Challenges of Premarital Education Program in Iran

Zahra Bostani Khalesi¹, Masoumeh Simbar^2*

¹Department of Midwifery, Assistant Professor, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

²Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Professor, Department of Midwifery and Reproductive Health, ShahidBeheshti University of Medical Science, Tehran, Iran

*Corresponding author: Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Professor, Department of Midwifery and Reproductive Health, ShahidBeheshti University of Medical Science, Tehran, Iran

E-mail: msimbar@sbmu.ac.ir

Received: 2015May 10; Accepted: 2015October 16            

Introduction

The efforts for strengthening marriage in Iran have focused on premarital education in recent years [1]. Premarital education is a great opportunity to increase couples’knowledge about their role in establishing a proper and fruitful relationship and influence their attitude and behavior [2]. Premarital education is a relatively new approach for the prevention of dissatisfaction with and failure in marriage [3] and is based on the concept that the couple can learn how to have a successful and stable life [4]. Such education covers a wide range of knowledge about the purposes of marriage, understanding the psychology of men and women, sexual health and skills required for marital life [5].

Premarital education dates back to 1931 [6].Such education was ratified in Iran in 1991 and the first educational booklet called “Smaller Families: More Prosperous, Healthier” waspublished in 1993.Subsequently, all health centers in provinces were assigned to offer premarital education and the head of marriage registrar offices were obliged to register marriages only ifthey had health certificates indicating undergoing necessary lab tests and passing educational courses. Currently running as Marriage, and emotional and social relationships, this program isa source of education with the aim to promote couples’ knowledge of Islamic ethics, law, their mutual rights, mental health, communication principles and skills, prevention of diseases and healthcare centers [7].Although family experts emphasize the efficacy of education, the premarital education program is facing challenges in Iran [8], and many needs of young couples are not met yet [9]. Operational challenges such as non-need-based educational content, insufficient duration and improper physical space have exposed the program to many difficulties and reduced its efficacy [10]. Policy making and proper execution of the premarital education can somewhat diminish these problems and facilitate their success [11].Premarital education should be executed in a coordinated, satisfying and high quality manner [12], because participating in these educational programs might be the couples’ first encounter with the healthcare system and their satisfaction with the services plays an effective role in their reuse of healthcare services [13].In order to achieve a comprehensive and effective premarital educational program, like other health programs, this educational program should be investigated, and its quality should be regularly surveyed to remove its weaknesses and update it [14].Many studies have been conducted on premarital education in Iran, however, lack of a disciplinary and analytical knowledge of the results of the studies and their applications have led to incomplete actions and their limited effects.The results of the present review can provide valuable information as the basis for strategies and interventions to promote premarital education in Iran.Therefore, this study was conducted to classify the findings of studies over the past two decades on premarital education in order to identify the challenges of the current premarital education program.

Materialsand Methods

A systematic review was conducted by searching the databases of PubMed, Elsevier, Magiran,IranMedex, SID Irandoc, Medlib and Google scholar to find articles in Persian and English language.The following keywords were used to find resources related to research purposes: couples, training, premarital, Iran, health program, preparation for marriage, educational needs, and divorce.The present study was conducted to have a systematic review of studies on the premarital education and find its challenges.The primary criterion for selecting papers wasthe relationship with the premarital education program and having one of the key words in the title.The inclusion criteria were as follows [1]: having Iranian authors and having been published in a local or foreign journal [2]; addressing one of the areas of educational needs, effectiveness of education, or a comparison of two premarital educational contents (including special education content and educational content approved by Ministry of Health) [3];publication time from the initiation of the program in Iran (1993) until the time of this review (2016) [4]; local papers published in scientific journals.

Quality Assessment of the Papers

Two reviewers independently searched for papers. After finding the papers in the databases using the above-mentioned keywords, all papers were evaluated by two raters using the Critical Appraisal Checklists Skill Program (CASP) standard check list. Any disagreements between the raters were reconciled by mutual agreement.

The relevance of the papers to the purpose of this study was assessed in three stages for the titles, abstracts, and full text of the papers.

After the above steps, the papers covering the following objectives were selected:

In descriptive studies:

1. Assessing the quality of the current premarital education program
2. Assessing the content of the current premarital education program
3. The views of marrying couples about the current premarital education program
4. The views of experts about quality of the current premarital education program
5. Needs assessment of marrying couples

6. Assessing the degree of satisfaction of marrying couples with the current premarital education program

In interventional studies:

1. Assessing the effectiveness of the current premarital education program
2. Comparing the effectiveness of different premarital education programs
3. Strategies and interventions promoting premarital education programs

In the first stage, 28 papers were found in the databases, 11 of which were excluded due to not meeting the inclusion criteria, lack of transparency in the methods, or just working on one specific aspect of premarital education such as reproductive health (Table 1). Among the published papers, only 17 papers met the inclusion criteria (Fig. 1).

As many Persian journals are indexed in most Iranian databases, many Persian papers were repeated in various databases.

