Factors Influencing Paternalistic Clinical Environment in Iran: An Exploratory Research Brief

Abstract

This study aimed to explore the factors that contribute to the presence of paternalism within the Iranian healthcare system. The study was conducted in 2024, conducting 15 semi-structured interviews. The study sample comprised chronic disease patients discharged from a major public hospital in southwestern region of Iran. The interview sample consisted of approximately 54% males with a mean age of 46 years. About 46% of the participants had diabetes, while the remainder had cardiovascular disorders. After completion of the interviews and the subsequent data gathering, Braun and Clarke's method was utilized in order to conduct a thematic analysis on the acquired data. The thematic analysis presented several themes including ‘patient trust in physicians’, ‘lack of patient empowerment’, ‘patient psychological and communication barriers’, and ‘healthcare system and infrastructure limitations’. While, the latter theme was the most frequently addressed theme of factors by the study participants, ‘limitations in governmental hospitals’ was the most frequently addressed item among the sub-themes of the study findings. The presence of paternalism in Iran's healthcare system was delineated to be primarily influenced by the existing limitations in the Iranian healthcare system and its infrastructure. Further research is necessary to investigate and elaborate on this phenomenon in greater detail.

Introduction

‘Paternalism’ denotes instances of authority exercised by the physician in guiding the provision of care and allocation of resources to patients, even in the absence of the patient's complete informed consent. These actions are undertaken with the aim of advancing the well-being or welfare of the individual in question. ¹

The studies suggest that the healthcare system in Iran has a historical association with paternalism, characterized by healthcare providers making decisions on behalf of patients without actively engaging them in the decision-making process.^2–4 In this regard, some studies claim that Iranian patients have expressed a preference for paternalistic care, noting its significance in providing essential support and attention, especially in the absence of family assistance.^3,5–8 In such context, it is reported that cultural attitudes towards paternalism vary, with some societies considering it a beneficial aspect, while others prioritize patient independence. ⁷ Moreover, it is observed that patients’ inclinations towards participation in decision-making vary significantly and are shaped by demographic and situational factors. ⁹

A study in the Iranian healthcare system identified several barriers to patient participation in clinical decision-making. These barriers included the significant power imbalance between healthcare providers and recipients, mistrust in the healthcare system, healthcare system characteristics, and cultural barriers. The significant power imbalance between healthcare providers and recipients is characterized by the healthcare provider`s unilateral decision-making, inability to disagree with physicians, despair, and perceived objectification for secondary gain. Mistrust in the healthcare system encompasses the existence of mistrust in physicians, nurses, and facility/equipment. And, Healthcare system challenges include limitations in services, poor communication, and cultural factors such as language barriers and religious beliefs. ¹⁰ Another study delineated various obstacles impeding the participation of patients in clinical decision-making. These barriers encompassed patient-related challenges, such as educational levels and knowledge gaps, especially prevalent in low-income and illiterate demographics, as well as cultural issues like unfamiliarity with decision-making processes and patient rights. Additionally, physician-related hindrances were identified, including insufficient resources like time and specialist availability per capita, a lack of an established evaluation framework for overseeing patients’ rights in decision-making, and the absence of suitable role models among medical educators. ⁶

In alignment with the research findings concerning Iran, there is evidence indicating that patients in the UAE also exhibit a similar approach, preferring paternalism in healthcare services. In contrast to the outcomes observed in Western nations, as highlighted in the study, a significant proportion of Arabic-speaking patients expressed a preference for a paternalistic decision-making model. ¹¹ This offers novel insights into patient-centered care, highlighting that the involvement of patients in clinical decision-making is not a universal fundamental requirement or preference across all global societies.

