What are the vulnerabilities and solutions of noncommunicable diseases in rural areas? A descriptive qualitative study in Iranian villages

Abstract

Background

The increasing prevalence of noncommunicable diseases (NCDs) worldwide is a major global health challenge. Each year, more than 15 million people between the ages of 30 and 69 die prematurely from NCDs. While the prevalence of NCDs is greater in urban areas, there are significant structural changes in rural areas, and certain socioeconomic factors increase the likelihood of developing NCDs. This study aimed to explore vulnerabilities in rural areas of Natanz County to address NCDs and provide solutions.

Methods

This descriptive qualitative study was conducted in Natanz County, Iran, in 2024, focusing on 17 villages with varying prevalence rates of NCDs. The study design involved identifying the 5 villages with the highest prevalence rates of NCDs for in-depth analysis. The study population comprised residents from these selected villages, and a total sample size of 22 residents was purposefully chosen to participate in the study. Data were collected using focused group discussions, which facilitated rich, qualitative insights. The transcribed data were analyzed through Braun and Clarke’s thematic analysis, allowing for the extraction of codes, subthemes, and themes. The data analysis was conducted using MAXQDA Analytics Pro 2020.

Results

Vulnerabilities were categorized into 6 themes and 18 subthemes, and in the area of proposed solutions, 7 themes and 20 subthemes were recognized. The identified vulnerabilities included social factors, lifestyle changes, political factors, economic factors, individual factors, environmental factors, and comprehensive health services. The proposed solutions can be categorized into social factors, lifestyle changes, political factors, economic factors, individual factors, environmental factors, comprehensive health services, and research factors.

Conclusion

Diabetes and hypertension are prevalent in the studied villages and are driven by unhealthy lifestyle choices and a lack of trust in healthcare services. To address these issues, targeted interventions focusing on education, health promotion, and rebuilding trust in healthcare are essential for promoting healthier lifestyles and improving treatment strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-25242-2.

Introduction

The increasing prevalence of NCDs worldwide is a key challenge to global health [1]. According to the World Health Organization (WHO), NCDs are defined as conditions that result in “a reduction in the structure or function of the body that necessarily leads to a change in the patient’s normal life and persists over a long period of time“ [2]. The important features of these diseases include their chronic nature, disability, irreversibility of cognitive changes, and need for patient education and care to continue living [3]. Examples of these diseases include cardiovascular diseases, diabetes, chronic respiratory diseases, allergies, certain types of cancer, osteoporosis, and hypertension [4]. The World Health Organization reported that NCDs claim 41 million lives annually, accounting for 74% of all deaths worldwide. Each year, more than 15 million people between the ages of 30 and 69 die prematurely from NCDs. 85% of these premature deaths occur in low- and middle-income countries. Cardiovascular diseases account for the largest number of NCD-related deaths, with 17.9 million deaths per year, followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million). These four groups of diseases account for more than 80% of all premature NCD deaths [5], with nearly three-quarters of these deaths occurring in low- and middle-income countries such as Iran [6]. Among the three major groups of diseases and injuries (preepidemiological transition diseases, NCDs, and injuries), NCDs impose the greatest burden of disease in Iran, accounting for 45% of the burden in men and 33% in women [7].

The prevalence of NCDs varies across rural areas, with some studies reporting higher rates in rural areas than in urban areas [8, 9], whereas others reporting the opposite [10, 11]. On the other hand, the results of some studies suggest that the prevalence of risk factors for noncommunicable diseases (NCDs) in rural areas is a significant concern due to high rates of smoking and alcohol consumption, physical inactivity, and inadequate fruit and vegetable consumption [12–14]. These risk factors are associated with older age, male sex, illiteracy, and lower socioeconomic status [12]. Furthermore, developing awareness programs to change behavior, particularly in rural areas, is essential for modifying these risk factors and preventing NCDs [14].

Rural areas face multiple vulnerabilities in terms of NCDs, including challenges in healthcare service delivery, such as poor access, human resource shortages, and an irregular drug supply. Patients in rural areas also face difficulties in accessing healthcare due to geographical distance, limited access to healthcare specialists, and cultural factors [15]. While the prevalence of NCDs is greater in urban areas, there are significant structural changes in rural areas, and certain socioeconomic factors increase the likelihood of developing NCDs [14].

The study site is the rural area of Natanz County. Natanz County is located in Isfahan Province, 120 km from the provincial capital, Isfahan. With an area of approximately 3397 square kilometers, the county is situated between the cities of Aran and Bidgol and Kashan to the north and Isfahan to the south. The county’s elevation is 1600 m above sea level, and it is adjacent to the Central Desert of Iran. According to data collected from the SIB system of the Ministry of Health and Medical Education, the population of Natanz County in 2022 was 42,541, with approximately 8,331 people residing in rural areas. Furthermore, on the basis of statistics received from Natanz County health centers through the same system, diabetes, with a prevalence of 16.5%, and hypertension, with a prevalence of 19.6%, are among the most common noncommunicable diseases in the study area. Therefore, considering that one of the important dimensions of vulnerability in human societies is the prevalence of noncommunicable diseases, the present study aims to identify vulnerabilities and solutions in relation to NCDs in the rural areas of Natanz County, Isfahan Province.

Methods

Study design and setting

The study setting for this descriptive qualitative research was carefully chosen to focus on the rural areas of Natanz County (Isfahan, Iran), specifically targeting villages with significant health concerns related to NCDs in 2024. Here’s how the study setting was determined:

1. Identification of Villages: Among the 17 villages in Natanz County, the selection process began by identifying those with the highest prevalence rates of NCDs. This approach ensures that the research focuses on areas where the impact of these diseases is most pronounced, allowing for a deeper understanding of the challenges faced by residents in managing and coping with NCDs.

2. Purposeful Selection: From the identified villages, five were purposefully selected based on their prevalence rates of NCDs. The prevalence data for noncommunicable diseases was obtained from the Health Network of Natanz County. This county comprises 17 inhabited villages, among which five villages exhibited the highest rates of hypertension and diabetes. The officials of the Natanz Health Network questioned why the prevalence of these diseases was higher in these villages compared to others. Consequently, these five villages were selected for the study. Additionally, the data related to disease prevalence has been recorded in the Natanz Health Network and has not undergone any further refinement. This purposeful sampling strategy is critical in qualitative research as it allows researchers to gather rich, detailed information from participants who are directly affected by the research topic. By concentrating on villages with higher rates of disease, the study aims to capture relevant insights into the specific vulnerabilities and coping strategies related to NCDs.

