Table 1:

Factors affecting CHW performance

Main themes	Sub-themes	Content
Compatibility of services with health-demographic transition	Change in demographic structure	– Increasing trend in the migration of villagers to cities – Decrease in fertility rate and tendency to have controlled fertility – Change in age pyramid and aging rural population
	Change in lifestyle	– High pace in rural urbanization and consequent lack of interest in rural lifestyle and willingness of villagers to urban behavior – Decreased physical activity and change in people’s dietary habits
	Change in disease patterns	– Change of disease patterns from communicable to non-communicable diseases – Growing trend of chronic diseases risk factors (hypertension, obesity and inactivity risk factors)
Acceptability of services with regard to change in attitudes and expectations of rural communities	Increase in the level of people’s awareness and expectations	– Increased expectations due to higher level of literacy and awareness among villagers from healthcare services – Reduced interest of people in being advised by CHW due to his/her inability to meet higher expectations of people – Increased tendency of people to visiting physicians out of referral route and to access better quality of care because of rural family physician implementation – Expecting prescriptions and use of new medical technologies and methods from CHW – Increase in the level of general information and improved individual knowledge of society due to expansion of mass-media has resulted in expectations beyond the ability of CHW.
	Poor compatibility of training contents with changed role of CHW	– Lack of studies and training need assessments, and consequently low level of attention to the population health needs in the training plans for CHW – lack of elderly care training for CHW – Officials operate based on personal preferences in defining training contents and courses
CHW motivation and expectations	Increase in the range and scope of CHW assigned activities	– Expecting CHW to perform time consuming jobs and the ones beyond the job description – Increase in the range of care and workload along with demographic transition – Expecting provision of services by CHW at all hours of day (people expectations) – Duplication and repetition of care affairs due to the integration of new plans into PHC system and demographic change – Failure to include required time to meet cultural expectations, trust building and engagement with rural society as part of CHW performance
	CHW’s job motivation	– Poor incentive mechanisms, financial and non-financial – Inattention to the strengths and exclusive focus on the weaknesses of CHW performance – Inattention to CHW’s views in decisions made in rural councils – High job stress and psychological pressure due to rising expectations of authorities and the public
	Increase in Beaverz’s expectation contrary to primary policies in selection of CHW as a local workforce	– Expecting the creation of opportunities for education in higher levels – Expecting the possibility of getting job promotion – Expecting the provision of welfare facilities similar to cities – Expecting equality and equal respect in comparison with physicians
Team communication and organization	Supportive-supervisory barriers	– Inattention to physical spaces and standard health house facilities – Unsystematic supervision and monitoring systems and poor feed-backing for CHW empowerment and training
	Neglecting CHW role in rural family physician plan	– Overlapping functions and lack of coordination and interaction with other health providers – Disruption of duties in the absence of physicians due to communication problems between health houses and rural healthcare centers – Lack of clarity in the place of CHW in the referral system since rural health centers pay little attention to health houses in villages – CHW is not informed of patients status for future follow-ups – inter-sectoral disagreement regarding CHW training which is due to poor inter-sectoral collaboration and team working in health networks