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

In-depth assessment of Iraqi physicians'... | F1000Research "use strict";function _typeof(t){return(_typeof="function"==typeof Symbol&&"symbol"==typeof Symbol.iterator?function(t){return typeof t}:function(t){return t&&"function"==typeof Symbol&&t.constructor===Symbol&&t!==Symbol.prototype?"symbol":typeof t})(t)}!function(){var t=function(){var t,e,o=[],n=window,r=n;for(;r;){try{if(r.frames.__tcfapiLocator){t=r;break}}catch(t){}if(r===n.top)break;r=r.parent}t||(!function t(){var e=n.document,o=!!n.frames.__tcfapiLocator;if(!o)if(e.body){var r=e.createElement("iframe");r.style.cssText="display:none",r.name="__tcfapiLocator",e.body.appendChild(r)}else setTimeout(t,5);return!o}(),n.__tcfapi=function(){for(var t=arguments.length,n=new Array(t),r=0;r 3&&2===parseInt(n[1],10)&&"boolean"==typeof n[3]&&(e=n[3],"function"==typeof n[2]&&n[2]("set",!0)):"ping"===n[0]?"function"==typeof n[2]&&n[2]({gdprApplies:e,cmpLoaded:!1,cmpStatus:"stub"}):o.push(n)},n.addEventListener("message",(function(t){var e="string"==typeof t.data,o={};if(e)try{o=JSON.parse(t.data)}catch(t){}else o=t.data;var n="object"===_typeof(o)&&null!==o?o.__tcfapiCall:null;n&&window.__tcfapi(n.command,n.version,(function(o,r){var a={__tcfapiReturn:{returnValue:o,success:r,callId:n.callId}};t&&t.source&&t.source.postMessage&&t.source.postMessage(e?JSON.stringify(a):a,"*")}),n.parameter)}),!1))};"undefined"!=typeof module?module.exports=t:t()}(); dataLayer = dataLayer || []; // Standard GTM initialization - Google Consent Mode handles consent automatically (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl+ '>m_auth=hzk0Vc3qFsQYhCrIoHz68A>m_preview=env-1>m_cookies_win=x';f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MWFK8L5J'); ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; ;NREUM.loader_config={accountID:"438030",trustKey:"438030",agentID:"772317073",licenseKey:"97f8f67f26",applicationID:"772317073"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"97f8f67f26",applicationID:"772317073",sa:1} ;/*! For license information please see nr-loader-spa-1.236.0.min.js.LICENSE.txt */ (()=>{"use strict";var e,t,r={5763:(e,t,r)=>{r.d(t,{P_:()=>l,Mt:()=>g,C5:()=>s,DL:()=>v,OP:()=>T,lF:()=>D,Yu:()=>y,Dg:()=>h,CX:()=>c,GE:()=>b,sU:()=>_});var n=r(8632),i=r(9567);const o={beacon:n.ce.beacon,errorBeacon:n.ce.errorBeacon,licenseKey:void 0,applicationID:void 0,sa:void 0,queueTime:void 0,applicationTime:void 0,ttGuid:void 0,user:void 0,account:void 0,product:void 0,extra:void 0,jsAttributes:{},userAttributes:void 0,atts:void 0,transactionName:void 0,tNamePlain:void 0},a={};function s(e){if(!e)throw new Error("All info objects require an agent identifier!");if(!a[e])throw new Error("Info for ".concat(e," was never set"));return a[e]}function c(e,t){if(!e)throw new Error("All info objects require an agent identifier!");a[e]=(0,i.D)(t,o),(0,n.Qy)(e,a[e],"info")}var u=r(7056);const d=()=>{const e={blockSelector:"[data-nr-block]",maskInputOptions:{password:!0}};return{allow_bfcache:!0,privacy:{cookies_enabled:!0},ajax:{deny_list:void 0,enabled:!0,harvestTimeSeconds:10},distributed_tracing:{enabled:void 0,exclude_newrelic_header:void 0,cors_use_newrelic_header:void 0,cors_use_tracecontext_headers:void 0,allowed_origins:void 0},session:{domain:void 0,expiresMs:u.oD,inactiveMs:u.Hb},ssl:void 0,obfuscate:void 