In many countries around the world, community health workers play a unique role in establishing a link between the healthcare system and society. Today, development and transformation of social health needs have resulted in the development of health programs and management of unpredictable cases. Therefore, selection and employment of suitable people who can fulfill the assigned tasks and roles and also meet the needs of the society are among the main priorities of the healthcare system.

The present study explored the perceptions and experiences of health system stakeholders at different levels, based on the criteria used for selecting and employing CHWs to help identify qualified people and provide effective community-based services. The present findings are promising due to the localization of employment criteria in order to select highly qualified people. Moreover, instructional barriers to selecting competent people were highlighted according to the perspectives and experiences of DBTC managers and supervisors (Table2). The exploratory themes extracted in this study and their relationships are presented as concepts and sub-themes.

Some of the general requirements based on the MOH instructions are the lack of addiction to cigarettes, narcotics, and psychotropic substances, lack of a history of criminal offenses or convictions, having physical and psychological health, and not being banned from employment in governmental institutions according to legal organizations. The findings of the present study showed that all the participants had a positive attitude toward the general requirements in the MOH instructions. However, the some sub-themes identified in this study did not fulfill some of these general requirements; these sub-themes could not be evaluated when completing the registration form.

The participants believed that providing community health services was one of the difficult tasks of the CHWs, who were required to have physical and psychological agility. Some individuals may choose this occupation just to have a source of income and may be less motivated, which contributes to their poor performance. All the participants believed that the CHWs should be interested in their job, besides being compassionate, inspired, reliable, responsive, and sociable. An ample amount of evidence suggests that these features should be considered when employing people as social service providers [1819]. Studies have also shown that confidentiality and poor trust are among key barriers to hiring CHWs who can provide maternal and pediatric health services [20].

In a previous review, the most important criteria for the employment of CHWs were their personal characteristics, such as interest in the field, willingness to learn, and compassion. It has been also reported that non-financial incentives, such as trust, respect, familiarity with the community, and self-esteem, are among the potential triggers of favorable performance. In this regard, Mishra et al., in a study in India, explained that CHWs should be more interested in their job than money [21,22,23].

The primary education level is one of the specific requirements for being accepted as a CHW; therefore, all candidates need to have at least 12 years of academic study [15]. According to the sub-themes identified in this study, the participants believed that the quantity and quality of education were associated with competency-based selection. Common people stated that the CHWs should have a high level of education to be trusted. Interestingly, common people also cared about the university where the CHWs had studied.

According to the supervisors and managers of the CHW training schools, a persons basic education, including the field of study and academic records, was an important criterion. They believed that people graduating with a diploma in experimental sciences were better prepared to receive the necessary health education and were usually more successful than their graduated counterparts. Another important background factor was the persons records in their last educational course. People with poor academic records usually face more problems in the CHW training courses. The importance of the basic educational level of CHWs, as highlighted in this study, has been also reported in previous research. Evidence shows that the CHWs inadequate education or certifications can negatively influence the communitys belief about their effective response and reaction to their needs. Besides, CHWs with higher educational levels may become convinced to quit their job after being employed [22, 2425].

In Uganda, the community had lower acceptance for people with low education levels [26]. In Brazil, having a formal educational degree boosted the acceptance of CHWs in the society, as well as peoples trust in them. Moreover, the professional activity of CHWs in cooperation with other health workers increased their social credibility [27]. A study in Bangladesh showed that less literate people did not receive the required training for their occupation, contributing to their poor functionality [2528]. However, conflicts and instability in the work environment of CHWs generally impede recruiting people with a specific level of education. This challenge is heightened in critical situations, such as the outbreak of diseases, or when there is a shortage of human resources [24, 2930].

According to studies in some countries, people do not believe that the CHWs should have a basic level of literacy, as they can receive the necessary training after employment. Evaluation of healthcare delivery by illiterate and less literate people in countries, such as Nepal, shows that these individuals receive effective and need-oriented training by their supervisors after employment [13, 31]. A study concluded that completion of primary school education should be considered as the minimum educational requirement for the CHWs to meet the care needs of underprivileged and remote communities [3233].

