Iran's women investigate health priorities

Volunteer women researchers are determining Iran's health and development needs

SUMMARY: Hossein Malekafzali, Deputy for Research and Technology, Ministry of Health and Medical Education, Iran, explains how community volunteers - who are mostly women - are helping with Iran's health research and decision-making. Other countries should do it, he says.

>RHN: Tell us about use of the community to do research in Iran. It’s striking that you believe that ordinary people can do research, but I understand that you’ve found in practice that they can - and that their work is useful to address some kinds of health problem.

Hossein Malekafzali: You know that one of the important issues in health is community participation. That has three levels. The first is for the community to give, for example, money for some activity, such as building a health centre. The second is that they can be involved in service delivery – for example in Iran we have women working as health volunteers, delivering health services to the people. But the third and highest part of community participation is when the community is involved in decision-making. So I was considering how I could establish that highest level of participation, in practice.

Fortunately in Iran the community is highly educated. After the revolution the literacy rate, especially among women, increased tremendously – because before the revolution, there was no chance for women to go to university and schools. But after the revolution, because the culture of the family and the culture of the universities became the same, most of the girls have the chance to study.

>RHN: So women’s rights improved after the revolution?

HM: Women’s rights to education improved.

>RHN: That’s quite to opposite of what happened in Afghanistan, for example, under the Taliban.

HM: In Iran before the revolution there was a virtual barrier for women to go to university, related to the culture, the environment, of the universities. It was a Western culture, not adjusted to what families expected of their girls. But after the revolution, the university environment became Islamic – so it matched family expectations. So now families send their girls to the universities.

>RHN: But this is counter-intuitive, if you compare with another Islamic interpretation of education, under the Taliban, which was totally against education for women…

HM: Yes, but that was a misinterpretation of Islam. Because Islam says that everyone should be educated. But the interpretation of Islam is different in different countries! In my country, we say that “If science is in China, go to China” – this is from the Prophet Mohamed – because at that time China seemed a very very long way from Saudi Arabia. But he said you must go to China to be trained in science! And the emphasis is on training of both men and women.

So in Iran during this 25 years the education rate, especially among women, has increased. You know at this moment that among students in universities in Iran there are more women than men. For example in medical schools in Iran, 70% are women, and only 30% men! It’s a big problem, because when they’ve graduated the girls want to stay in the big cities and not go to the rural areas.

But to get back to community participation – due to this increase of education in the community, especially the women, three years ago
I began actually to involve the people in decision-making.

>RHN: What kind of decisions were you hoping for?

HM: The philosophy behind this is that the people are the most important ones to decide their own needs. If we have an educated population, we can empower that population to do needs-assessment, by themselves – and to identify their needs, not only health needs, development needs too. Based on some criteria they can come to some priorities. And then they will tell us how we can intervene for solving these problems.

Further, they themselves can evaluate what we have done! This is the involvement of the community in research.

>RHN: So this is more than good democracy.

HM: It is democracy. We divide a region of 50 000 people in 100 clusters of 500. On a democratic basis each cluster is free to select one man and one woman (with at least a high school diploma) from each 500 who volunteer to be trained for research.

Actually most of them – perhaps 90% - turn out to be women. In my country, women are more interested in participating in volunteer activities. And that’s good, because most health problems, especially inside the family, are in the care of the women.

And these women are empowered to go to the various sectors, to talk to people and discuss the development of the local area.

So first of all we organize the community; and then accept two people from each cluster; and then train them for qualitative and quantitative research! It’s very very simple methodology. We have specific books to guide them. And with these books we explain what the problem might be, how they can analyse the problem, how they can collect information, and summarise it.

>RHN: Can you give me an example of a problem that they might study?

HM: For example, people go to their neighbours with a small questionnaire, and ask them what their problems are.

>RHN: What kind of problems do they ask about?

HM: General ones. Not just health. They do focus group discussions. They collect people, young, old, everyone.

>RHN: So this is not just the Ministry of Health’s programme.

HM: The Ministry of Health was the pioneer! But now the other sectors are also coming in. Now we have the Ministry of Education, the local Mayor and so on.

So the representative of the people will go to that cluster, speak with the people, ask them questions, discuss and collect information. And based on that they analyse the data and come to some priorities.