3. Community Engagement: To enhance the relevance and effectiveness of the study, village officials, including village heads and council members, were consulted. Their involvement helped identify informed individuals who could contribute meaningfully to the discussions, ensuring that the selected participants had a comprehensive understanding of the village affairs and the impacts of NCDs in their communities.

4. Focus on Long-term Residents: The inclusion criteria specified that participants must have resided in their respective villages for at least 10 years. This criterion was established to ensure that the participants had sufficient experience and knowledge of the local context, including the health challenges and social dynamics related to NCDs.

Study population and eligibility criteria

The study population consisted of residents from the villages in Natanz county. The eligibility criteria included:

• Residing in the village for a minimum of 10 years.

• Being over 25 years old.

• Having at least basic literacy skills.

• Being informed and involved in village affairs.

Participants who demonstrated a lack of willingness to participate in focused group discussions and a lack of willingness to continue attending group discussion sessions were excluded from the study.

Sampling and sample size

A total of 22 residents were purposefully selected from the five chosen villages, which have an approximate population of 5,600. This sample size was determined based on the need to gather rich qualitative data while ensuring that participants could provide diverse perspectives on the issues related to NCDs in their communities.

Data collection tool

Data were collected using Focused Group Discussions (FGDs). The FGD guide was developed specifically for this study by the research team, incorporating relevant themes related to vulnerability and capacity in the context of NCDs (Supplementary Table 1).

Data collection procedures

To conduct the focused group discussion, the stages proposed by Tobius et al. (2018) were followed [16], as shown in Fig. 1.

Fig. 1.

Flow chart of the steps of the focus group discussion in 5 vilages

The study involved two four-hour focused group discussions, which were arranged by contacting interested and qualified individuals via phone calls and inviting them to participate if they were willing. FGDs were conducted by S.T (MSc student at Isfahan University of Medical Sciences), M.A.R and G.A (Associate professors at Isfahan University of Medical Sciences). S.T and G.A are female and M.A.R is Male. G.A and M.A.R as faculty members have experienced in qualitative study and S.T was trained to conduct the FGDs. Prior to the discussions, the participants attended an orientation session at the village council, where the research team provided an overview of the study’s objectives, methodology, and benefits, as well as explanations of key concepts such as vulnerability and capacity in the context of noncommunicable diseases. The team also explored the social, economic, and environmental factors that influence NCDs. No anyone else present besides the participants and researchers in FGDs sessions. During the discussions, the participants were asked to identify vulnerabilities and coping strategies related to a specific noncommunicable disease in their village and to propose solutions to mitigate its impact. Throughout the process, a research team member was present to facilitate the discussion, summarize the opinions expressed, and address any questions that arose. With the participants’ consent, their quotes and narratives were recorded in both audio and video formats and transcribed, and the facilitator took detailed field notes to capture key points. FGDs were lasted between 2 and 3 h. FGDs sessions were continued till achieving saturation point in which no new ideas, insights or data arose from the FGDs participants.

Data analysis

Braun and Clarke’s [16] step-by-step thematic analysis was used to extract codes, subthemes, and themes from the transcribed data, employing an inductive approach to data analysis.To conduct the thematic analysis, the following steps were performed: (1) To become acquainted with the qualitative data, all the authors immersed themselves in it by listening to audio-taped focus groups and reading the transcripts repeatedly; (2) initial codes were obtained from the data through open coding with a focus on the vulnerability and capacity of nonchronic disease. The codes were reviewed by all team members. (3) To integrate and combine the initial codes into more abstract and comprehensive themes and subthemes, two of the authors (ST and GA) independently reviewed the initial codes and their corresponding coded segments. They also assigned each theme and subtheme a working title. (4) Team members met in four 3-hour meetings to discuss and resolve issues and gain consensus on developing themes. Themes and subthemes were decided upon and completed during this process. (5) At this stage, the team members established and further refined the themes and subthemes and tagged them. (6) Finally, a scholarly report was created addressing the themes and subthemes related to the vulnerability and capacity of nonchronic diseases in rural areas. MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin) Release 20.2.1 was used to manage and interpret the transcripts systematically.

Applying MAXQDA

To effectively utilize MAXQDA for qualitative data analysis, the following steps were undertaken:

1. Importing Data: Transcripts from FGDs were imported into MAXQDA, allowing for easy access and organization of data.

2. Coding: Using Braun and Clarke’s thematic analysis framework, initial codes were generated by highlighting relevant segments of text. These codes were then organized into categories to form subthemes.

3. Creating Themes: The subthemes were reviewed and refined to develop overarching themes that encapsulate the key findings related to noncommunicable diseases.

4. Reporting: Finally, the findings were compiled into a comprehensive report, detailing the identified themes and subthemes, which was facilitated by MAXQDA’s reporting features.

By following these steps, MAXQDA provided a robust platform for systematically managing and interpreting qualitative data, enhancing the depth of analysis in the study.

Quality assurance

To ensure the quality of the qualitative data, the 4 criteria for evaluating qualitative research proposed by Lincoln and Guba were followed.

1. Credibility: To increase the credibility of the data, in addition to the researcher’s prolonged engagement with the study, triangulation was used in all stages of the research, including data collection methods (group interviews and field notes).

2. Transferability: To ensure transferability, efforts were made to select suitable samples and collect and analyze data simultaneously.

3. Dependability: This concept encourages researchers to provide opportunities for review and scrutiny by other researchers. Dependability was achieved through the use of complementary opinions from external reviewers in coding and analyzing qualitative data.

4. Confirmability: To ensure confirmability, the research team tried to minimize the influence of personal values and theoretical biases in the research process, data analysis, and finding extraction.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki. The following ethical principles were upheld:

• Respect for Persons: Participants were fully informed about the nature of the study, the voluntary nature of participation, and their right to withdraw at any time without penalty. Informed consent was obtained from all participants. Also, the privacy of participants and the confidentiality of their data were protected by the researchers.

