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Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study
  1. Mahmoud Radwan1,2,
  2. Ali Akbari Sari1,
  3. Arash Rashidian1,
  4. Amirhossein Takian1,3,
  5. Aymen Elsous1,
  6. Sanaa Abou-Dagga4
  1. 1 Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences (IC-TUMS), Tehran, Iran
  2. 2 International Cooperation Directorate, Palestinian Ministry of Health, Gaza Strip, Palestine
  3. 3 Health Equity Research Centre (HERC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
  4. 4 Department of Research Affairs and Graduates Studies, Islamic University of Gaza, Gaza Strip, Palestine
  1. Correspondence to Dr Mahmoud Radwan; mradwan78{at}


Objective Despite a high number of the internationally produced and implemented clinical guidelines, the adherence with them is still low in healthcare. This study aimed at exploring the perspectives and experiences of senior doctors and nurses towards the barriers of adherence to diabetes guideline.

Setting The Palestinian Primary Health Care-Ministry of Health (PHC-MoH) and Primary Health Care-United Nations Relief and Works Agency for Palestine Refugees in the Near East (PHC- UNRWA) in Gaza Strip.

Participants Individual face-to-face in-depth interviews were conducted with 20 senior doctors and nurses who were purposefully selected.

Methods Qualitative design was employed using the theoretical framework by Cabana et al to develop an interview guide. Semi-structural and audio-recorded interviews were conducted. Data were transcribed verbatim and thematically analysed.

Results The key theme barriers identified by participants that emerged from the analysed data were in regard of the PHC-MoH lack reimbursement, lack of resources and lack of the guideline trustworthiness, and in regard of PHC-UNRWA the time constraints and the lack of the guideline trustworthiness. The two key subthemes elicited from the qualitative analysis were the outdated guideline and lack of auditing and feedback.

Conclusion The analysis identified a wide range of barriers against the adherence to diabetes guideline within the PHC-MoH and PHC-UNRWA. The environmental-related and guideline-related barriers were the most prominent factors influencing the guideline adherence. Our study can inform the policy makers and senior managers to develop a tailored interventions that can target the elicited barriers through a multifaceted implementation strategy.

  • general diabetes
  • quality in health care
  • primary care
  • qualitative research

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  • Contributors All authors have contributed significantly in this research work. The authors (MR, AAS, AR, AT) significantly contributed in the study design and the critical review of the manuscript. The principal investigator (MR) collected, analysed, interpreted the data and wrote the first draft of the manuscript. The authors (SA-D, AE) highly contributed in the analysis and interpretation of data. Final approval was given by all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethical approval has been obtained from ethical approval committee in Gaza, and administrative approvals from the PHC-MoH, PHC-UNRWA. Verbal consent has been obtained from all interviewees to participate after giving them brief explanations about the purpose of the study. The study participants were informed about their right to participate or not to participate in the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The interview guide is available from the first author on request.

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