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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 systems

Original sub-themes extracted from studies

Studied themes

Major themes

Major 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

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–

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