• Justice: The selection of participants was conducted fairly, ensuring that no specific group was disproportionately burdened or excluded from the benefits of the research.

• Scientific Validity: The research was designed to be scientifically valid and ethically justifiable.

• Transparency: Findings were reported transparently, including limitations and challenges faced during the research process.

• Accountability: esearchers were held accountable for their research practices, and studies were reviewed by an appropriate ethics committee or institutional review board. This study received the required ethics approval from the Isfahan University of Medical Sciences Ethics Committee (No. IR.MUI.RESEARCH.REC.1400.391) Isfahan, Iran.

Results

The results related to the demographic characteristics of the participants are presented in Table 1. Vulnerabilities were categorized into 6 themes and 18 subthemes, and in the area of proposed solutions, 7 themes and 20 subthemes were recognized (Table 2).

Table 1.

Characteristics of the participants in the group discussion session

Village Number	Education	Age	Sex	Participant Number
1	M.Sc	50	Male	1
2	B.Sc	33	Male	2
2	B.Sc	49	Female	3
1	Elementary	59	Female	4
1	M.Sc	41	Female	5
1	B.Sc	29	Female	6
1	B.Sc	30	Female	7
1	M.Sc	52	Male	8
1	Diploma	32	Female	9
3	Diploma	35	Male	10
4	B.Sc	37	Male	11
3	High school	42	Male	12
5	Diploma	51	Male	13
4	Diploma	42	Male	14
3	B.Sc	34	Male	15
5	B.Sc	40	Male	16
3	Diploma	54	Male	17
5	Diploma	60	Male	18
4	Associate degree	46	Male	19
3	M.Sc	57	Male	20
5	Associate degree	36	Male	21
3	B.Sc	56	Male	22

Table 2.

Vulnerability to noncommunicable diseases in the studied villages

Theme	Subtheme	Code
Socio-economic Factors	Occupational Components and Changes	− Rise in night shifts − Rise in clerical work − Unemployment − Shift from traditional to industrial occupations − Occupational stress
	Changes in Customs and Habits	− Decrease in hosting and throwing parties − Decline in traditional social meetings. − Reduction in local and national celebrations and games.
	Decrease in Social Vitality	− Excess in holding religious mourning ceremonies. − Decline in national celebrations. − Spread of discouraging content and bad news on social media.
	Decrease in Purchasing Power	− Decrease in people’s purchasing power for healthy food. − Decrease in purchasing power for medical equipment, facilities, and treatment supplies. − Decrease in people’s purchasing power for essential medications related to diseases.
	Insufficient Resource Allocation	− Lack of attracting charitable financial resources for disease control and prevention. − Insufficient budget allocation to prevention programs.
Individual-Lifestyle Factors	Transition from Rural to Urban Lifestyle	− Excessive use of virtual space. − Decrease in the use of rural-made materials.
	Changes in Dietary Habits	− Tendency toward fast food consumption. − Increased consumption of oil, salt, and sugar. − Overeating. − Ignoring of traditional foods habits − Decreasing consumption of traditional foods. − Lack of access to suitable and nutrient bread in rural areas. − Lack of healthy and organic foods.
	Lack of Physical Activity	− Absence of suitable spaces for exercise and walking, especially for women. − Decrease in physical activities.
Political Factors	Impose Sanctions and Political Restrictions	− Restrictions on the Import of Essential Medicines. − Increase in Drug Prices Due to Sanctions.
	Inappropriate Government Health Policy	− Priority on treatment over prevention. − Lack of prioritization and implementation of control and prevention programs for noncommunicable diseases.
Individual Factors	Poor Health Literacy	− Following incorrect medical and health information. − Misinterpretation of medical information. − Trusting false medical information. − Promoting false medical information.
	Personality Traits	− Envy and Rivalry − Being Pretentious − Hedonism − Living in Regret for the Past − Self-Diagnosing − Normalization of Illness − Jealousy − Resentment − Noncompliance with Medical Instruction
	Genetic Factors	− Genetic history of noncommunicable diseases.
Environmental Factors	Water and Soil	− Specific physical and chemical properties of the region’s water and soil. − Soil pollution due to excessive use of chemical fertilizers.
Health care Services issues	Follow-up and Check ups	− Inactive follow-up by healthcare providers. − Lack of timely and appropriate follow-up of high-risk individuals. − Increase in costs of check-ups and diagnostic tests. − Lack of timely follow-up of patients during treatment.
	Specialized Services	− Shortage of specialized service facilities. − High cost of specialized services. − Inadequate access to specialized laboratory and diagnostic services. − Inadequate access to specialized medications.
	Health Education	− Lack of public responsiveness to healthcare education. − Lack of public trust in health education.
	Human Resources in Health	− Lack of Motivation of healthcare providers. − Inadequate presence of nutritionists in health centers. − Inadequate presence of psychologists in health centers. − Inadequate presence of physicians in health centers.

Vulnerability to noncommunicable diseases

Socio-economic factors

Occupational components and changes

The participants mentioned factors such as increased night shifts, increased employee numbers, unemployment, changes in job style from traditional to industrial, and job-related stress. Regarding the increase in night shifts as a harmful factor for noncommunicable diseases, one participant said, “Working in a textile factory involves night shifts, and after that, employees have to work on their farms or livestock for 4–5 hours during the day. Now, see how this person has sleep disorders and cannot rest. Their sleep is disrupted, and they have metabolic problems, which can lead to diabetes.” (Participant 10).

With respect to the change in job style from traditional jobs to industrial jobs, participants stated that, owing to the decrease in agricultural water resources, most people have become involved in factory work or office jobs. Even village women have become involved in sales and desk jobs.

Changes in customs and habits

The participants mentioned changes in customs and habits, including reduced social gatherings and family reunions and reduced local celebrations and games. With respect to social gatherings, one participant said, “Social connections, when there are gatherings and parties, can help control blood pressure… Unfortunately, it is hard to find two families that are closely related, even two brothers who have a close and intimate relationship.” (Participant 4).

