In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study

Study design

This qualitative study involved individual, semi-structured interviews with physicians from various specialties who had experience working with treatment guidelines. The sample size was determined based on the principle of data saturation—a fundamental criterion in qualitative research—where data collection ceased once no new themes emerged and participant responses became repetitive. The study employed thematic analysis as its methodological orientation to systematically identify and interpret patterns within the data. To approach participants, face-to-face interviews were used. This study included both male and female specialists. Purposive and snowball sampling were employed to recruit specialists across diverse fields.⁹ Two physicians refused to participate because they were not interested.

Settings

All interviews were performed face-to-face at Kirkuk province’s public hospitals. The study’s time frame was from December 2021 to May 2022. Each interview lasted 10–15 minutes. Demographic data were used for the sample description.

Eligibility criteria

Participating in the research were physicians who worked in public hospitals, had experience with guidelines, and one of the following specialties: internal medicine, nephrology, gynecology, neurology, cardiology, rheumatology and pediatrician.

Exclusion criteria

Physicians whose specialties were outside the scope of the study were excluded and other health workers who did not deal with guidelines.

In order to remove prejudice, participants with hearing, speech, or cognitive impairments that hinder topic understanding were eliminated from the sample.

Study sampling

A purposive sampling method was used to select physicians who work in public hospitals in the province of Kirkuk was taken between December 2021 and May 2022. The physicians were invited in-person to participate in the study. The purposive sampling method was employed initially to identify “individuals who have extensive knowledge of or experience with an interesting phenomenon”.¹⁰ To expand the sample, a snowballing approach was also used, whereby initial participants recommended other specialists who met the inclusion criteria and might be willing to participate. Hence, the study employed two sampling techniques: purposive and snowball. All interviews were conducted face-to-face at hospital sites by a single researcher. Some participants asked for the interview guide ahead of time so they could prepare themselves for answers and to save time. The interviews continued until the point of data saturation was achieved. To ensure participant comfort and minimize deterrents to participation, audio recording was offered as optional. For those who declined recording, responses were documented through handwritten notes provided by the interviewees and supplemented by interviewer notes taken during the session.

The interviewer was a male pharmacist with five years of professional experience and a Bachelor of Science in Pharmacy. Prior to the commencement of the study, he established rapport with participants and disclosed his status as a master’s student. Arabic transcripts were translated into English by two bilingual researchers to ensure linguistic accuracy and contextual fidelity.

Interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency). Participants were given interview instructions (questions) by the author. No repeated interviews were conducted. Several individuals were interviewed using an audio recorder. Notes taken during and following interviews. The audio data were written words by words (transcribed verbatim) by the researchers. Data saturation was considered achieved when no new information or themes emerged from subsequent interviews.⁹

Interview guide

This study was conducted to evaluate the adherence of Iraqi physicians to medical guidelines for the treatment of various diseases. The interview guide was broken up into two parts. Part-1 included full participant characteristics were gender, occupation, level of education, professional title, area of expertise, years of practice, and workplace. Part-2 consisted of eleven questions posed to specialists in various fields ( Table 1). The interview guide was not piloted. The interview began by introducing the researcher and the purpose of the study. The names of participants were not reported.

Ethical approval

The Scientific Committee at the Department of Clinical Pharmacy and the Central Ethical Committee of the College of Pharmacy at Baghdad University reviewed and approved the research proposal including objectives and methodologies (ethics board approval number:2206). Before administering the interview questions, the researcher described the goal of the study and got each participant‘s verbal consent. Participants were not provided with any incentives. The interviewees’ information was maintained confidential.