The exploration of the factors underlying the existence of paternalism within the Iranian healthcare system appears to be of significant importance for policymakers and researchers both in Iran and on the international stage, due to the rarity of such a phenomenon in the global context. However, only a limited number of studies have been conducted to investigate the factors contributing to the manifestation of paternalism in Iran.^6,10 Investigating the underlying factors contributing to the existence of paternalism in the Iranian healthcare system is crucial due to its significant implications for healthcare policymakers, researchers, and most notably, patients (particularly those diagnosed with chronic disorders) as the primary beneficiaries of healthcare services. The findings of such investigations can furnish policymakers with the necessary data to enhance patient participation in clinical decision-making by identifying the factors that influence the prevalence of paternalism. Furthermore, these results can provide researchers with implications for future studies, enabling a more comprehensive analysis of the topic and its context.

Method

This exploratory study conducted in Iran in 2024, employed a qualitative methodology, involving multiple semi-structured interviews with a sample of patients within the Iranian healthcare system. The study was conducted adhering to the consolidated criteria for reporting qualitative research (COREQ) guideline. ¹²

Research Question

The research question was formulated as: ‘What are the factors influencing lack of patient participation in clinical decision-making in the Iranian healthcare system?’.

Study Setting and Participants

The study was conducted in Shiraz, a city located in the southwestern region of Iran, which is recognized as one of the prominent healthcare hubs within the area. ¹³ The participants comprised patients diagnosed with chronic diseases who had been discharged from Namazi, one of the most prominent public hospitals in the city and the region as a whole during the time period of 2023–2024.Using the purposive sampling method, the participants were restricted to individuals diagnosed with diabetes and cardiovascular disorders. This selection was predicated upon the considerable prevalence of these conditions in Iran, contributing significantly to the country's burden of diseases. ¹⁴

Inclusion/Exclusion Criteria

The inclusion criteria encompassed patients (or their chaperones in case of their inability to communicate) diagnosed with diabetes or cardiovascular disorders. The study's exclusion criteria encompassed patients (or their chaperones) who did not provide consent to participate in the research and those who did not meet the inclusion criteria. And, those individuals affiliated with the clinical or administrative staff of the hospital in order to safeguard the study from potential conflicts of interest.

Data Collection

Data were collected via telephone-based, semi-structured interviews with a purposively selected sample of patients. Patient contact information was obtained from hospital records. Following researcher introduction, objectives explanation, and identity verification, informed consent was secured from participants or chaperones. Interviews, lasting 15–40 min (median 30 min), commenced with an open-ended question regarding factors influencing patient participation in clinical decision-making in Iran. The question was, ‘What has influenced your decision to participate or not participate in decision-making during your time at the hospital?’. Initial interviews validated question effectiveness. Data collection continued until saturation, achieved after 15 interviews. Chaperones were consulted when patients could not effectively communicate. Field notes were taken during and after interviews. Audio recordings were transcribed verbatim using a pre-designed form (Appendix 1: Data Collection Form), including participant identifiers, demographics, disorder, and relevant quotes.

Data Analysis

This phase aimed to identify factors contributing to limited patient participation in clinical decision-making, as revealed by interview data. Data were analyzed using Braun and Clarke's six-step thematic analysis method: familiarization, coding, theme generation, theme review, theme definition/naming, and write-up finalization. ¹⁵

Initially, two authors independently reviewed interview data to achieve comprehensive familiarization. Subsequently, data were categorized according to research objectives. Sub-themes and overarching themes were identified by structuring and clustering codes using Microsoft Word 2016. Themes underwent iterative review to ensure integrity and reliability. Themes and sub-themes were then defined and labeled according to their core essence. Finally, themes, sub-themes, and codes were integrated into a single document. The analysis findings were compared with the original data to ensure consistency. A third author mediated any disagreements between the initial researchers.

Validity and Reliability

The collection and analysis of the data within the study rigorously followed the guidelines established by Lincoln and Guba for qualitative research, aiming primarily to uphold the validity and authenticity of its findings. Consequently, the study was structured around the four key criteria essential to qualitative research, encompassing credibility, transferability, dependability, and confirmability, which are fundamental aspects crucial for ensuring the quality and reliability of the research outcomes. ¹⁶ To ensure credibility, the authors engaged extensively with interview content and incorporated peer debriefing. Transferability was supported by detailed data descriptions and purposive sampling. Data trail auditing ensured reliability. Triangulation was achieved through varied data gathering methods, including guided interviews and multiple open semi-structured interviews. Data extracted from interviews underwent meticulous review and revision to maintain reliability.

