Bridging the implementation gap: a qualitative study of barriers to integrating psychological care into rheumatoid arthritis services in Iran.

BACKGROUND

Despite robust evidence and explicit guideline recommendations, psychological care is rarely integrated into routine Rheumatoid Arthritis (RA) services in Iran. This study explored the multilevel barriers to this implementation gap.

METHODS

A qualitative study guided by the Consolidated Framework for Implementation Research (CFIR) was conducted. Semi-structured interviews were held with 34 stakeholders (12 patients, 8 rheumatologists, 7 nurses, 4 psychologists, 3 hospital managers) in Iranian rheumatology clinics. Data were analyzed using directed content analysis.

RESULTS

Barriers interacted across CFIR domains, forming an interpretive model of a reinforcing cycle. Financial exclusion (Outer Setting) reinforced biomedical clinic culture (Inner Setting), which diminished professional self-efficacy (Characteristics of Individuals) and nullified implementation processes. Stigma and lack of structured pathways were key themes.

CONCLUSION

The integration gap reflects systemic misalignment, not a lack of evidence. Closing it requires coordinated policy, organizational, and educational reforms, not isolated interventions.