Barriers Toward the National Program for Prevention and Control of Diabetes in Iran: A Qualitative Exploration

Document Type : Original Article


1 Research Center for Social Determinants of Health, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Department of Endocrinology & Metabolism, Internal Medicine, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

4 Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

5 Ministry of Health and Medical Education, Center for Non-communicable Disease Control, Tehran, Iran

6 Internal Medicine and Endocrinology Shohada Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

7 Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran


Despite the achievements of the national program for the prevention and control of diabetes (NPPCD) over the past two decades, the available evidence indicates a high prevalence of this disease in Iran. This qualitative study aims to investigate barriers to the NPPCD by pursuing the perspectives of relevant policy-makers, planners, and healthcare workers.

A grounded theory approach was used to analyze participants’ perceptions and experiences. Semistructured interviews (n=23) and eight focus groups (n=109) were conducted with relevant policy-makers, planners, and healthcare workers in charge of Iran’s national diabetes management program. Of the 132 participants, ages ranged from 25 to 56 years, and 53% were female. Constant comparative analysis of the data was conducted manually, and open, axial, and selective coding was applied to the data.

Two main themes emerged from data analysis: implementation barriers and inefficient policy-making/ planning. Insufficient financial resources, staff shortage and insufficient motivation, inadequate knowledge of some healthcare workers, and defects in the referral system were recognized as the NPPCD implementation barriers. Inappropriate program prioritizing, the lack of or poor intersectoral collaboration, and the lack of an effective evaluation system were the inefficient policy-making/planning problems.

Current results highlighted that inefficient policy-making and planning have led to several implementation problems. Moreover, the key strategies to promote this program are prioritizing the NPPCD, practical intersectoral collaboration, and utilizing a more efficient evaluation system to assess the program and staff performance.