In Iran, the CHWs are employed by the government and are paid monthly, which is a relatively strong motive for entering this occupation and performing well [15]. The findings of this study showed that the type of employment (contractual or permanent) was an influential factor in the CHWs motivation for self-improvement and self-learning to remain in the system. The participants of this study believed that people who were hired officially and permanently had less motivation for self-improvement and delivery of quality services. However, the CHWs on contract tried to exhibit better performance to maintain their status and acquire the approval of the system. Ample evidence suggests that financial incentives are among factors improving the performance of CHWs. Today, health systems are moving in this direction to increase the CHWs motivation and durability in the system by offering them financial advantages [34].

According to national instructions, one female CHW and if required, one male CHW should be employed for every 1000 villagers. Based on the findings of this study, the participants assumed that women and married CHWs would provide more efficient services. In various countries, such as India, Brazil, Pakistan, and Nepal, which have a reputation for community-based plans, two factors, that is, female gender and being married, were the main criteria for hiring the CHWs. In these countries, community-based services focused on the family, children, and women and were tailored to the cultural framework; also, stranger men were not allowed to enter peoples homes [13].

Generally, recruitment of female CHWs is challenging in countries, such as Afghanistan, where women are not allowed to travel unattended; therefore, one woman and one man are always selected as CHWs to provide healthcare services. Similarly, in Kenya, both males and females were recruited for this purpose [13, 15, 35]. Since some services are more easily delivered by females in some countries, women are mobilized and encouraged to choose this occupation. In some underprivileged communities, the CHWs are selected among women for empowerment [30, 36].

The MOH instructions have determined a specific age range for employing the CHWs; the maximum age should not exceed 30 years. According to the codes extracted in the present study, age was recognized as an influential criterion in the effectiveness of services provided, learning ability, and capability to fulfill responsibilities and duties defined for the CHWs. Findings show that age is an important factor in hiring the CHWs in many countries, where a certain age range has been specified [13, 15].

In many countries, selection of CHWs from the community where they are expected to serve is one of the basic principles for providing community-based services; this principle has been strongly recommended by the WHO [13, 15]. In the rural regions of Iran, selection of CHWs is strictly based on the WHO recommendations (i.e., selection of CHWs from the community where the service is to be delivered); this is one of the specific criteria that candidates need to fulfill before registration. According to the instructions, if there are enough candidates (usually three people with High school diplomas) from the main village, they will be selected and hired after passing the exam and interview. And if there is not enough candidate from the main village, candidates from the neighbouring villages can register to take the exam and get hired [15].

One of the challenges of DBTC managers and supervisors was that candidates coming from the main village did not obtain the required credit score in the written entrance exam (i.e., selection of incompetent people). Moreover, the present findings showed that inflexible adherence to the core instructions of MOH, besides the restricted selection of candidates from the main village, hindered the employment of qualified people from nearby villages or other areas. Overall, it is important to explore the perceptions of stakeholders, including the managers and supervisors of DBTCs (as service providers) and the society (as a service demander). The managers stated that employing incompetent people caused many workers to be either fired from their job due to poor performance or resign themselves; this turnover imposed high costs on the system and led to the waste of resources. Supervisors also complained about the difficulty of teaching people with low capabilities.

Evaluation of common peoples perception showed that they did not care if the selected CHW was a native of the village or not. Instead, they preferred highly literate and skilled people for employment to support them and respond to their needs; substantial evidence from different countries supports this finding. According to previous research, the CHWs, by participating in the community they serve, can mobilize the community to improve a wide range of health practices. However, this goal is only achievable when the community has a positive attitude toward the CHWs and accepts them. Studies show that many parameters can affect the social acceptance of CHWs. The priority of these factors may vary in different societies, depending on the cultural, economic, and climatic conditions. The critical importance of this parameter lies in the acceptance of CHWs by the community where they serve, besides increasing the motivation, responsiveness, and accountability of the CHWs [24, 37]. A report from Ghana and Rwanda indicated that being chosen by the community boosted the CHWs sense of responsibility, motivation, and pride when fulfilling their roles [3839].

However, outcomes vary from one country to another, as selection does not always proceed according to the instructions. The results of an ethnographic study by Rafiq et al. in Tanzania, investigating the relationship between professional outcomes and the CHWs personal and social identity, showed that distinguishing personal identity from professional identity was difficult in CHWs working in rural regions. This study also demonstrated that the CHWs personal identity sometimes prevented them from talking about issues related to family planning and sexual health [40]. Moreover, the findings of a study from Kenya revealed that CHWs, selected by the community, as well as those whose selection was not related to the community, showed similar adherence to the instructions [41]. Besides, reports from India and Ethiopia indicated that the CHWs were selected without seeking the communitys opinion; however, in Uganda, some community members preferred non-natives as CHWs [4243].