Decreased social vitality

One of the factors contributing to decreased social vitality, according to the participants, is the excessive holding of mourning and religious ceremonies. According to the participants’ statements, the holding of religious ceremonies in these villages is very frequent, and owing to the presence of multiple religious groups, these ceremonies are often excessive. In this regard, one participant said, “The discussion of mourning is a bloodletting during the months of Muharram and Safar. On these days, a person goes from one house to another, attending mourning sessions every hour… Well, this excessive mourning injects sorrow and grief into individuals and takes away their joy, affecting their spirit and blood pressure.” (Participant 12). Additionally, the spread of discouraging content and bad news through mass media and social media can reduce social vitality: “When discouraging things are constantly published on TV, mobile phones, and social media, instead of giving hope, they spread despair. There’s no doubt that it affects people’s nerves.” (Participant 15).

Decreased in purchasing power

The decreased purchasing power of people to obtain healthy and organic food, decreased purchasing power to provide medical equipment and facilities for the treatment and prevention of diseases such as diabetes and hypertension, and decreased purchasing power to access essential medications related to these diseases are among the economic factors. One participant stated, “Medications have become expensive, like Zipmet, a foreign medication for diabetes, but since the price has gone up, they are forced to take regular metformin, and their sugar levels do not decrease anymore.” (Participant 20).

Insufficient resource allocation

The allocation of resources (financial, human, and equipment) for planning, implementing, and monitoring control and prevention programs for noncommunicable diseases has not been properly established. One participant stated, “If philanthropists are to provide financial assistance, they prefer to invest in building schools and mosques. In the health sector, they may invest in hospital construction, but there is no cultural establishment for attracting philanthropic investment in health and disease prevention.” (Participant 17) Additionally, participants mentioned that, owing to insufficient budgets in the health sector, adequate attention is not given to control, screening, and prevention programs for noncommunicable diseases.

Lifestyle changes

Transition from rural to urban lifestyles

The participants mentioned the transition from a rural lifestyle to an urban lifestyle, citing the excessive use of virtual space and social media. The use of virtual space has led to a decrease in real social networks and gatherings with family, neighbors, and fellow villagers. Another vulnerability mentioned in this area is the decrease in the use of rural elements such as mud-brick houses, dirt alleys, and traditional rural architecture, which have all been replaced by urban-style construction. One participant stated, “If we look back, most alleys were dirt roads, and houses had traditional architecture with mud and brick, maybe reflecting sunlight and absorbing energy. However, now, with smaller houses and the use of blocks and cement, the reflection of light and energy in the home space has completely changed.” (Participant 7).

Changes in dietary habits

The participants mentioned that traditional and healthy rural foods have been replaced by sweet, fatty, and salty foods, as well as fast food. In the past, villagers used natural fats for cooking, but currently, industrial oils have taken their place. In the past, the bread needed for the family was baked at home, but currently, bread is purchased from bakeries, which lack quality because of the use of baking powder and chemical additives in the baking process. Additionally, owing to water scarcity, organic and beneficial products such as grapes are less cultivated, and people have replaced them with sugar and sweets: “The food that people in the village used to eat was natural and organic. They would make their own bread at home or in the village, but the flour they use is now unknown or the food that is now industrially produced and consumed. They would raise their own sheep and make a local dish called ‘Qormeh’ with it, and they had less blood pressure or diabetes. However, now, since the lifestyle has changed and become more industrialized and fast-food oriented, this has an impact on diseases.” (Participant 1).

Lack of physical activity

In the past, villagers were able to meet many of their primary needs themselves, which contrasts with the current situation, where lifestyle changes and the decline of physically demanding jobs such as agriculture, livestock farming, and carpet weaving by women led to a lack of physical activity and reduced physical activity. Additionally, the lack of suitable spaces for exercise and walking, especially for women, has also contributed to the decrease in physical activity.

Political factors

Impose sanctions and political restrictions

The impact of sanctions and political restrictions on noncommunicable diseases, access to necessary medications, increase in drug prices due to sanctions and the quality of medications is evident. One participant stated, “In recent years, we have felt the impact of sanctions on diseases. For example, in diabetes, owing to the shortage of insulin and foreign medications, the patient’s condition has worsened, leading to amputation. In the past month, we had two amputations in the village. One unfortunately passed away, and the other is a young person who, God willing, will recover.” (Participant 16).

Inappropriate government health policy

According to the participants, government policies in the health sector are focused mostly on treating diseases. Attention to prevention and prioritizing it over treatment, especially for noncommunicable diseases, is less common. In other words, planning, implementing, and monitoring control, screening, and prevention programs for noncommunicable diseases are not a priority in the health system, unlike treatment.

Individual factors

Poor health literacy

Poor virtual health literacy is one of the vulnerabilities that participants mentioned from various aspects. In recent years, the use of social media and virtual networks has increased, leading to the spread of incorrect medical information, misinterpretation of medical information, trust in false medical information, and promotion of false medical information. One participant stated, “Currently, women are more active on social media and get their information from there. It is not clear how much of this information is correct or incorrect. Sometimes this information becomes the basis for action and can have negative consequences. What’s worse is that this false information circulates and spreads on social media.” (Participant 5).

Personality traits

Additionally, individual personality traits increase vulnerability at the individual level. Envy, pretentiousness, luxury-seeking, nostalgia, jealousy, grudge-holding, and hypocrisy are among the individual traits that make people vulnerable to noncommunicable diseases. Furthermore, self-diagnosis and normalization of disease were also mentioned by the participants. Regarding envy and jealousy, Participant 18 said, “I think there is a lot of envy in our village, which itself leads to hypertension, diabetes, and nervous diseases.” With respect to nonadherence to medical instructions, one of the interviewees said, “They say go get tested, for example, I will mention my own father, who refuses to go for testing. He does not take his medication, even though he knows his blood pressure is high, and sometimes he does not take it for a week.” (Participant 16).

Genetic factors

Participant 16 stated, “The same tribe that has diabetes in village A and their relatives in village B also have diabetes. 70–80% of these two tribes have diabetes and hypertension.”

