas. In recent years, by adaptation of the declaration of Alma-Ata, Iranian administrators have paid particular attention to primary health care (1-5). The national health network of Iran was established in 1985, prioritizing less privileged rural areas of the country.
In the healthcare system of Iran, a health house (HH) is the most comprehensive health unit. At this point, there are 16,000 HHs all over the country, and their major responsibility is to provide primary health care for clients (2008). The effects of these HHs on improving the population’s health against contagious diseases, maternal and neonatal mortality, life expectancy, and vaccination have been reported (6-9).
Health is a global and multifaceted issue, influenced by various factors. Among these factors, one can mention health education (10). Previous studies have revealed that education can positively affect health. Overall, the goal of education is to enhance health awareness and attitude, which in turn improves the individual’s behaviors and promotes health, comfort, and overall performance in all areas of health (11, 12).
Based on the definition proposed by Green and Kreuter, health improvement is a combination of educational and environmental support, promoting a healthy lifestyle (13). In the primary health network of Iran, HHs are among these training centers. One important responsibility of these HHs is to educate people and increase their cooperation in different areas.
Based on the definition of the world health organization (WHO) (14), evaluation aims to present some information regarding efforts to enhance the effectiveness of interventions. Based on this evaluation, training planning is an important factor. The significance of the present study is the proper implementation of effective interventions on a proper target group and evaluation of the cost-effectiveness of the program.
2. Objectives
This study was conducted on the processes of educational interventions in HHs during April-September 2011 in order to provide a more accurate planning, to promote changes in administrative actions, and to provide the required education through interventions by the ministry of health.
3. Methods
In this descriptive study, 10% of all HHs under the coverage of the ministry of health and medical education (MOHME) of Iran were selected via systematic random sampling. For this purpose, a number was randomly selected, and 1600 HHs, affiliated to 45 universities of medical sciences, were selected, according to the sample formula in Microsoft Excel 2007. After determining the desired week and HHs, a list of health education and health priorities of HHs, selected among universities of medical sciences, was requested. The topics of group education sessions and other subjects were described in 2 forms from April to the end of September 2011 on a weekly basis.
Rural primary healthcare workers completed the data, which were then checked by an expert. The questions in the first form included the list of health priorities, registered priorities, level of priorities, and method of determining priorities (2 open and 3 closed questions). The training subject, target groups, reasons for education, number of participants, and date of education were requested in the second form. Characteristics of healthcare workers and the covered population were at the top of the second form. The items were prepared and validated in joint sessions by healthcare network professionals, as well as experts in health education. All the processes were conducted through official correspondence by the health network on behalf of the department of health education and promotion in 2011. Follow-up was performed via phone calls to complete the forms.
Data were entered into Excel 2007. After coding and categorizing the data into educational topics and target audiences, they were entered into SPSS version 16. Descriptive tests were used to analyze the data. This study was approved by the committee of the department of ethics and health policies.
4. Results
In this study, 1498 out of 1600 HHs completed the questionnaires (response rate, 93.6%). The forms were sent to 1498 HHs. The data from 3 universities of Kurdistan, Hamadan, and Neyshabur were not considered in the final analysis due to lack of response. Distribution of HHs based on the covered population size is presented in Table 1. Due to the shutdown of HHs or leave/transfer of primary healthcare workers, 325 (21.6%) HHs included no group education from March to July. The mean number of primary healthcare workers was 2.1 ± 0.98 in HHs; most selected HHs had at least 1 male and 1 female primary healthcare worker.
Table 1.Categorization of the Selected Health Houses (HHs) Based on the Covered Population Size
| Category | No. (%) |
|---|---|
| < 500 | 315 (21.6) |
| 500 - 1000 | 495 (34) |
| 1000 - 1500 | 300 (20.6) |
| 1500 - 2000 | 165 (11.3) |
| > 2000 | 182 (12.5) |
| Total | 1457 (100) |
The educational sessions for employees in HHs involved topics on family planning (9%), feeding infants and children (6.8%), and intestinal-seasonal diseases (5.8%). Women’s cancers accounted for 3.2% and safe delivery for 1% of sessions. In total, 28.3% of educational programs was related to the field of reproductive health. The educational topics were highly dispersed, ranging from sanitary waste disposal, professional health in carpet weaving, and farming to risky behaviors, such as substance abuse and smoking.
Most education in the field of infectious diseases was respectively related to brucellosis, rabies, tuberculosis, malaria, and influenza, which are mostly zoonotic diseases (4.4%). Intestinal diseases mostly included Eltor and diarrhoeal diseases. Education about noncontagious diseases, thalassemia, diabetes, hypertension, and iodine-related diseases was more than other conditions; Table 2 presents this information.