Results

Following the completion of numerous interviews, as reported earlier, data saturation was attained subsequent to 15 interviews. The participation rate was 100% and none of the interviewees refused to participate within the study. The demographic composition of the interviewees revealed that males comprised approximately 54% of the sample. The mean age of the interview participants was 46 years. Additionally, approximately 46% of the interviewees were diagnosed with diabetes, with the remaining individuals had cardiovascular disorders. And, about 46% of the participants were the chaperones.

Thematic Analysis

The thematic analysis of the data acquired from the interviews resulted in the identification of four themes, each comprising of multiple sub-themes (Table 1). The themes included ‘Patient trust in physicians’, ‘Lack of patient empowerment’, ‘Patient psychological and communication barriers’, and ‘Healthcare System and Infrastructure Limitations’, each addressed by approximately 53%, 66%, 46%, and 80% of the study participants (Figure 1). Meanwhile, ‘Limitations in governmental hospitals’ was the most frequently addressed item among the sub-themes (66%). Furthermore, Appendix 2 (Interview Data) presents the quotes of the study participants in detail.

Table 1.

Thematic Analysis of the Data.

Theme	Sub-theme	Number of citations
Patient trust in physicians	Trust in physicians` expertise	8
Lack of patient empowerment	Lack of patient education and literacy	8
	Lack of patient awareness	3
	Lack of patient guidance	2
Patient psychological and communication barriers	Existence of mental and emotional pressure	3
	Fear of physicians	2
	Authoritative behavior of physicians	3
Healthcare system and infrastructure limitations	High cost of medical care and physician visits	6
	Limitations in governmental hospitals	10
	Limitations in non-developed areas	5

Figure 1.

Distribution of Themes in Terms of Their Addressal by the Study Participants.

Patient Trust in Physicians

This theme consisted of a single sub-theme. The sub-theme included ‘Trust in Physicians` Expertise’, addressed by 53% of the participants. ‘Trust in physicians` expertise’ presents that Patients often place significant trust in physicians’ expertise, believing that doctors have better knowledge and understanding of medical conditions, which leads to a reluctance to question or participate in decision-making.

Lack of Patient Empowerment

This theme comprised of three sub-themes including ‘lack of patient education and literacy’, ‘lack of patient awareness’, ‘lack of patient guidance’, each addressed by 53%, 20%, and 13% of the participants. ‘Lack of education and literacy’ delineates that patients with lower levels of education and literacy may experience diminished confidence in engaging with healthcare providers and may struggle to articulate their concerns effectively. ‘Lack of awareness’ presents that patients may not be aware that they can participate in decision-making. And, ‘lack of guidance’ presents that patients refrain from participating in clinical decision-making in the absence of guidance on how to find the avenues to express their views.

Patient Psychological and Communication Barriers

This theme consisted of three sub-themes including ‘existence of mental and emotional pressure’, ‘fear of physicians’, and ‘authoritative behavior of physicians’, each addressed by 20%, 20% and 13% of the study participants. ‘Existence of mental and emotional pressure’ delineates that an unfavorable mental condition can prevent patients from actively participating in discussions with their healthcare providers. ‘Fear of physicians’ presents that fearing the outcomes of questioning or presenting views to the physicians can hinder participation of patients in decision-makings. Moreover, ‘Authoritative behavior of physicians’ delineates that the authoritative behavior of physicians can intimidate patients, making them less likely to engage in discussions or question decisions.

