Concerns about non-communicable diseases are serious global problems that will cause many problems not only in these years but also in the future (1). Insulin-dependent diabetes (type 2) is one of the four major non-communicable diseases along with cardiovascular disease, cancer, and chronic respiratory diseases, which together account for 63% of non-communicable disease deaths worldwide (2). The results of the first phase of the Tehran Lipid and Glucose Study indicate a worrying and very high prevalence of risk factors, including hypertension (24%), overweight and obesity (63%), hyperlipidemia (54%), diabetes (14%) and cigarettes smoking (14%) was present in Tehran citizens and also showed that more than 70% of hospitalizations and deaths were due to non-communicable diseases (3). According to the latest reports from the International Diabetes Federation, there are 425 million diabetics in the world, which will increase to 629 million by 2045; Also, according to this report, the number of patients with diabetes in Iran is 5 million, which will increase by nearly 10 million by 2045 (4). The results of the studies of the WHO stepwise approach to surveillance of non-communicable diseases (STEPS) in 2016 in Iran showed that the prevalence of diabetes in Mazandaran province based on FPG ≥ 126 is 12.93% in total (9.34 to 11.1% in men and more than 14.85% in women) and also the prevalence of diabetes based on HbA1c ≥ 6.4 is 12.38 to 14.38% in total (9.44 to 10.9% in men and more than 16.77% in women). The reports obtained from this study showed that Mazandaran province is one of the three most prevalent provinces in the country regarding the prevalence of diabetes (5).
Some predictors of pre-diabetes, e.g., age and family history of diabetes, are not preventable, but other factors that are effective and preventable in the development of pre-diabetes should be considered by officials, policymakers, and planners. Bodyweight in both sexes, waist size in women, fasting blood sugar level and two hours after a meal, and triglyceride and HDL cholesterol levels can be controlled with extensive public education programs for healthy eating and increased physical activity. Quitting smoking and increasing literacy levels are other important factors in reducing the incidence of pre-diabetes (6, 7). There is ample evidence that lifestyle modification, e.g., physical activity and healthy eating, can manage pre-diabetes and prevent or delay diabetes so that behavioral changes alone can greatly decrease the risk of developing diabetes. Therefore, identifying educational needs for preventive interventions seems to be essential (8–10).
The World Health Organization identifies community health workers (CHWs) as those responsible for providing health care and has received less training than other health care workers; Also, because they have to meet the community's needs, they are selected from people in the same community. They are typically trained for specific tasks such as prenatal care or vaccination (11). Community health workers have successfully provided essential health services to the public, such as reducing maternal and infant mortality rates, encouraging people to get vaccinated, promoting breastfeeding, and educating about infectious diseases. They have recently played a useful role in preventing AIDS through control, educating communities, and performing tasks such as testing, counseling, etc. (12–14). Even in areas with limited physicians, the responsibilities of community health workers have increased, which can be seen all over the world. This transition has led community health workers to use non-communicable diseases as well, as community health workers have played an increasing role in preventing and controlling non-communicable diseases over the past ten years, and the available evidence shows promising results. 15). In the Iranian health care system, community health workers are the first category of human resources in the provision and training of health care (16) that the use of appropriate and efficient methods and models will enable them to play their educational and executive role (17).
Pre-diabetics not only need knowledge and information to deal with diabetes-related issues and problems but also the skills, abilities, and motivations to engage in self-care behaviors; community health workers and therapy teams play an important role in educating these issues (18). By observation of pre-diabetic care by community health workers in health centers, interviews with diabetes experts and health education experts in Mazandaran province and Nowshahr city, study of epidemiological indicators that indicate the high prevalence of diabetes in Mazandaran province (5) and also, the results of educational needs assessment of community health workers, it was found that they do not have the desired ability in terms of non-communicable diseases and educational skills (19); Therefore, providing a self-care program is essential to improve the skills of community health workers.
Health education experts have proposed a range of different models to describe the factors affecting behavior, of which the Precede-Proceed model is a framework and a design model for identifying needs in health education and health promotion. This model is a process for changing behavior and explains the possible outcomes of a training program. According to the results of different researches, the Precede-Proceed model provides a framework according to which predisposing factors (knowledge, attitude, perceptions, beliefs, etc.), reinforcing factors (influence of others, family, peers, health workers, and etc.), and enabling factors (availability of resources, skills, etc.) are determined as factors affecting behavior in educational diagnosis. In fact, the most useful application of this model is to explain the factors related to behavior (20–23).
Due to the increasing prevalence of diabetes and the importance of self-care in controlling the progression of diabetes in pre-diabetic people, and that the studies on diabetes self-care programs in which pre-diabetic people have received less attention and the need for special attention to this group in order to prevent or delay diabetes and concerning the effective and undeniable role of community health workers and concerning the Sustainable Development Goals (SDGs), the third goal of which is entitled "Ensuring a life with health and welfare promotion for all at all ages", this study was conducted to evaluate the skills of community health workers in providing self-care program for pre-diabetic people in Mazandaran province based on the Precede-Proceed model.