Thematic analysis

The qualitative data obtained from the interviews was analyzed using thematic analysis. During the data’s thematic analysis, based on participant comments, two authors (AA and IY) reviewed the text and constructed themes. We followed Braun and Clarke’s six phases of thematic analysis, which included acquainting ourselves with the data (comments), generating initial codes, searching for themes, evaluating themes, defining and naming themes, and writing the report.¹⁰ As quotations, the completed statements (ideally with examples) were selected. The study team double-checked the transcription. The qualitative analysis was reviewed by peers and debriefed to make sure that the results were accurate and trustworthy. A data-driven inductive analytic technique and a constructivist worldview were employed.¹⁰ This means that, rather than relying on a pre-existing framework, we derived the themes from prevalent patterns that emerged from the participant responses. The data was coded with two data codes. No software was utilized in this study. There was consistency between the presented data and the findings. The findings clearly present major and minor themes. Two authors independently developed coding trees based on initial transcripts, which were refined through consensus and applied to all data. Finally, peer verification and debriefing were conducted twice to confirm the findings.

Demographics

Using medical guidelines to cover nearly all specialties was one of the study’s strengths, and the majority of participants were well-regarded professionals having considerable experience. The study’s participants were physicians with knowledge or expertise of medical guidelines.

The adherence of physicians to medical guidelines in their treatment approaches

In this study, the majority of specialists demonstrated strong familiarity with clinical guidelines relevant to their respective fields and reported actively following updates to incorporate new recommendations into patient care, aiming to optimize treatment outcomes. In this study, the author observed that specialist physicians consistently adhered to the most recognized and globally reliable guidelines. This adherence was largely influenced by their postgraduate training, which was grounded in these guidelines, as well as by the guidelines’ simplicity, societal relevance, and demonstrated clinical benefits. However, specialists did not implement all guideline recommendations, primarily due to previously noted barriers and other contributing factors. Treatment approaches among specialists were not influenced by gender, as all adhered to the same set of guidelines.¹¹ The fragmented use of international guidelines reflects both resource constraints and the absence of a unified national framework. This inconsistency may contribute to variability in care and underscores the need for centralized guideline development and dissemination.¹²

Several studies have examined the primary sources of information on antibiotics used by physicians. While most physicians demonstrated familiarity with antibiotic prescribing guidelines, adherence varied. For example, in Sudan, only 32.6% of physicians consulted the Sudan National Formulary or the British National Formulary when making prescribing decisions, whereas the majority did not refer to any formal reference source.¹³

Unavailability of Iraqi treatment guidelines for various diseases

Most specialists reported the absence of Iraqi clinical guidelines covering the majority of diseases relevant to their specialties. Currently, Iraq lacks a centralized body responsible for developing comprehensive guidelines for conditions commonly managed in public healthcare settings. Specialists emphasized the need for the Ministry of Health and Medical Associations to develop national guidelines that are practical, culturally appropriate, and aligned with available resources. While the Iraqi Ministry of Health has issued guidelines for chronic conditions such as diabetes and hypertension, many specialists reported limited access or awareness. This may reflect insufficient dissemination strategies and a lack of structured educational initiatives within public healthcare settings, as reported in previous studies examining similar challenges faced by hospital-based healthcare providers.^14,15

In contrast, most developed countries have well-established national treatment guidelines. For instance, several European countries—including the United Kingdom, Scotland, Croatia, Switzerland, and Romania—utilize a unified guideline for all primary headache disorders, including migraine. Denmark’s guideline encompasses both migraine and tension-type headache, while Spain and France have developed migraine-specific guidelines. Given that clinical guidelines serve to establish recognizable and acceptable standards of good practice, their implementation in primary care settings should be actively promoted.¹⁶

Specialists’ connections to physicians and clinical pharmacists

Specialist physicians reported frequent and constructive discussions with permanent and rotating colleagues concerning diseases and clinical guidelines. In contrast, interactions with pharmacists regarding guideline-related matters were notably limited.¹⁷ A previous Iraqi study found low physician acceptance of pharmacist recommendations suggests that physicians may underestimate the risk of drug-drug interactions. In fact, some of these contacts were classified as grave mistakes.¹⁸