Healthcare System and Infrastructure Limitations

This theme comprised of three sub-themes including ‘High cost of medical care and physician visits’, ‘Limitations in governmental hospitals’ and ‘Limitations in non-developed areas’, each addressed by 40%, 66% and 33% of the participants. ‘High cost of medical care and physician visits’ presents that the high cost of medical care and physician visits can limit patients’ options to seek advice or care from multiple sources, leading to a reliance on the decisions made by the available healthcare providers. ‘Limitations in governmental hospitals’ delineates that challenges specific to government hospitals including overcrowding, busy schedules of physicians, longer queues, limited resources particularly insufficient clinical staff can hinder patient-physician communication, collaboration, and ultimately patient participant in decision-makings. Furthermore, ‘limitations in non-developed areas’ delineates the lack of facilities and specialists in certain non-developed areas forces patients to accept the available care regardless of being satisfied with it. These issues can discourage patient participation in decision-makings.

Discussion

The results of our study highlighted a significant issue in Iranian public hospitals regarding the distribution of healthcare infrastructure and personnel. Our findings revealed that high medical costs limit patients’ options, forcing them to rely on available healthcare providers. This situation indirectly was presented to lead to a lack of choices and fostering paternalism. Challenges in government hospitals, such as overcrowding, busy schedules, and limited resources, has hindered patient-physician communication, which can be considered another factor contributing to paternalism. Furthermore, the lack of facilities and specialists in certain areas has further reduced patient participation in Iranian public hospitals.

The private healthcare sector in Iran has been observed to deliver superior service quality compared to public hospitals, with patients reporting a higher perceived quality of services in private healthcare facilities. Patients’ satisfaction levels are generally more elevated in private hospitals, particularly in areas such as service quality, physical aspects of care, and the doctor-patient relationship, which is closely associated with the subject matter of this study. Furthermore, private hospitals often prioritize addressing patients’ needs and expectations, resulting in enhanced satisfaction and trust among the patient population.^17,18 In this regard, As our study delineated, patients from less developed regions, due to the lack of adequate facilities and healthcare workforce, opt for treatment in developed areas, leading to overcrowding and resource constraints in public hospitals, a phenomenon backed by the previous literature^19,20; This dynamic compromise the ability of these facilities to deliver optimal care, underscoring the need for a more equitable distribution of healthcare resources across the country.

Our findings concerning the influence of patient education on their participation in clinical decision-making and communication with healthcare providers align with existing literature emphasizing the significance of patient education in improving shared decision-making.^21–23 In such context, it is reported that patients with limited health literacy may encounter challenges comprehending medical terminology, adhering to prescribed treatment regimens, and effectively conveying their preferences to healthcare professionals.^24,25

The findings of our study presented that the existence of trust in physicians` expertise by patients can potentially act as a barrier for patients to participate in clinical decision-making. These findings are aligned with the literature. In this regard, a study has delineated that Iranian patients have demonstrated a substantial degree of trust in their physicians. Over half of the participants surveyed expressed a high or unwavering level of trust in their physicians, suggesting a favorable assessment of physicians’ knowledge, skills, and competence within the Iranian healthcare system. ²⁶ This phenomenon has the potential to result in patients refraining from expressing their views and preferences to physicians, instead deferring to the physicians’ perspectives and decisions, which ultimately fosters a paternalistic dynamic.

As our findings have elucidated, the issue of trust expressed by at least some of the study participants was supposedly attributed to the certain conditions they encountered within the hospital, which left them with no recourse but to place unwavering trust in their physicians - a phenomenon that is referred to as ‘coercive trust’ in the literature. ²⁷ Consequently, the high level of trust exhibited by Iranian patients towards their physicians seemingly presents a complex scenario with both favorable and unfavorable consequences, making it a double-edged sword in healthcare contexts.