Table 2.Topics of Education in the Selected Rural Health Houses (HHs)
| Field and Topic of Education | (%) |
|---|---|
| Reproductive health | 28.3 |
| Occupational and environmental health (agriculture) | 6.9 |
| Seasonal and intestinal diseases | 5.8 |
| Elderly health | 5.1 |
| Zoonotic diseases | 4.4 |
| Nutrition and food hygiene | 4.3 |
| Infectious diseases | 4.1 |
| Healthy lifestyle | 3.8 |
| Cardiovascular diseases | 3.4 |
| Mental health | 1.8 |
| Risky behaviors (smoking and drug use) | 1.8 |
| Thyroid diseases | 1.7 |
| Accidents and first aid | 1.2 |
| Oral health | 0.7 |
| Other common topics | 20.4 |
| Total | 100 |
According to the results, the mean length of education was 33.6 ± 18.0 minutes per week. The maximum time of education was 64.67 ± 32.6 minutes per week at the University of Ilam. The reason for holding educational sessions was health priority in 679 (55.5%) HHs and health emergencies in 47 (8.3%) HHs. Other reasons included the city’s health center notifications (17.2%), special calendar time (7.5%), and other reasons (16%), respectively.
As the results showed, in all provinces of Iran, women and mothers eligible for reproductive health services accounted for 39.9% of the target groups. The second largest group included villagers, followed by pregnant and breastfeeding mothers. The primary healthcare workers and smokers comprised the lowest percentage of target groups (0.1%). In addition, East Azerbaijan, Isfahan, and Mazandaran provinces included more eligible women in the target groups, respectively; the results are presented in Table 3.
Table 3.The Target Groups of the Selected Health Houses (HHs)
| Target Groups | Percentage |
|---|---|
| Mothers and women eligible for reproductive health services | 39.9 |
| General public | 12.7 |
| Pregnant or breastfeeding women | 10.8 |
| Elderly | 7.9 |
| Farmers | 3.2 |
| Patients and families | 2.8 |
| Students | 2.7 |
| Housewives | 2.4 |
| Healthcare workersa | 1.7 |
| Council members and rural municipal administrators | 1.4 |
| Workers | 1.4 |
| Young couples | 1.3 |
| Primary healthcare workers | 0.1 |
| Smokers | 0.1 |
| Other target groups | 11.6 |
| Total | 100 |
aHealthcare workers as the medium between primary healthcare workers and people.
In terms of family planning, most education was provided for cities with a higher population growth, such as Sistan-Baluchestan and Hormozgan. Regarding the area of breast feeding, Khuzestan, Khorasan, Tehran, Yazd, Kermanshah, and Bushehr provinces received more education; Table 4 presents this information.
Table 4.Topics of Education in Provinces and Medical Universities Under Study
| Province (University or City) | Topics | Percentage | |
|---|---|---|---|
| 1 | Mazandaran | RH | 17.3 |
| 2 | Gilan | ZD and ID | 18.9 |
| 3 | Semnan (Semnana and Shahrud) | IDD | 27.3 |
| 4 | Yazd | CN | 13.2 |
| 5 | Ardabil | OC | 10.3 |
| 6 | East Azerbaijan | EH and ZD | 21.4 |
| 7 | West Azerbaijan | EH | 17.3 |
| 8 | Khorasan (Mashhad, Sabzevar, Torbat-e Heydarieh) | RH | 30.2 |
| 9 | Ilam | CN and ID | 25.7 |
| 10 | Tehran and Karaj | CN | 24 |
| 11 | Golestan | Elderly health and OC | 20.6 |
| 12 | Kohgiluyeh and Boyer Ahmad | EH | 11.5 |
| 13 | Isfahan and Kashan | OC | 13.3 |
| 14 | Kerman (Kerman, Jiroft, Rafsanjan) | RH | 28.6 |
| 15 | Zanjan | Intestinal diseases | 9.6 |
| 16 | North Khorasan | CN and elderly health | 20 |
| 17 | South Khorasan (Birjand) | OC and ZD | 23.8 |
| 18 | ChaharMahal and Bakhtiari (Shahrekord) | Water sanitation | 14 |
| 20 | Bushehr | CN and EH | 28 |
| 21 | Kermanshah | CN and EH | 25 |
| 22 | Khuzestan (Dezful, Ahvaz) | CN and food hygiene | 18.6 |
| 23 | Hormozgan | OC | 19.4 |
| 24 | Markazi (Arak) | OC and ZD | 19.6 |
| 25 | Sistan and Baluchestan (Zahedan) | OC | 15.9 |
| 26 | Lorestan | Intestinal and parasitic diseases | 13.2 |
| 27 | Fars (Shiraz and Jahrom) | Women’s cancers | 12.8 |
| 28 | Qazvin | Women’s cancers | 9.5 |
Abbreviations: CN, child nutrition; EH, environmental health; ID, infectious diseases; IDD, iodine deficiency disorders; OC, contraceptive methods; RH, reproductive health; ZD, zoonotic diseases.
aCity.
5. Discussion
The present study revealed that most of the provided education in HHs was related to the fields of family planning, maternal and child health, and reproductive health. In recent years, the high rate of reduction in total fertility has been discussed, and new approaches are necessary in this area. Overall, studies on the efficacy of education for family planning seem inadequate (15).