Environmental factors

Water and soil

The physical and chemical characteristics of a village’s water and soil can be a vulnerability factor related to noncommunicable diseases. In this regard, one participant stated, “For example, we did not have kidney stones in the village before. I myself have been suffering from kidney stones for a few years. I have had several lithotripsy procedures, but my disease has relapsed. I think it is due to the water we consume in this village… both the water and soil here are problematic.” (Participant 17) Additionally, the use of chemical fertilizers in agricultural lands can contaminate the soil. The use of chemical fertilizers can have indirect negative effects on health. For example, the use of chemical additives and fertilizers can contaminate soil and water, reducing the quality of agricultural products. These food products are used as sources of nutrition for humans, so increasing the consumption of contaminated agricultural products can lead to an increase in diseases such as diabetes and hypertension.

Comprehensive health services health care services issues

Follow-up and check-ups

Regular and continuous follow-up and check-ups can help reduce the incidence of complications and harm associated with noncommunicable diseases. Given the importance of this issue, especially for high-risk individuals, follow-up and check-ups should be actively provided at health service centers in villages. However, participants stated that follow-ups for noncommunicable diseases are not actively performed by healthcare providers: “I do not remember the last time I went to the doctor’s office and had a check-up, at least for myself, usually once a year, and it is been at least 7–8 years since I had a regular check-up and lab tests. This is very important, and the healthcare system should follow up.” (Participant 3) The increase in the cost of check-ups and diagnostic tests is another vulnerability that participants mentioned in relation to the reduction in regular check-ups. Additionally, the lack of timely follow-up of patients during the treatment process can lead to disruption of treatment and worsening of the disease. “For example, if I’m a villager with diabetes, the healthcare provider should remind me to check my blood sugar or blood pressure tomorrow or check my waist circumference. These things are not done on time, and the patient’s condition worsens.” (Participant 1).

Specialized services

According to the participants, one of the components that can lead to increased vulnerability to noncommunicable diseases is the lack of specialized services in rural areas. From the participants’ perspective, rural areas face a shortage of facilities providing specialized services and inadequate access to laboratory, diagnostic, and pharmaceutical services. Moreover, these services, when available, are expensive, and villagers cannot afford to pay for them. “Look, a patient with diabetes, hypertension, or cardiovascular disease, the healthcare services provided in the village are not sufficient, and they have to travel to the city or places that offer specialized services, wait in line, and when their turn comes, the specialized services are expensive, and they may face payment problems.” (Participant 2).

Health education

Health education in rural areas is often provided by healthcare workers who do not have high levels of education. Given the increasing level of education among villagers, especially young people, up to university levels, the health education provided by healthcare workers is not effective, and even, according to participants, people are distrustful of these educational programmes. In this regard, one participant said, “You all know the village healthcare worker, they have a diploma… Now, when someone has a master’s degree, they do not listen to him, who only has a diploma. This village has 40 physicians, all with high education, and they will certainly come to the conclusion that the healthcare worker does not have the information to give me that I do not have. Unfortunately, people are no longer interested in health education and have become distrustful of these programs.” (Participant 16).

Human resources in health

One of the vulnerabilities in the field of human resources in health is the lack of motivation among healthcare workers. The participants stated that, owing to the failure to consider the interests, skills, and abilities of individuals when they hire them as healthcare workers, they become demotivated over time, which disrupts the provision of comprehensive health services to villagers. “A healthcare worker who was not properly motivated from the beginning and whose abilities were not assessed naturally has no motivation to work and only comes to fill the administrative time, i.e., comes at 8 am and leaves at 2 pm, and this is our problem.” (Participant 13) Regarding the presence of various specialists in health service centers, participants mentioned the inadequate presence of specialists such as nutritionists, psychologists, and psychiatrists. Even due to the lack of a resident physician in the village, the participants mentioned the inadequate presence of physicians in the village. “We do not have any physicians here in the village. The physicians who visit health houses visit for only a short time, for example, two hours, and then leave. Now, for example, a child comes, an old man and an old woman come, and they wait… two hours are not enough.” (Participant 8).

Proposed solutions related to noncommunicable diseases

The proposed solutions were categorized into social factors, lifestyle changes, political factors, economic factors, individual factors, environmental factors, comprehensive health services, and research factors (Table 3).

Table 3.