In alignment with our research findings on the influence of unfavorable mental conditions on patient participation in clinical decision-making, existing literature highlights that individuals facing high-stress scenarios such as a cancer diagnosis may encounter emotions like fear, anger, or distress that impede their capacity to effectively interact with healthcare providers and make well-informed choices.^28,29 Moreover, the study's results regarding the phenomenon of authoritative behavior exhibited by physicians, as observed within our research, are substantiated by existing literature. Notably, a study reveals that the authoritative conduct of Iranian physicians extends beyond interactions with patients to encompass relationships with lower-level clinical personnel, including nurses. This investigation highlights that Iranian physicians frequently exert dominance over nurses, attributed to an imbalance in both actual and perceived power dynamics. ³⁰ In the context of physician-patient interactions, research suggests that certain demographic characteristics of the healthcare provider, such as gender, age, and professional experience, can shape patients’ perceptions of the physician's authority and expertise in Iran. ³¹

Implications

Regarding the healthcare systems and infrastructural limitations leading to paternalism in Iran, the existing evidence suggests that the implementation of healthcare regionalization policy has significantly enhanced population access to healthcare services, rational distribution of medical resources, improved health conditions, full accessibility and coverage, coordinated health activities, and cost-effective care. ³² This approach organizes the health service network at regional or local levels, decentralizes services in specific geographical areas, concentrates health activities under unified leadership, and improves care quality while maximizing resource utilization. ³² Furthermore, regionalization fosters better coordination and integration of healthcare delivery, controls expenditures, boosts efficiency, promotes equity, responsiveness, and ultimately citizen and patient participation in healthcare decision-making as the primary topic of our research, showcasing its multifaceted benefits in optimizing healthcare systems and improving overall health outcomes. ³³ This policy has the potential to serve as a crucial solution for addressing the prevalent disparities among regions within the Iranian healthcare system. As the findings of our study backed by the literature delineated, these disparities are recognized as fundamental factors contributing to the challenges faced in healthcare service delivery in Iran.^19,20,34,35

The literature has also proposed various solutions for patient education deficiencies; these include creating easily understandable educational materials, dedicating time during appointments for provider-patient education, and organizing workshops to equip patients with necessary knowledge and skills. Additionally, healthcare providers could get educated on shared decision-making principles and effective communication techniques to enhance patient engagement and promote patient-centered care. Moreover, digital health tools like patient portals and telehealth platforms also provide on-demand access to educational resources and support for shared decision-making.^36,37

The literature also proposes several strategies to mitigate authoritative behavior among physicians in healthcare organizations, including raising awareness and responsiveness, establishing clear policies and procedures to manage disruptive behaviors, implementing a consistent reporting and review process to identify and address authoritative conduct, offering education and training on diversity, conflict management, and communication skills, providing behavioral support through coaching, counseling, and intervention, and acknowledging and recognizing physicians’ efforts to foster a culture of appreciation and collaboration. ³⁸

This study yielded significant implications for healthcare policymakers, administrators, and researchers to address. Initially, the phenomenon of paternalism was observed within the healthcare system in Iran, which seemed to be considerably tolerated by patients. The findings of our study provide a foundation for Iranian healthcare policymakers, service providers, and researchers to investigate and develop solutions for the factors influencing paternalism in healthcare and lack of patient participation in clinical decision-making in Iran addressed by the study. Furthermore, the study presented conflicting findings regarding patient trust in physicians, demonstrating both positive and negative aspects, reporting the potential existence of a coercive trust in physicians in some cases due to certain circumstances. This finding can be an implication for future researchers within the context, as further research is necessary to investigate and elaborate on this phenomenon in greater detail.

Limitations

The study had a limitation to address. In this regard, due to constraints in time and resources, the patient population was restricted to those receiving care at a single healthcare facility leading to a relatively small study sample size. However, this institution was one of the most prominent hospitals in the region, serving a large and diverse patient population in terms of socioeconomic status and geographical background.

Conclusion

As the findings delineated, the phenomenon of paternalism within Iran's healthcare system was primarily attributed to the existing limitations and infrastructural constraints of the system. In this regard, the study highlighted the significant role played by the limitations in governmental hospitals in Iran. Additional factors contributing to the rise of paternalism in the Iranian healthcare system were presented to be the lack of patient empowerment, patient trust in physicians, and psychological and communication barriers experienced by patients. Further research is necessary to investigate and elaborate on this phenomenon in greater detail.