Gap analysis and status quo investigation on palliative care in the Iranian National Health Care System (INHS): a health promotion paradigm-focused mixed method case study

Abstract

Introduction: Palliative care is still not routinely provided in hospitals in Iran, despite emphasis on its importance in community health indicators and its role in the health-promoting hospitals initiative. Therefore, it is necessary to gauge the feasibility of integrating palliative care into routine hospital services in Iran and identify potential barriers and gaps in meeting palliative care needs. Objectives: To recognize existent models of hospital-based palliative care (HBPC) provision, clarify quality of the dying care in Iran, and pinpoint the barriers to integrate palliative care into the routine hospital care in the country. Methodology: This study was conducted in three stages. In the first stage, a scoping review was conducted according to JBI guideline. The HBPC models were identified and classified into six general categories. The second stage involved psychometric testing of the quality of dying care evaluation (CODE) with 32-item to be applied in appraising the status of palliative care provision in Persian-speaking context. The standard forward-backward translation was performed on the original and translated CODE by four experts in related fields. Face and content validities of the Persian translated CODE (CODE-P) were performed by a panel of experts. Cultural adaptability and construct validity of the CODE-P was assessed using the data collected from 280 relatives of deceased patients in the selected hospitals in Ardabil, the capital city of Ardabil province, Northwest of Iran. In the third stage, deep insights of the 27 key informants about the barriers to integrate palliative care into routine hospital services were identified and prioritized using the Q method. Factor analysis using varimax rotation was applied in the conducted Q method. Findings: The most important finding of the first stage was the introduction and classification of HBPC models according to their emphasis on providers, technology, elements, issue, time, and standard. Based on the data obtained from the second phase, the quality of end-of-life care for symptom management was high (mean score: 9.39 on a scale of 0-12), but significant communication needs that remained unmet, included failure to inform about death time`s symptoms, and lack of effective patient and family participation in treatment decisions (mean score: 1.26 on a scale of 0 to 5). The findings of the third phase presented five major barriers to integrate palliative care, which included: shortage of physical space and number of the healthcare providers (20%), inadequate involvement of the patient's family in making treatment decisions (11%), communication barriers (9%), and deficient palliative care skills of healthcare providers (7%). These four factors (barriers) explained a total of 47% of the variance. Conclusion: The study findings helped to tabulate diverse hospital-based palliative care provision models across the globe, which categorized into six broad groups based on their inherent characteristics and ultimate archetype of provision. None of the identified models are presented as a global gold standard model; therefore, their selection by health policymakers should be based on unique features of healthcare systems and arrangement of hospital care across the countries. Hospital care quality enhancement is main goal and deceased relatives in this study indicated significant unmet needs with regard to palliative care in the Iranian hospitals and especially in the area of information and participation. From the perspective of participant health professionals in this study, there are significant barriers to integrate palliative care into routine hospital care in Iran among them insufficient physical space and the insufficient number of health providers were paramount. The identified barriers could help resource-limited countries to have evidence-informed and efficient policies for integration of palliative care into the package of provided care in hospitals.

Key Words: Delivery of Health Care; End of life care; healthcare providers; healthcare system; Health promotion