  1. Cho N, Shaw J, Karuranga S, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes research and clinical practice. 2018;138:271-281.
  2. Esteghamati A, Larijani B, Aghajani MH, et al. Diabetes in Iran: prospective analysis from first nationwide diabetes report of National Program for Prevention and Control of Diabetes (NPPCD-2016). Scientific reports. 2017;7(1):1-10.
  3. Javanbakht M, Mashayekhi A, Baradaran HR, Haghdoost A, Afshin A. Projection of diabetes population size and associated economic burden through 2030 in Iran: evidence from micro-simulation Markov model and Bayesian meta-analysis. PloS one. 2015;10(7):e0132505.
  4. Susan van D, Beulens JW, Yvonne T. van der S, Grobbee DE, Nealb B. The global burden of diabetes and its complications: an emerging pandemic. European Journal of Cardiovascular Prevention & Rehabilitation. 2010;17(1_suppl):s3-s8.
  5. Harris MD. Psychosocial aspects of diabetes with an emphasis on depression. Current Diabetes Reports. 2003;3(1):49-55.
  6. Lin X, Xu Y, Pan X, et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Scientific reports. 2020;10(1):1-11.
  7. Harding JL, Pavkov ME, Magliano DJ, Shaw JE, Gregg EW. Global trends in diabetes complications: a review of current evidence. Diabetologia. 2019;62(1):3-16.
  8. Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update. Hypertension. 2001;37(4):1053-1059.
  9. Roglic G. Global report on diabetes: World Health Organization; 2016.
  10. Seuring T, Archangelidi O, Suhrcke M. The economic costs of type 2 diabetes: a global systematic review. Pharmacoeconomics. 2015;33(8):811-831.
  11. Organization WH. Forty-second world health assembly. Report of the Technical on the Health of Youth: WHO Geneva; 1989.
  12. Azizi F, Gouya M, Vazirian P, Dolatshahi P, Habibian S. The diabetes prevention and control programme of the Islamic Republic of Iran. EMHJ-Eastern Mediterranean Health Journal, 9 (5-6), 1114-1121, 2003. 2003.
  13. Alavi Nia M, Ghotbi M, Kermanchi J, Mahdavi Hazaveh A, Nasli Esfahani A, Yarahmadi S. National Program for Prevention and Control of Diabetes Type II in Urban Areas. Department of Endocrinology and Metabolic. Center for Non-Communicable Disease Control. Office of Hospital Administration and Clinical Service Excellence. Treatment Deputy. Ministry of Health and Medical Education, editor. Tehran, Iran. 2012.
  14. Faraji O, Etemad K, Sari AA, Ravaghi H. Policies and programs for prevention and control of diabetes in Iran: a document analysis. Global journal of health science. 2015;7(6):187.
  15. Organization WH. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020.
  16. Noshad S, Afarideh M, Heidari B, Mechanick JI, Esteghamati A. Diabetes care in Iran: where we stand and where we are headed. Annals of global health. 2015;81(6):839-850.
  17. Farzadfar F, Murray CJ, Gakidou E, et al. Effectiveness of diabetes and hypertension management by rural primary healthcare workers (Behvarz workers) in Iran: a nationally representative observational study. The Lancet. 2012;379(9810):47-54.
  18. Valizadeh R, Vali L, Bahaadinbeigy K, Amiresmaili M. The challenges of Iran's type 2 diabetes prevention and control program. International journal of preventive medicine. 2019;10.
  19. Kolb SM. Grounded theory and the constant comparative method: Valid research strategies for educators. Journal of emerging trends in educational research and policy studies. 2012;3(1):83-86.
  20. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24(2):105-112. doi:
  21. McBrien KA, Naugler C, Ivers N, et al. Barriers to care in patients with diabetes and poor glycemic control—A cross-sectional survey. PLoS One. 2017;12(5):e0176135.
  22. Simmons D, Peng A, Cecil A, Gatland B. The personal costs of diabetes: a significant barrier to care in South Auckland. The New Zealand medical journal. 1999;112(1097):383-385.
  23. Zgibor JC, Songer TJ. External barriers to diabetes care: addressing personal and health systems issues. Diabetes spectrum. 2001;14(1):23-28.
  24. Anand S, Bärnighausen T. Health workers and vaccination coverage in developing countries: an econometric analysis. The Lancet. 2007;369(9569):1277-1285.
  25. Cometto G, Witter S. Tackling health workforce challenges to universal health coverage: setting targets and measuring progress. Bulletin of the World Health Organization. 2013;91:881-885.
  26. Epping-Jordan J, Pruitt S, Bengoa R, Wagner EH. Improving the quality of healthcare for chronic conditions. BMJ Quality & Safety. 2004;13(4):299-305.
  27. George JT, Warriner DA, Anthony J, et al. Training tomorrow's doctors in diabetes: self-reported confidence levels, practice and perceived training needs of post-graduate trainee doctors in the UK. A multi-centre survey. BMC Medical Education. 2008;8(1):1-7.
  28. Van Uden C, Winkens R, Wesseling G, Crebolder HF, Van Schayck C. Use of out of hours services: a comparison between two organisations. Emergency Medicine Journal. 2003;20(2):184-187.
  29. Adeleye OA, Ofili AN. Strengthening intersectoral collaboration for primary health care in developing countries: can the health sector play broader roles? Journal of environmental and public health. 2010;2010.
  30. Smith PC. Some reflections on priorities for health systems strengthening in the WHO European Region: World Health Organization. Regional Office for Europe;2015.
  31. Brewster L, Aveling E-L, Martin G, et al. What to expect when you're evaluating healthcare improvement: a concordat approach to managing collaboration and uncomfortable realities. BMJ Quality & Safety. 2015;24(5):318-324.
  32. Tragakes E, Vienonen M. Key issues in rationing and priority setting for health care services: WHO, Regional Offoce for Europe, Health Care Systems, Health Services Management; 1998.
  33. van Dale D, Lemmens L, Hendriksen M, et al. Recommendations for effective Intersectoral collaboration in health promotion interventions: results from joint action CHRODIS-PLUS work package 5 activities. International journal of environmental research and public health. 2020;17(18):6474.
  34. Kilic B, Kalaca S, Unal B, Phillimore P, Zaman S. Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey. International journal of public health. 2015;60(1):47-53.
  35. Fretheim A, Oxman AD, Lavis JN, Lewin S. SUPPORT tools for evidence-informed policy-making in health 18: planning monitoring and evaluation of policies. Health research policy and systems. 2009;7(1):1-8.
  36. Hamilton KES, Coates V, Kelly B, et al. Performance assessment in health care providers: a critical review of evidence and current practice. Journal of nursing management. 2007;15(8):773-791.
  • Receive Date: 02 November 2021
  • Revise Date: 14 August 2022
  • Accept Date: 19 September 2022
  • First Publish Date: 20 September 2022