The present study was conducted to communication barriers to education to referrals from the perspective of referrals to health centers and health care providers attendants.
Among the demographic variables related to HCP, education had a significant relationship with the domains of informational, physical-psychological, verbal-non-verbal barriers, so that in all domains, people with university education had a greater understanding of communication barriers than the group had a diploma.
Livne et al during their research, Also considered insufficient professional knowledge and skills as one of the communication barriers to patient education (21). In the research of Ghorbani and colleagues, the heavy workload was one of the barriers to educating patients, which was examined in our study in the form of psycho-physical domain (22).
Among the demographic variables related to RHC, education had a significant relationship with socio-cultural and environmental barriers. People with a high school education increasingly perceived socio-cultural factors as a barrier to health education. Also, people with university education considered environmental factors as a barrier to education more than others. The job variable was also significantly related to socio-cultural and environmental barriers. People who were employees perceive socio-cultural and environmental domains as barriers to effective communication for health education.
Regarding the communication barriers of education from the perspective of HCP and RHC, the most educational barriers were related to environmental and then the socio-cultural factors and the least barriers were related to the verbal-non-verbal domain.
In the present study, environmental barriers were factors such as congestion of health centers, lack of physical space, environmental noise, light and temperature of centers.
Many studies have pointed to the role of environmental factors as barriers to effective communication (23, 24). One prevalent barrier to communication is environmental noise. Environmental noise, further defined as equipment- and staff-related noise, usually refers to any extraneous sounds within the operational environment, such as conversation, tools, alarms, and ambient sounds from machinery (25). Perhaps one of the reasons that why environmental barriers are higher than other barriers is that the present study was conducted during the Covid 19 epidemic, so at this time environmental factors such as masks, shields, and personal protective equipment all affect the line of vision and reduce the nonverbal components of communication. Because Viewing the speaker's face is very effective in recognizing speech intelligibility.
One of the things that plays an important role in communication is culture (26). The HCP should be aware of the cultural differences of clients, one of the cultural influences is how people perceive illness, health and health education issues. If there is not enough knowledge about these cases, communication will be impaired. Overall, the HCP should be in line with the clients culture (23). The results of Schinkel et al.'s research also showed that from the perspective of immigrant patients, it is very important to pay attention to cultural barriers. raising awareness about cultural values differences, tackling the language barrier, increasing doctors’ cultural competencies to competencies to communicate adequately could raise participation levels of patients with doctors, and improve health outcomes (27). In the present study, socio-cultural barriers were in the second category of barriers that were perceived by RHC and HCP as communication barriers to education. In different studies, different factors have been considered in the field of cultural and social barriers. In the present study, the difference between the language of health care providers and clients was questioned as one of the items of socio-cultural barriers. In line with the present study, various studies have examined the language differences between HCP and RHC. For example, a study by Blackwell et al. examined language barriers to health care from a students' perspective, which found that language barriers create challenges between service providers and service recipients.And negatively affects various aspects of the health care process and effective communication (28).In a study conducted in Saudi, Linguistic and cultural differences between nurses and patients were considered as effective barriers to communication (29). Many studies have considered language barriers as effective communication barriers (30–34). Perhaps one of the reasons that cultural and social barriers are perceived as communication barriers is that although in Iran the number of immigrants may be less than other countries, but there are different ethnicities who speak different dialects, including dialect Turkish, Kurdish, Arabic. It seems that these linguistic differences affect effective educational communication. Also people in different parts of Iran have different customs, traditions and beliefs about health and disease so if RHC and HCP do not have the same culture and language all of this can affect an effective health communication.
One of the strengths of the present study was that for the first time, communication barriers were examined from the perspective of HCP and RHC. We also used two researcher-made questionnaires to examine the perspectives of HCP and RHC. We also tried to increase the sample size as much as possible to get more accurate information.
One of the limitations of the present study was to conduct the study only in Kerman, and therefore we have limitations in generalizing the results to other communities. Another limitation of data collection was self-report, which may affect participants' honest responses. One of the problems of the research was that the study was conducted during the epidemic of Covid disease, which made it difficult to collect information.