摘要：Objectives. The activities of community health workers (CHWs) have been identified as key to improvements in the health of Iran's rural population. We explored the perceptions of CHWs regarding their contribution to rural health in Iran. Methods. Three research assistants familiar with the Iranian primary health care network conducted face-to-face interviews with CHWs in 18 provinces in Iran. Results. Findings showed that Iranian CHWs have an in-depth understanding of health, including its social determinants, and are responsible for a wide range of activities. Respondents reported that trust-based relationships with rural communities, an altruistic motivation to serve rural people, and sound health knowledge and skills are the most important factors facilitating successful implementation of the CHW program in Iran. By contrast, high workload and the lack of a support system were mentioned as barriers to effective performance. Conclusions. The CHW program in Iran is a compelling example of comprehensive primary health care, in that CHWs provide basic health care but also work with community members and other sectors to address the social determinants of health. During the past 3 decades, Iran has implemented significant changes in its health system structure and witnessed major improvements in the health status of its population. The World Health Organization adopted a primary health care approach to achieve its vision of “health for all by the year 2000,” and Iran built on its existing primary health care services to develop a more comprehensive network. Health system reform coincided with the Iranian revolution in 1979, which spawned enormous political change within the country as well as an 8-year war with Iraq that had a major impact on socioeconomic and health conditions in Iran (e.g., economic deficits, material destruction). The new health system was based on comprehensive primary health care and also saw the integration of medical education and health care services beginning in 1984. 1 This integration occurred in response to health workforce shortages and aimed to improve the country's development of human resources for health and to match health personnel education to population health needs more effectively. Many studies conducted within the past few decades indicate that Iran has made remarkable progress in a range of health indicators despite its revolution and ensuing war. 2 – 4 Mortality rates among infants and children younger than 5 years decreased from 93 and 135 deaths per 1000 live births in 1974 to 28.6 and 36 deaths per 1000 live births in 2000, respectively. 2 – 4 In addition, the maternal mortality ratio, recognized as a sensitive indicator of both development and health services, 5 decreased sharply from 140 to 24 deaths per 100 000 live births between 1985 and 2007. 6 Life expectancy increased from 55.7 years in 1976 to 71.6 years in 2003, 6 and a trend analysis showed that Iran has been more successful than other countries in the Eastern Mediterranean region in improving health. 2 A primary goal of primary health care in Iran was not only to improve population health nationwide, but also to narrow the rural–urban health gap. A study conducted by the Statistical Center of Iran between 1973 and 1976 revealed a striking difference in infant mortality rates between rural (130 per 1000 births) and urban (13.9 per 1000 births) areas, attributable mainly to disparities in income, living standards, and access to basic health and social services. 4 This gap closed dramatically after the establishment of the primary health care system in Iran with its special emphasis on the rural poor. In 1985, rural infant mortality was almost twice that in urban areas (71 vs 33 deaths per 1000 live births). This gap had narrowed by 1996 (30.2 infant deaths per 1000 live births in rural areas vs 27.7 in urban areas 4 ), with rural infant mortality declining further to 23.7 deaths per 1000 live births in 2003. 7 It is unlikely that these improvements were achieved through primary health care alone given that the period also saw economic growth, increased literacy rates, and improvements in environmental services such as access to safe water and sanitation. Moreover, the role of physicians, dentists, and other allied health workers in improving rural health and narrowing the rural–urban health gap cannot be ignored. A particular feature of the primary health care reforms was refinement and expansion of a community health worker (CHW) program begun decades earlier. 8 , 9 The expansion of the program was specifically intended to extend basic health services to underprivileged areas. Iranian CHWs, called behvarzes in the Farsi language, are local health workers with specialized training in the health needs of the rural population. Behvarzes are selected from the rural areas where they live and are committed to reside in their area for at least 4 years after training. Nevertheless, some behvarzes , as a result of family concerns (e.g., their children's education and other living considerations), move and reside in urban areas close to the village where they work. To qualify as a behvarz , an individual must have a high school certificate and be approved by the rural council; also, they are interviewed and must pass a theory test. The minimum requirements in terms of education have become considerably more stringent over time; thus, the current corps of behvarzes includes a mixture of less educated, longer-serving behvarzes and better educated, more recently recruited workers. The 2-year behvarz training period, which includes theory and practical classes as well as clinical placement in rural areas, covers a broad range of topics from health care services to communication skills and social determinants of health. Behvarzes are permanent employees of and paid by the Iranian health system. They work from village health houses, health delivery facilities located in rural areas. Each health house is designed to cover a target population of approximately 1500. According to the most recent statistics, in 2007 there were about 17 000 health houses in Iran, with almost 31 000 male and female behvarzes working in these facilities, which cover most of the country's 65 000 villages. 10 Despite evidence indicating the comprehensiveness of the CHW program in Iran, 11 there has been little research examining in detail the factors influencing CHW performance and overall program sustainability. We attempted to fill this gap by exploring CHWs’ perceptions about their contribution to health gains in rural areas over the past few decades and examining facilitators of and barriers to the success of Iran's behvarz program.