Adherence of specialists to same guidelines within a specific specialty

Based on their clinical experience, most specialist physicians within a given specialty adhered to the same guidelines, with minor variations in specific treatment choices. For instance, while some preferred valsartan, others opted for candesartan—both from the ARB class—reflecting differences in post-residency training, patient response, and clinical outcomes. Notably, Iraqi physicians predominantly rely on internationally recognized guidelines, particularly American recommendations, which were the most frequently cited by participating physicians and hospitals. Some specialties also referenced European and British guidelines. Absence of agreement may arise when physicians disagree with the concept of clinical guidelines or the notion of prescriptive recommendations. However, while general disagreement with guideline theory is commonly expressed, this and prior analyses suggest that such disagreement tends to be less frequent when physicians are asked about specific, concrete guidelines.⁵ A national American study also revealed a significant disparity in guideline awareness and knowledge across different medical specialties. The study reported that cardiologists and primary care physicians demonstrated significantly higher levels of awareness and integration of cardiovascular disease (CVD) guidelines into clinical practice compared to physicians in other specialties.¹⁹

Access to approved medications and diagnostic tools in public health settings

The majority of medications and investigational tools that aid physicians in disease diagnosis were scarce or unavailable in Iraqi public health care settings. The shortage of life-saving treatments and the absence of important centers such as the stroke unit in all hospitals in the province make it difficult for specialists to diagnose and treat such cases, forcing them to refer patients to the private sector or recommend medication and lab tests from outside (private settings).

Similarly, across eight low-income countries—Bangladesh, Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal, and Tanzania—a secondary analysis of 797 public first-referral hospitals highlighted limited availability of essential equipment and medications for diverse acute and chronic non-communicable diseases and injuries (NCDIs). While facilities demonstrated moderate readiness for acute epilepsy and stage 1–2 hypertension, substantial service gaps were evident for diabetes, asthma, heart failure, and rheumatic heart disease, underscoring an urgent need for targeted investment in NCDI care readiness.²⁰

Barriers hinder guideline implementation in public healthcare

Regarding the implementation of guidelines for the treatment of various diseases, physicians faced significant barriers. Major barriers were the unavailability or shortage of medications; investigational tools (laboratory tests, x-rays, MRIs, CT scans, etc.); patients’ education; adherence; and physician follow-up. Several Iraqi studies report that, due to the Ministry of Health’s constrained budget, public healthcare settings frequently experience shortages of essential medications—particularly high-cost drugs.^21,22 Incapability to properly answer questions on the content of the guidelines, as well as self-reported unfamiliarity with the material, constituted a lack of familiarity. About two-thirds of the physicians were willing to prescribe low-cost medications, but only about half of them reported prescribing generic medications to their patients. This indicates a discrepancy between physician intent and prescribing behavior. Again, the risk of therapeutic failure is a key concern for physicians when they prescribe generic medications, especially in the private sector.²³ As the volume of medical research continues to grow, it becomes increasingly difficult for physicians to stay fully informed and consistently implement all relevant clinical guidelines. Moreover, limited acquaintance or general awareness does not necessarily reflect true familiarity with, or the practical ability to apply, these guidelines in clinical settings.⁵

Iraqi physicians demonstrated a preference for biosimilar medications approved by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA), likely reflecting greater confidence in the rigorous regulatory standards upheld by these agencies for ensuring the safety and efficacy of biosimilars. In contrast, biosimilars manufactured in neighboring countries and imported into Iraq often lack such international certifications, which may contribute to physicians’ reluctance to accept or prescribe them.²¹ Belgian cross-sectional survey of Dutch-speaking insurance physicians found that while most respondents held positive attitudes toward evidence-based medicine (EBM) and clinical practice guidelines, their actual knowledge and application of EBM were limited. Key barriers included lack of time and insufficient EBM skills, highlighting the need for tailored resources and improved access to structured, high-quality evidence relevant to insurance medicine.²⁴