The results of the present study revealed that people sometimes avoided sharing their physical and psychological problems with native CHWs due to concerns over confidentiality issues, fear of information disclosure, and social stigma. Several studies from different countries reported problems when hiring natives in places where there was stigma over a certain disease, for example, AIDS in African countries. Therefore, it is preferable to employ non-native CHWs for these people and sometimes for male immigrants [33, 4445].

Discrimination in offering services and paying special attention to relatives by native CHWs were among factors that challenged the communitys trust in them; nevertheless, findings are controversial. Some studies carried out in different countries have reported the positive effects of kinship ties on the professional roles of CHWs working in rural communities. Other studies in Nigeria and South Africa have also confirmed the central role of kinship and self-identity in the positive and trusting relationship nurtured between the CHWs and the community where they work [33, 46]. The results of an ethnographic study in Tanzania also revealed that the use of kinship terms, such as father and mother for male and female CHWs, could facilitate the interaction between personal and shared roles and professional duties to build trust and a sense of ownership in health-related programs [40].

On the other hand, the communitys participation in the selection of CHWs can also cause several problems. When the selection process is not transparent, there may be misinterpretations in supporting certain groups, which can hurt the community emotionally and make them lose the spirit of cooperation. When the selection of CHWs is managed by traditional kinship structures, despite the increased social participation and effectiveness of interventions in the kinship group, it can lead to the exclusion of other community groups and discrimination against them. Conflicting findings have been reported in Uganda and India [47, 48].

Based on previous findings, local hiring and increased access to health services may not always yield desirable outcomes. Many factors related to both suppliers and demanders should be addressed to achieve equity. According to previous studies, deprived and underprivileged groups are usually less capable of adhering to the CHWs recommendations due to economic and non-economic reasons [37, 45, 49].

Some findings suggest that selection of CHWs from communities living in suburb and remote areas can improve access to health services. Also, according to previous reviews, selection and employment of low-educated CHWs from communities with low literacy levels or poor people in poor communities can improve access to health services and lead to the fair distribution of these services. Moreover, home visits can be helpful for people who are prevented from visiting health centers due to cultural obstacles. The engagement of traditional healers can help provide services to groups with certain cultural traditions [45, 49].

Based on the findings of the current study at the macro level and exploration of concepts and codes extracted at the micro level, it is obvious that the societys expectations of service providers are increasing, the importance of attention to the health of villagers, being supportive, providing high-quality services, and CHWs ability to provide new and diverse services. The participants also believed that CHWs with higher levels of literacy and capability could perform better in establishing vertical equity and mobilizing at formal levels [37]. The present findings about CHWs indicate the expansion of professionalization, increased service quality in scale and variety, transforming roles, and coping with unpredictable situations [24]. In recent years, professionalization has expanded due to increased interactions between communities and health systems and increasing demands for diverse, high-quality, and up-to-date services, provided by more professional individuals [50, 52,53,54,55].

For health programs to be effective, selection and employment of CHWs should be tailored to the societys needs and underlying conditions. Even in a single country, the criteria for selecting CHWs may vary from one place to another. Therefore, CHW recruitment programs are recommended in various regions for comparison to optimize relevant policies; otherwise, challenges are unavoidable. Therefore, it is important for managers to show flexibility to upgrade and expand the CHW recruitment strategies [13, 33].

Iran is a country with great diversity in terms of climatic, geographic, cultural, social, and economic conditions in different areas. In some regions of the country, villages are far from cities and other villages, while in some regions, cities and villages are interconnected; therefore, people living in different regions may have variable access to facilities. The present study was conducted in Golestan Province in north of Iran; therefore, generalization of the findings to other parts of the country with different backgrounds may be challenging. It is necessary to modify the CHW selection and recruitment criteria in a way that guarantees the employment of most suitable individuals who can fulfill the assigned roles, address the communitys needs and demands at the place of service, and minimize depreciation in the system.

One of the limitations of this study was the small number of samples. Although, based on the current guidelines sample size for qualitative studies is varied. Data saturation is a significant measure to determine a sufficient sample size in qualitative studies. Given that each study has a unique characteristic and the saturation point can vary, it is also possible that no data is truly saturated. In any case, the study should be carried out with more samples to discover the dimensions of the subject [56].

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