Reproductive health includes physical, mental, and social health, besides different aspects, processes, and functions of the reproductive system. It encompasses family planning services, HIV/AIDS and other sexually transmitted diseases, maternal and neonatal health, sexual violence (16), and all aspects of human health from birth to death. The international conference on population and development (ICPD) in Egypt highlighted the need to promote reproductive health programs around the world (17). Therefore, it seems that considering women’s health issues, it is necessary to increase the coverage of family planning. Some provinces, which have the highest rates of family planning, also have a total fertility of less than 2 children in Iran.
Another topic was rural environmental health, which was mostly discussed in the marginal cities of Southwest and Northwest of Iran near the Lake Urmia. It seems that the poor conditions of rural environmental health have prompted primary healthcare workers to provide more instructions for patients. The rural culture is changing towards consumerism, which in turn leads to the production of imperishable waste. On the other hand, the rural population is still oblivious to waste management and environmental health (18). Although the exact content of these educational programs is not the focus of this study, it seems necessary to create an intersectional partnership in the area of rural environmental health education, as rural municipal administrators manage rural environmental health.
Another issue was related to zoonotic diseases, which are common in provinces, such as Isfahan (19) and Yazd (20). However, the prevalence in these provinces is much lower than the mean national rate. Previous studies have emphasized on the importance of education for coetaneous leishmaniasis (21) in the endemic regions of Isfahan (22). The healthcare system should determine whether the given education is in accordance with the recognized importance of diseases in the region or is inconsistent with the region’s priorities.
In case of intestinal diseases, more education was provided in rural HHs, perhaps since most education was provided in summer, when diarrheal and intestinal diseases, such as Eltor, are more common. Coronary heart disease (CHD) is the leading cause of mortality in Iran, comprising about 50% of all deaths (23, 24). Other studies have focused on the increasing prevalence of metabolic syndrome and obesity in Iran and have proposed various interventional methods (25, 26).
Although the mentioned diseases comprise the health priorities of Iran and less educated people (such as rural populations) are at a great risk of these diseases (27), only a small part of HH training was dedicated to cardiovascular diseases and risk factors in our study. In rural populations of Alabama (USA), India, and Egypt, similar results have highlighted the need for education regarding the risk factors (28-30). The limited education may be related to the negligence of this issue as a priority for human forces, low capacity for the desired level of education, and lack of attention by the authorities.
In a study by Mooney LA and Franks AM, instructions about cardiovascular risk factors were accompanied by disease screening (31). Since the prevalence of CHD is higher in men than women and the relationship between education and CHD risk factors varies according to gender (32), different types of education and training are necessary for men and women.
Road accidents are the second leading cause of death in Iran (33). In fact, the mortality rate is 10 times higher than the global mortality rate due to car accidents (34). Moreover, mortality rate due to road injuries is higher than the average rates in other countries (35). However, despite its great importance, limited instructions are provided in this area. The need for safety education and control of road accidents in Iran is reportedly similar to Pakistan (36). It seems that intersectoral attempts at training in this area must be in collaboration with the police force, highway patrol, mass media, and ministry of health.
In a study conducted in Fars Province, Iran, 10.7% of all deaths were related to accidental injuries (unintentional injuries) in rural regions (37). Therefore, special attention should be paid to the education of male drivers, accompanied by an injury surveillance system. Considering the target groups, it seems that besides mothers (with children < 5 years), pregnant women, and eligible women for family planning, particular attention should be paid to teenagers and their risky behaviors, as well as patients with chronic diseases, risk factors for chronic diseases, and men with high-risk jobs.
Self-care education should be considered in diseases, such as hypertension and diabetes. Iran is a country with diverse ethnicities, languages, and priorities (38). Therefore, these differences and priorities, as well as people’s needs and beliefs, should be taken into consideration in the design of training programs in HHs.
Among the limitations of the present study, one can mention the absence of a detailed examination of the content, effectiveness, and efficiency of educational programs; lack of examination through the year is another shortcoming. However, a major strength of this study is the comprehensive and nation-wide review of health clinic education.
5. Conclusions
This study examined the public educational programs of HHs, considering the health priorities of each region and the target rural groups. It seems that most education in these HHs does not correspond to the needs of the region. Regarding contagious diseases and infections, some of the provided education did not match the prevalent diseases in the region. Despite the great importance of contagious diseases, little efforts have been made to educate people, and there is limited education on this subject. Although cardiovascular diseases, road traffic accidents, and cancers are the major causes of mortality in Iran, most provided education focused on reproductive health and mother and child health.
We suggest reforms at all levels of the primary health network of Iran. Similar to other WHO health promotion programs, such as health promotion hospital (HPH), which considers education and health promotion of clients, staff, organization, and community (39, 40), multidimensional education can be integrated in Iran. On the other hand, new methods of education, such as use of mobile phones and social networks, are suggested to improve evidence-based education in the future.
Implications for health policymakers/practice/research/medical education
This study can be helpful in the development and promotion of health education in Iranian health houses.