For example the first priority might turn out to be unemployment. The second might be addiction. Then third might be environmental health. The fourth might be safety - violence. And so on.

So we get a list of priorities. And the point is that these priorities have come from needs assessment and priority setting by the people themselves. It’s not coming from the universities, choosing a topic of research. The subject of research is coming from the community. That is the difference, between traditional research and this.

>RHN: The concept is very radical. But can you give me an example of how this has worked for health?

HM: For example, in one area they said the first priority was garbage collection, from the houses and the streets. They said the streets were unsanitary, and the mayor doesn’t care. So they sat together, the community and the mayor, and they came to a solution – that the people have to do this and this, and bag their garbage at a specific time and place it outside their doorways, and the mayor would arrange collection.

>RHN: So the community not only does research, but ends up taking action.

HM: Yes – that was action research.

>RHN: What about its relevance, for example, to non-communicable diseases, which require behaviour change?

HM: Take cardio-vascular diseases, where the people need to take exercise, and change their eating habits, or stop smoking, or reduce stress… There the people sat together and organized how they can for example begin public sport, every Friday – when we don’t work. The women decided to collect together and go to the mountains for sport.

Or take nutrition. They went to shopping centres and tried to persuade shopkeepers not to sell oils that are harmful to the heart, or cigarettes and so on. So they changed the enabling environment for health.

>RHN: So the way it works is this: there has been some academic research which has shown that this or that oil is dangerous for the heart; and in the community women’s research those results are engaged with community action, to create a practical change in behaviour.

HM: Exactly. This is operational research, it’s not to find the risk factors.

>RHN: But it seems to me it also their ownership of the solution; instead of being told what to do, they learn what to do themselves.

HM: We don’t expect to discover the impact of cigars, say – we know that from the literature. We want to know how to stop smoking, based on our own culture, because the way people are going to stop smoking is different in every country.

>RHN: Do you think this is a technique that other countries could adopt?

HM: Sure, sure! I’ll give you another example. One of the biggest issues is adolescent health. The girls and the boys, when they are adolescent, don’t communicate with their parents. And there is no chance to speak with them in the schools – there is nothing in the curriculum. So they are trained by their friends! And sometimes by satellite TV! This is dangerous.

So we started a pilot project, and we talked to the parents. We said this is your son or your daughter, and if you want to keep him or her, you have to communicate! And gradually it started. We trained the parents about adolescence. And the parents talked to the girls and boys. And the result is that the families are happier!

>RHN: That’s fundamental - if you managed to change the relationship between parents and adolescents - that’s almost a biological challenge…

HM: Well this is one of the studies we did in Iran. It worked because it is an Islamic principle, that it is the duty of parents to train and educate their children.

>RHN: I believe that in the matter of family planning, you took a quite sophisticated approach to discussing the issue with religious leaders, by being extremely sensitive to their constraints and views. It seems to me that that principle is generalizable – instead of researchers telling government what to do, we ought to be listening to government and understanding their constraints and needs more. Can you expand on that a little?

HM: The point was that the religious leaders who govern the community, based on Islamic principles, said that we must increase the population of the Moslem countries. That was the concept. So for ten years they encouraged people to have more children. But at the Ministry of Health we were worried about the consequences.

So we thought carefully what we had to do. And we went to the principles of Islam; and we understood that in Islam the protection of the body is more important than everything. So based on this principle… if I put my finger on the health of the mother and child, they would listen. Because it is an Islamic principle to protect them.

So I collected the health information and made a graph which showed that for example having a short gap between children increased the mortality rate of mother and child, the effects of early pregnancy and late pregnancy; so when they saw that this increased the mortality rates they said OK, we can’t say no!

And that was very important, because later the International Conference on Population and Development put family planning in the package of health, with mother and child health care.

So they accepted family planning for health promotion – not for population control. That’s the point.

>RHN: That’s a very interesting story. And I think it’s true in general, that if you want a health minister, for example, to take an interest in some research that you’ve done, that you think is relevant to health improvement in the country, you also need to think about what are the minister’s problems, what context is he working in.

HM: The important point is that when we talk to policy-makers, we have to know to what aspect of policy they are most sensitive. And we have to collect the data that’s relevant to that aspect. That’s the point.

Hossein Malekafzali was speaking to Robert Walgate at the High-Level Ministerial Meeting on Health Research, Accra, 15-17 June 2006.

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