Proposed solutions related to noncommunicable diseases

Theme	Subthem	Code
Social Factors	Improving the Employment Status of Village Residents	− Follow-up by the village council and mayor to attract facilities to establish small-scale, high-yield workshops − Training on reducing occupational fatigue in hard jobs and night shifts by the occupational health unit of the Natanz County Health Network − Promoting income-generating jobs at the village level, such as establishing rural ecotourism resorts
	Reviving Beneficial Village Customs	− Culturalization and education of people to revive and nationally register local festivals and games of the village by the Ministry of Cultural Heritage − Holding traditional social gatherings by the village council and mayor in cooperation with the people
	Promoting Social Vitality	− Intervention by rural Friday prayer leaders to promote moderation in holding religious mourning ceremonies at the village level, in collaboration with the council and mayor, and replacing them with national and religious celebrations − Holding joyful street theater performances in the village − Planning and implementing joyful plans for students, such as recreational camps
Changing Life Style	Reducing the Effects of Rural-to-Urban Migration	− Holding training courses on cyberspace harm diagnosis and prevention specifically for students − Increasing the revival of using rural construction elements with the entry of supervisory institutions such as the Housing Foundation, mayor’s office, and engineering offices to preserve the traditional texture of the village
	Improving the Quality of Nutrition and Consumed Food	− Training nutrition experts and healthcare workers at the health house to raise awareness and sensitize the community about healthy nutrition − Reviving traditional food habits and old traditional foods by holding periodic local food festivals in the village − Proper supervision by environmental health units and the Agricultural Jihad Administration to ensure access to suitable and quality bread in the village -Training related professions such as bakers and providing them with skill certificates to increase bread quality − Providing facilities and creating a conducive environment for producing healthy and organic food in the village − Promoting healthy nutrition breaks in village schools − Supervision of school buffets in the village by the nutrition unit of the health network
	Increasing Physical Activity	− Providing and equipping suitable and enclosed spaces for women’s sports and walking by the sports and youth administrations and authorities in the village − Holding public sports events in the village to increase physical activities
Economic Factors	Increasing People’s Purchasing Power	− Allocating rural loans by the council, mayor, and Relief Committee in the village -Increasing the ceiling of health insurance coverage for Iranians − Creating facilities for purchasing medicines and medical equipment
	Providing Credit Facilities	− Organizing charitable activities in villages by the council and mayors, and utilizing influential and capable individuals to attract financial resources from benefactors.
Individual Factors	Health Literacy Promotion.	− Continuous community education to promote health literacy and prevent the spread of health-related rumors. − Providing and introducing credible resources to people for obtaining medical information in the form of physical or electronic libraries in health centers.
	Holding Skill-Building Courses.	− Holding social skills and personal development training in villages by psychologists at health centers. − Teaching life skills and parenting skills by psychologists providing services at health centers. − Teaching self-care courses for addiction among youth by school teachers, healthcare providers, and psychologists at health centers.
	Attention to Genetic Factors	− Sensitization training with an emphasis on families with a genetic history of noncommunicable diseases
Environmental Factors	Improvement of Water Health and Sanitation	− Specialized examination of the physical and chemical properties of the region’s water. − Providing solutions to counter and adjust the harmful properties of the region’s water by experts and strengthening the supervision of environmental health units in rural health networks. − Monitoring of chlorine levels in the region’s water by environmental health units. − Continuous and periodic training of chlorine treatment personnel in the regional water and sewage administration by health networks.
	Improvement of Soil Health and Sanitation.	− Specialized examination of the physical and chemical properties of the region’s soil. − Providing solutions to counter and adjust the harmful properties of the region’s soil by experts. − Educating farmers and gardeners on reducing the use of chemical fertilizers.
Comprehensive Health Services	Screening	− Increased involvement of healthcare providers in education and sensitization of villagers on the importance of timely screening. − Conducting screening campaigns during special occasions (Health Week, Elderly Week). − Establishing a unified procedure and reducing the repetitive changes in the implementation of screening programs
	Primary Care	− Enhancing the activity of healthcare providers in actively following up with patients during treatment. − Following up with pharmaceutical units and developing health networks to ensure maximum availability of primary medications in health centers. − Investigating and addressing the causes of reduced referrals to health centers. − Strengthening the use of traditional medicine in disease treatment, considering its integration into the health network system.
	Patient follow-up.	− Proper supervision of healthcare providers for timely follow-up of high-risk individuals and patients
	Medical facilities and equipment.	− Following up with development units, charities, and public participation in health networks regarding the provision of equipment and facilities for periodic check-ups and treatment. * Ensuring access to specialized medical, laboratory, and pharmaceutical services. * Increased supervision and follow-up by the Food and Drug Administration on private pharmacies to complete the list of required medications.
	Health education.	− Training healthcare providers on teaching skills and communication with learners by the in-service training unit. − Gaining public trust in health education by employing suitable and experienced instructors. − Updating healthcare providers’ information by the in-service training unit to conduct effective education on disease prevention and treatment.
	Human resources	− Increasing the presence of nutritionists and psychologists in health centers. − Employing higher-educated individuals for healthcare jobs in rural areas. − Ensuring an adequate number of physicians in health centers considering the population coverage. − Attracting motivated and capable healthcare providers. − Holding orientation sessions for healthcare job applicants on their responsibilities and expectations.
Research factors	Conducting needs-based research in the village	− Specialized research on the effects of the physical and chemical properties of the region’s water on health. − Specialized research on the effects of the physical and chemical properties of the region’s soil on health. − Monitoring and evaluating the effectiveness of previous measures in controlling noncommunicable diseases in the mentioned villages.

Discussion

The present study aimed to identify the vulnerabilities of selected villages in Natanz County regarding noncommunicable diseases and provide solutions on the basis of local perspectives. The findings of our study highlight various vulnerabilities and challenges related to noncommunicable diseases (NCDs) in rural areas. Our research categorized these vulnerabilities into multiple themes, including socio-economic factors, individual-lifestyle factors, political factors, individual factors, environmental factors, and healthcare service issues.

Socio-economic factors

In recent decades, social determinants have been recognized as crucial factors in the emergence of noncommunicable diseases by policymakers and researchers in the health system. This study identified unemployment, changes in occupation, and decreased social interaction as social vulnerabilities leading to noncommunicable diseases. According to village-level surveys, individuals often become homemakers because of factory and workshop closures, a lack of job opportunities, and ultimately, family livelihoods. Similarly, Jain et al. reported that patients with high social vulnerability to cardiovascular diseases often have lower education levels, lower income, and higher unemployment rates than other patients do [15]. The results of Lemos’ research indicated that multifaceted interventions, including education and continuous follow-up, can lead to significant improvements in the control of blood pressure and diabetes in rural communities [17]. In a study by Azizi et al., risk factors for noncommunicable diseases were significantly greater in married women than in single women and in housewives than in working women [18]. However, previous studies have not specifically addressed the impact of employment on women and instead have highlighted the prevalence of a sedentary lifestyle as a risk factor in society. They have also mentioned the shift of housewives from activities such as carpet-weaving to shopkeeping, labor, and office work as risk factors, which differs from the findings of the present study.

Additionally, the increasing prevalence of noncommunicable diseases, given their chronic, progressive, and debilitating nature, will lead to numerous problems for societies in the nondistant future. These diseases are among the main obstacles to the development of countries, and the staggering costs associated with them challenge healthcare and medical systems. The decline in people’s ability to purchase healthy food, medical facilities and equipment, and essential medications—resulting from economic pressures on the population—was one of the issues addressed in this research. In this context, Ghibi Gondeh and colleagues, in their study on noncommunicable diseases, focused on economic and social factors within households, alongside behavioral factors, which aligns with the behavioral aspects of this research. Economically, the emphasis was placed on the decrease in purchasing power for essential goods and healthy food, indicating that ensuring healthy nutrition becomes dependent on having a suitable household economy. The results from this perspective are consistent with each other [19]. There is a direct relationship between poor health and low income, which leads to food insecurity, the purchase of cheaper and unhealthier food products, and a lack of ability to access expensive treatments. Low-income individuals feel that they occupy a lower status in society, which prevents them from participating in social life [20].