A study, conducted in the United States, found that physicians often recommended screening procedures more frequently than published guidelines, while patients desired even more extensive screening than either physicians or guidelines endorsed. Physicians recommended screening procedures more frequently than published guidelines in 48 situations and less frequently in 18 situations. Physicians did not consistently follow their own recommendations or published guidelines, especially for procedures they were expected to perform personally.²⁵

Patients may resist guideline recommendations or perceive them as unnecessary, disrespectful, or embarrassing. Moreover, adherence to clinical practice guidelines may require adjustments beyond the physician’s control, such as securing additional resources or facilities. The study identified several barriers to guideline implementation that may lie beyond physicians’ control, including the absence of reminder systems, limited counseling materials, insufficient staff or consultant support, inadequate reimbursement, increased practice-related costs, and greater liability exposure.⁵ A review of 69 studies emphasized that barriers to guideline implementation and adherence must be contextually analyzed to tailor strategies to specific settings and target populations. To effectively influence physician behavior, interventions should be multifaceted, addressing both knowledge and attitudes.²⁶

Reasons for physicians to adhere to treatment guidelines

The majority of participating physicians rely on and adhere to guidelines for a variety of reasons, including that they are simple to use, based on real-world studies, more applicable in our society, updated, provide good results/benefits, are used globally, and have been taught in our post-graduate/specialty program.

A review article emphasizes that therapy adherence is critical for achieving optimal clinical outcomes, reducing healthcare costs, and improving patient quality of life—especially in chronic conditions like diabetes, hypertension, and cardiovascular disease. Poor adherence leads to disease progression, complications, and increased hospitalizations. Conversely, improved adherence results in better disease control and fewer complications. The review highlights the pivotal role of healthcare professionals in fostering adherence through effective communication, patient education, simplified treatment regimens, and trust-building. Digital health tools and personalized interventions are also noted as promising strategies to overcome adherence barriers.²⁷

Implementation rate of the guidelines by physicians in their daily work

The type of guideline used varied a lot from branch to branch and from ward to ward, depending on the hospital. Due to the many barriers that were pointed out in this study, most specialists said that less than 70% of guideline were followed. However, some specialists said that more than 70% of recommendations were followed in some cases and diseases.

The British Thoracic Society (BTS), together with the National Asthma Campaign and the Royal College of Physicians, performed a study in 36 hospitals looking at the process of acute asthma management The study defined many aspects of care for which there were specific guideline recommendations and was set up as a confidential study to encourage participation from hospitals.²⁸ Significantly, we observed that physicians’ prescribing decisions draw upon multiple sources of evidence, not just the aggregated outcome data underlying clinical guidelines. Indeed, physicians relied upon experiential evidence, distinguishing between the goals of caring for individuals vs. caring for the health of populations, to selectively implement or modify guidelines. Barriers to adherence with guidelines might be creatively addressed through greater acceptance of the logic of complementarity of evidence from a variety of sources when evaluating quality of care and prescribing practices.²⁹

Follow the recommendations of the guidelines in both public and private settings

The majority of specialists followed the same guidelines Across both the private and public sectors. In the private sector, some physicians use their experience or a mix of guidelines. However, the large number of facilities available in the private sector gives physicians a lot of options and flexibility in how they treat their patients. Health care professionals require ongoing education on guideline recommendations and must be equipped with the necessary tools and resources to support their consistent implementation. Strategies shown to be effective in some settings include repeated audit and feedback, reminder systems, education, academic detailing and financial incentives.^29,30

Limitations

As a qualitative study, the findings may not fully represent all Iraqi physicians due to sample size and specialty distribution. However, by using a maximum variation sampling approach, whereby we collected data from various types of specialists, the researcher been able to capture a wide spectrum of attitudes and practice which is likely to reflect practice in the broader profession. In addition, the study didn’t cover all diseases and all medical branches. The vast majority of physicians refused to record interviews and crowded consultant clinics, which were interrupted interviews.