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Table 2 Data extraction by thematic analysis using the modified WHO key components of health systems framework and original themes from included articles

From: Challenges of managing diabetes in Iran: meta-synthesis of qualitative studies

WHO components of health systemsOriginal sub-themes extracted from studiesStudied themes
Major themesMajor themes
Holistic understanding of patients in his/her environment- Insufficient attention/training from the therapeutic team [24]
- Lack of time spent with clients by physicians [21]
- Lack of belief among patients in services provided by general practitioners (first level) [23].
- Lack of physicians’ success in earning patients trust [22]
- Mistrust of health care providers’ advice [21]
- Lack of mutual understanding about patient situation between patients and family members [24]
- Being ignored by family members [20]
- Lack of support from family [20]
- Medically inappropriate expectations of relatives (e.g. To eat more with them) [21]
- Patients feel embarrassed injecting insulin in public [21]
- Insufficient awareness of public regarding the diabetes [21, 27]
- Lack of appropriate programs in media [21]
- Lack of free exercise facilities at public parks could be an asset [21]
- High living costs resulted in stresses that did not allow diabetes to be as a priority [21].
- Weak organization and performance of NGOs [27]
Holistic understanding of patients in his/her environment- Insufficient attention to patients
- Lack of patients trusts in healthcare and healthcare providers
- Insufficient family support
- Insufficient community support
Leadership and governance- Ineffective inter-sectoral coordination (e.g. Health and treatment deputy [23]
- Lack of integrated care [23]
- Low cooperation of other service providers [27]
- Ineffective healthcare systems [17]
- Physical separation of first and second level health centers [27]
- Incompliance of health network with non-communicable diseases [27]
- Weak performance evaluation [27]
- Lack of continuous supervision on evidence based instruction performance [25]
Leadership and governance- Ineffective care coordination
- Weak performance evaluation
Service delivery- Insufficient facilities [24] such as shortage of specialists centers [24] diabetic foot management canters [27]
- Lack of support in terms of access to services [21]
- Unavailability of drugs [19]
- There are no local services [21]
- Insufficient laboratory services for thesecond level patients [27]
- Unavailability of services [28]
- Lack of care at hospital despite timely hospitalization [24]
- Long hospital waiting times [24].
- Difficulties in receiving service from public centers [27] and unsuitable working hours [27]
- Overcrowded hospitals and outpatient clinics [23]
- Problems accessing modern treatments and technologies [21]
- Inadequate packages and guidelines [23, 28]
- And specialized protocols [23]
- No need-based organization chart [25]
- Unsuitable health care services for diabetic patients [28]
- Patients ignore self-care [26] and have low motivation in this regards [27]
- Patients do not consider diabetes as a serious health threat [26]
- Patients are not committed to visit the physician regularly [18, 25] and timely [24], to follow ordered nutrition and drug use and regular exercise [18, 24, 25]
- Lack of self-efficacy to change lifestyle [21] and difficulties in integrating treatment with daily activities [26]
- They avoid to take insulin because they considered insulin consumption as a symptom of their disease deterioration [24]
- Most patients did not do regular tests for controlling their blood sugar level [24]
- Lower priority of diabetes management compared to other needs (e.g. Children need) [21]
- Patient education/training is inadequate [18, 21, 24]
- Patients’ poor knowledge and skill regarding the disease [26]
- Lack of resources to educate patients [21]
- Patients are not committed to participate in group training courses [25]
- Misconceptions about diabetes among patients [20]
- Patients are unaware of their disease up to appearance of an ulcer [24]
- Insufficient information about their nutritious diet [24] and the normal level of blood sugar [24].
- Incomplete information about alternative therapies [21]
- Self-medication [19, 20, 24]
- Voluntary disorganization of drug use consumption based on self-perception [20]
- Negative perceptions of Iranian medicines [21]
- Lack of effective follow up system [18, 23,24,25, 27], especially in elderly patients [27]
- Passive referral and lack of coordination in referral [27].
- Low motivation of first level physicians [27]/ High turnover of first level physicians [27]
Service delivery- Self-management problems:
 ➢ Lack of patients commitments
 ➢ Insufficient patients knowledge/training/ skill
 ➢ Self-medication
- Access difficulties
- Shortage of diabetes specific facilities
- Weak referral system
- Inadequate treatment guidelines
Workforce- Shortage of human resources [24, 27] such as nutritionists [18], nursing [23]
- Inadequate knowledge of physicians [22]
- Lack of continuous primary training among physicians [22]
- Inadequate supervision on physician training process [22]
- Lack of integrated education system [27]
- Limited interaction among physician and nurses [18]
- Lack of shared discussion among the specialists about the curing approach [24]
- Lack of physicians’ success in earning colleagues’ trust [22]
Workforce- Workforce shortage
- Insufficient knowledge/training
- Weak teamwork
Financing- Insufficient insurance coverage of first level services [27]
- Insurance coverage is not adequate (lack of coverage for blood glucose test strips, glucometers) [21]
- Unaffordability of some medicines [27]
- Lack of support in terms of cost [21]
- High treatment cost [19, 28]
Financing- Insufficient insurance coverage
Information and research- Not recording the visit date or the test results [18]
- Defective records registration [25]
- Information system failure [27]
- Inactive information dissemination [23]
Information and research- Weak information technology
Technologies and medical products