Individual-Lifestyle factors

The transition from a rural to an urban lifestyle has led to excessive use of virtual space and decreased use of rural-made materials. Dietary habits have shifted towards fast food consumption, increased intake of oil, salt, and sugar, and overeating, while traditional food habits have been neglected. Physical activity has decreased, especially among women, due to a lack of suitable exercise spaces. Although a sedentary lifestyle and unhealthy diet may not seem significant at first glance, their long-term effects can be devastating, and the resulting obesity plays a crucial role in increasing the incidence of noncommunicable diseases. In this study, unhealthy diet, lack of physical activity, and nonadherence to treatment protocols in patients with noncommunicable diseases were identified as major vulnerabilities. Issues such as replacing traditional foods with fast food; excessive consumption of oil, salt, and sugar; and habits such as overeating; lack of access to healthy and organic food in rural areas; and the absence of sports facilities and infrastructure for physical activity are risk factors for noncommunicable diseases. Sedentary lifestyles are increasing due to the reduction in physical activity related to changes in occupation and the lack of infrastructure for exercise and physical activity. Similarly, a study by Nouravaran Feizabadi et al. revealed that low physical activity and an unhealthy diet were risk factors for cardiovascular diseases, which is consistent with the findings of the present study [21]. Another study highlighted physical inactivity as a contributing factor to diseases such as diabetes and hypertension [22]. Eshrati’s research recognized obesity and overweight as major risk factors for noncommunicable diseases, which is consistent with the findings of the present study on vulnerability related to lifestyle, including overeating and physical inactivity, which are contributing factors to obesity and overweight [23]. The results of Ramalivhana’s study revealed that rural and urban lifestyles impact social determinants differently, leading to varied risk factors for non-communicable diseases (NCDs) like physical inactivity, smoking, and unhealthy diets. These risk factors contribute to obesity, hypertension, dyslipidemia, and type 2 diabetes [24].

Political factors

Sanctions and political restrictions have impacted the import of essential medicines, causing drug prices to rise. Government health policies prioritize treatment over prevention, with inadequate implementation of control and prevention programs for NCDs. The findings of the study by Torabi highlight the importance of strengthening NCD prevention policies and regulations, emphasizing that strict health regulations are essential. The study underscores the need to address all health risk factors and to prioritize health in parliamentary agendas. Additionally, the research points to the necessity of imposing higher taxes on harmful products, as policy levers are critical in combating NCDs. It also stresses the importance of legislation promoting health equity to alleviate the disproportionate burden of NCDs on disadvantaged populations, particularly affecting women and children. While promoting equality is vital, some level of disparity between the wealthy and the poor may be acceptable if it ensures improved access to healthcare resources for those in need [25].

Individual factors

Poor health literacy, personality traits such as envy, rivalry, and hedonism, and genetic factors were identified as contributing to the vulnerabilities of rural communities.

Moreover, individual characteristics that pose risks increase the odds of developing noncommunicable diseases. Some of these risk factors include sex, genetic factors, and personal traits. In the present study, a lack of health literacy, personality traits, and genetic factors were identified as personal vulnerabilities related to noncommunicable diseases. Families play a vital role in shaping both positive and negative behaviors; on the one hand, considering the established role of genetics and hereditary factors in the onset of noncommunicable diseases, and on the other hand, regarding their place in shaping individual lifestyle patterns, they significantly influence the creation and persistence of risk factors for these diseases. During the study, it was clear from the statements of the locals that certain individuals had a notably higher incidence of disease within their families [26]. Additionally, Fekrat reported that family history is among the factors associated with the development of noncommunicable diseases, which aligns with the findings of this study regarding the impact of hereditary factors and family background on the incidence and prevalence of diseases [27]. The results from Khoshroo and colleagues revealed that 74.28% of patients with latent autoimmune diabetes in adults (LADA) and 42.5% of type 1 diabetes patients had a positive family history of diabetes. Additionally, a significant relationship was observed between a family history of diabetes and the occurrence of LADA [28]. In another study by Liu and colleagues, a significant correlation was found between breast cancer incidence and family history among first-degree relatives, concordant with the results obtained in this study [29].

Another observed issue at the village level was the lack of health literacy and the presence of incorrect and misleading information, which led to misconceptions among residents regarding various health matters. This aligns with the findings of the study by Khodabakhshi and colleagues, who reported a positive correlation between health literacy and the quality of life of male type 2 diabetes patients, indicating that the higher the patients’ health literacy is, the better their quality of life in terms of physical, psychological, and social aspects [30]. Another study conducted by Taghipour and colleagues considered patients’ acquired knowledge as a positive factor in disease management, which did not align with the results of this research and could, in a way, intensify the issue of self-medication in communities [31]. In societies where a disease becomes common, people gradually start to self-treat by sharing experiences, which could have negative consequences and disrupt effective treatment outcomes and prevention strategies. Masoudi Alavi’s research also identified self-medication as a negative factor in controlling noncommunicable diseases, which, according to the findings of this study, categorizes self-medication and self-diagnosis as vulnerabilities, thus confirming the results of the present study [32].

Environmental factors

Specific physical and chemical properties of the region’s water and soil, along with soil pollution from excessive use of chemical fertilizers, were notable environmental factors.

Moreover, scientific evidence indicates that exposure to environmental risk factors, such as chemical agents, radiation, and air pollutants, during the early years of life can increase the risk of noncommunicable diseases throughout a person’s life. In this study, environmental factors such as contaminated water and soil were identified as environmental hazards related to noncommunicable diseases. Drinking water is an area whose physical and chemical characteristics are continuously monitored in various regions. Moon and colleagues examined the levels of arsenic in water (chemical properties) and concluded that the presence of arsenic in drinking water increases the risk of cardiovascular diseases [33]. In another study by Ghias, the highest levels of heavy metals, including manganese, copper, lead, chromium, and nickel, were found in the soils of villages with relatively high incidences of hypertension and cancer; there was also a significant positive relationship between the presence of heavy metals in water and the total incidence of noncommunicable diseases, including hypertension, diabetes, and all types of cancer [34].

Healthcare services issues

Challenges in healthcare services include inactive follow-up by healthcare providers, increased costs of check-ups and diagnostic tests, shortage of specialized services, lack of public trust in health education, and inadequate presence of healthcare professionals like nutritionists, psychologists, and physicians in health centers.