Figure 1.The process of assessing the studies

Results

The published studies information along with objectives, author and the number of participants, methods, and findings are presented in Table 2 (intervention studies) and Table 3 (non-intervention studies).

The study findings onchallenges of premarital education program are presented in Table 4.The challenges are classified in two main categories of policy making and operational challenges and 6 subcategories of lack of evidence-based policy, financial resource management, human resource management, inattention to indigenous and regional cultures, and operational challenges including challenges in structure, content, educators and monitoring and assessment systems.Categories were inductivelyextracted from the results of the studies.In this approach, the researcher studied the results of the studies several times without considering any predetermined categories and extracted the subcategories from the study databased on the questions and objective of the study. Then, main categories were formed through the semantic similarities of subcategories.

Discussion

Reviewing the relevant studies led to the extraction of the most important challenges in two main categories of policymaking and operational challenges.

Evidence-based policymaking and the need to strengthen policy making in Iran’shealthcaresystem and increasing its role in reforms have been continuously emphasized in Iran in recent years [7].According to marrying couples, evidence-based policy making is the most important step in quality premarital programs [15]. The lack ofthe policymakers’direct contact with marrying couples have led to improper prioritization [10], which has failed the services to meet the couples' needs, hence creating a gap in service quality [16].Policymakers should always monitor the structure and functions of the healthcare system and evaluate its results with respect to the objectives, efficiency, effectiveness and many other factors and thus identify problems in different parts and make policies based on the available evidence [17].Better use of evidence in premarital education program policy making can reduce the incidence of divorces and increase marital satisfaction [18].

One of the challenges of premarital education program in Iran is the insufficient allocation of financial resources [16, 19, 20].Today, the management of financial resources is the most essential tool for achieving the goals and effectiveness of programs in any organization [21].Management of financial resources is one of the four fundamental functions of the healthcaresystem [22] and optimal provision of health services needs sufficient and justice-based financial resources [23]. Fair allocation of resources is one of the most important challenges of any healthcare system and the main part of the decision-making process, which can hinder the execution and success of organized empowerment healthcare programs [24].

Human resource management and its importance in educating marrying couples were considered in some studies in the present review [25 –29].For example,Salarvand et al. believed that cooperation between human resource managers and executives of premarital classes was one of the basic indicators of increased ability to effectively educate them [30].

Human resources are one of the major components of healthcare system [31].Given the importance of human development and that human is considered the axis of development, human resources will have a great importance [32] and the performance of any system depends on a mix of skills, availability, and performance of its human resources [33].Quality, efficiency, effectiveness and accessibility of services cannot beachieved without adopting policies that guarantee appropriate number of high quality and motivated forces at proper places, time and costs [34].

Some studies mentioned the lack of attention to indigenous and regional cultural issues in premarital education [19, 26, 35].Cultural factors also affect the results of premarital education [36].For example, understanding the ineffectiveness of such education might need understanding the cultural traditions of that city or society [37].These are factors that health sector executives cannot easily change [38].

The findings of this review showed that premarital education programs in Iran need structural reforms [20, 21, 26].Inappropriate dates, inadequate duration, failure to discuss the raised issues [12, 15, 19], and few number of sessions were the structural challenges of the premarital education program [16].Other structural challenges raised in the papers were lack of favorable physical facilities includingbuilding, classrooms, seats, ventilation [15, 16, 19], new equipment, and lack of using educational media by the educators [12, 16].In addition to engaging more senses of the students, educational media diversify learning conditions, consolidate and preserve the learned materials for a longer period, and change the attitudes [39].

The results of most of the reviewed papers in this study showed that the content of premarital education classes was not adequate [19, 20, 26], and most marrying couples reported inadequate knowledge of sexually transmitted diseases [27].About 320 million adolescents and young people under 30 years old are annually infected with sexually transmitted diseases in the world and one person is infected with HIVevery 6 minutes [40]. Couples asked for courses in the field of psychology such as communication, coping with emotions and stress, decision-making, and problem solving skills [12, 19].

Other weaknesses of the premarital education program were the emphasison lecture method [12, 16], limiting the educators to brief presentations [20], improper presentation of educational material, and not observing educational principles such as lack of an organized educational program [16] and low-skilled educators [12, 20]. Merzel and Afflitti also consideredtraining healthcare providers and specialists essential to the development of health education programs [41].

Since marriage changes the nature of people’s needs and lack of information or misinformation increases the risk of family and marital problems, premarital education is absolutely necessary for couples.Reviewing several studies showed that many of these needs are not met in the current premarital education programs, hence, the policy making and execution of the program needs a fundamental reform.Policy making in programs should be evidence-based and efficient allocation of financial and human resources can improve the premarital program.In terms of planning and execution, the structure, content, and educators should be selected based on the needs of the target group. The results of this study will allow us to design programs to improve the premarital education program based on the perceived needs and sexual health of the couples.

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