Furthermore, adherence to treatment is crucial in managing noncommunicable diseases. Barriers to effective and long-term adherence to treatment make achieving healthcare and treatment goals challenging. In this study, factors such as screening, initial treatment, patient follow-up, facilities and equipment, health education, and human resources were identified as various dimensions of service-related environmental hazards for noncommunicable diseases. In this context, Shah’s study suggests that an AI-based screening tool can be used to identify at-risk women. This tool aids in early diagnosis, timely referral, and treatment of non-communicable diseases, with the support of community health workers. This capacity can also be utilized in rural areas [35]. The results from Kalahzarzadeh and colleagues indicated that patients’ readiness for change (misunderstanding of conditions and consequences alongside cultural beliefs that hinder action), gaps in healthcare services, insufficient support for patients, and limited access to healthcare services (both physical access limitations and financial burdens) were noted as barriers to treating cardiovascular diseases, which aligns with the findings of this study [36]. Tapela also emphasizes that the strategies involve developing a multi-faceted training program for healthcare providers and actively engaging healthcare practitioners in the early stages of the process. This approach aims to enhance service delivery and ensure effective implementation of health guidelines [37].

Barriers to providing healthcare services to people include a lack of access to medications, specialized services and equipment, the absence of specialists in health facilities, and failure to prevent high-risk individuals, among others. Wood and colleagues also identified key barriers to providing quality care, such as shortages of essential drugs and equipment, inadequate knowledge and guidelines, the cost of services, geographical access issues, and patients’ lack of trust in primary healthcare systems, which corresponds with the results of this study [38].

Additionally, health policy consists of a set of guidelines developed by policymakers and senior health system managers in areas such as financing, resource production, and healthcare service delivery aimed at ensuring, maintaining, and promoting the health of the community. It serves as a guide for decision-making and planning for lower-level managers. In this study, factors such as sanctions and inappropriate government policies concerning health services were identified as political hazards related to noncommunicable diseases. In a study conducted by Bastani and colleagues, five main topics and 15 subtopics were identified, addressing the challenges facing the pharmaceutical supply chain under political and economic sanctions. These challenges include financial procurement, purchasing, importing, and producing domestic products, as well as storage and distribution issues, along with difficulties faced by the general population, especially patients. Notably, in many cases, due to financial and banking sanctions, the importation of medications has not been possible [39]. Although medications themselves are not sanctioned, this issue has led to shortages and high prices at times. A study by Alekajbaf and colleagues revealed that sanctions negatively impact the country’s healthcare system, particularly in terms of drug and medical equipment supply, and often serve as barriers to the entry of specific medications, slowing the influx of drugs and equipment, increasing the entry of counterfeit and low-quality drugs, and increasing the prices of the remaining medications, which is consistent with the findings of this study [40].

In conclusion, addressing the vulnerabilities and challenges associated with noncommunicable diseases (NCDs) in rural areas requires a multifaceted approach. It is crucial to recognize the unique socio-economic, lifestyle, political, environmental, and healthcare service issues that these communities face. Tailored intervention programs, improved health literacy, and better resource allocation are essential to mitigating these risks. Additionally, leveraging the capacity of community health workers and innovative tools like AI-based screening can significantly enhance early diagnosis and effective management of NCDs in rural settings. By implementing these targeted strategies, we can improve health outcomes and quality of life for rural populations. Also, incorporating the concept of community-based empowerment throughout this study is essential for understanding the dynamics of health interventions in rural areas. By actively engaging community members in the identification of health issues and the development of solutions, we not only enhance local ownership of health initiatives but also leverage the unique insights that the community possesses regarding their own health challenges. This approach fosters a collaborative environment where community members feel valued and empowered to contribute to their health outcomes. As highlighted in our findings, addressing noncommunicable diseases such as diabetes and hypertension requires more than just healthcare interventions; it necessitates a holistic strategy that includes community involvement in health promotion efforts. Therefore, integrating educational programs and resources that promote healthy lifestyle choices within the framework of community empowerment will be pivotal in effectively combating these diseases and improving overall health in rural populations.

Limitations

One of the limitations of this research, which is particularly relevant to group discussion studies, is that some participants occasionally expressed disinterest and lack motivation in expressing their thoughts, which may not be without impact on the results. Additionally, individuals may provide statements that do not accurately reflect their true thoughts to present a better image of themselves.

Conclusion

The research conducted in this study serves as a model of community-based empowerment, as it involved the active participation of the local community in identifying issues and proposing solutions through structured meetings and gatherings. This approach not only highlights the community’s role but also emphasizes the importance of their insights in addressing health issues. Diabetes and hypertension were identified as the most common noncommunicable diseases in the studied villages, underscoring the fragility of rural health conditions. To effectively tackle these challenges, it is essential to implement targeted interventions that focus on education, health promotion, and treatment strategies. The community recognizes that unhealthy lifestyle choices, including poor diet and lack of physical activity, significantly contribute to these diseases, compounded by genetic predispositions. Furthermore, the lack of trust in healthcare services and inadequate service delivery exacerbate the situation. Healthcare authorities must prioritize rebuilding trust in comprehensive healthcare services by leveraging existing research to inform their efforts. In light of your suggestion, we will also focus on developing materials related to community-based empowerment for health promotion. Education and awareness programs that promote healthy lifestyle choices, such as regular physical activity and balanced nutrition, are crucial components of a comprehensive strategy to address noncommunicable diseases in rural areas.

Authors’ contributions

GA and MA-R: Conceived the study, analyzed the data, collected the data, authored or reviewed drafts of the paper, and approved the final draft. ST: Collected the data, audited the initial analyses and interpretation, authored or reviewed drafts of the paper, and approved the final draft.

Funding

The study was financially supported by the Isfahan University of Medical Sciences, Isfahan, Iran. Research No. 3400709.

Data availability

The datasets generated and analyzed in this study are not publicly available due to the principle of confidentiality. They are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study received the required ethics approval from the Isfahan University of Medical Sciences Ethics Committee (No. IR.MUI.RESEARCH.REC.1400.391) Isfahan, Iran. The “informed consent” to participate was obtained from all of the participants in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.