0,jserrors:{enabled:!0,harvestTimeSeconds:10},metrics:{enabled:!0},page_action:{enabled:!0,harvestTimeSeconds:30},page_view_event:{enabled:!0},page_view_timing:{enabled:!0,harvestTimeSeconds:30,long_task:!1},session_trace:{enabled:!0,harvestTimeSeconds:10},harvest:{tooManyRequestsDelay:60},session_replay:{enabled:!1,harvestTimeSeconds:60,sampleRate:.1,errorSampleRate:.1,maskTextSelector:"*",maskAllInputs:!0,get blockClass(){return"nr-block"},get ignoreClass(){return"nr-ignore"},get maskTextClass(){return"nr-mask"},get blockSelector(){return e.blockSelector},set blockSelector(t){e.blockSelector+=",".concat(t)},get maskInputOptions(){return e.maskInputOptions},set maskInputOptions(t){e.maskInputOptions={...t,password:!0}}},spa:{enabled:!0,harvestTimeSeconds:10}}},f={};function l(e){if(!e)throw new Error("All configuration objects require an agent identifier!");if(!f[e])throw new Error("Configuration for ".concat(e," was never set"));return f[e]}function h(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");f[e]=(0,i.D)(t,d()),(0,n.Qy)(e,f[e],"config")}function g(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");var r=l(e);if(r){for(var n=t.split("."),i=0;i {r.d(t,{D:()=>i});var n=r(50);function i(e,t){try{if(!e||"object"!=typeof e)return(0,n.Z)("Setting a Configurable requires an object as input");if(!t||"object"!=typeof t)return(0,n.Z)("Setting a Configurable requires a model to set its initial properties");const r=Object.create(Object.getPrototypeOf(t),Object.getOwnPropertyDescriptors(t)),o=0===Object.keys(r).length?e:r;for(let a in o)if(void 0!==e[a])try{"object"==typeof e[a]&&"object"==typeof t[a]?r[a]=i(e[a],t[a]):r[a]=e[a]}catch(e){(0,n.Z)("An error occurred while setting a property of a Configurable",e)}return r}catch(e){(0,n.Z)("An error occured while setting a Configurable",e)}}},6818:(e,t,r)=>{r.d(t,{Re:()=>i,gF:()=>o,q4:()=>n});const n="1.236.0",i="PROD",o="CDN"},385:(e,t,r)=>{r.d(t,{FN:()=>a,IF:()=>u,Nk:()=>f,Tt:()=>s,_A:()=>o,il:()=>n,pL:()=>c,v6:()=>i,w1:()=>d});const n="undefined"!=typeof window&&!!window.document,i="undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self.navigator instanceof WorkerNavigator||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis.navigator instanceof WorkerNavigator),o=n?window:"undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis),a=""+o?.location,s=/iPad|iPhone|iPod/.test(navigator.userAgent),c=s&&"undefined"==typeof SharedWorker,u=(()=>{const e=navigator.userAgent.match(/Firefox[/\s](\d+\.\d+)/);return Array.isArray(e)&&e.length>=2?+e[1]:0})(),d=Boolean(n&&window.document.documentMode),f=!!navigator.sendBeacon},1117:(e,t,r)=>{r.d(t,{w:()=>o});var n=r(50);const i={agentIdentifier:"",ee:void 0};class o{constructor(e){try{if("object"!=typeof e)return(0,n.Z)("shared context requires an object as input");this.sharedContext={},Object.assign(this.sharedContext,i),Object.entries(e).forEach((e=>{let[t,r]=e;Object.keys(i).includes(t)&&(this.sharedContext[t]=r)}))}catch(e){(0,n.Z)("An error occured while setting SharedContext",e)}}}},8e3:(e,t,r)=>{r.d(t,{L:()=>d,R:()=>c});var n=r(2177),i=r(1284),o=r(4322),a=r(3325);const s={};function c(e,t){const r={staged:!1,priority:a.p[t]||0};u(e),s[e].get(t)||s[e].set(t,r)}function u(e){e&&(s[e]||(s[e]=new Map))}function d(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:"",t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:"feature";if(u(e),!e||!s[e].get(t))return a(t);s[e].get(t).staged=!0;const r=[...s[e]];function a(t){const r=e?n.ee.get(e):n.ee,a=o.X.handlers;if(r.backlog&&a){var s=r.backlog[t],c=a[t];if(c){for(var u=0;s&&u {let[t,r]=e;return r.staged}))&&(r.sort(((e,t)=>e[1].priority-t[1].priority)),r.forEach((e=>{let[t]=e;a(t)})))}function f(e,t){var r=e[1];(0,i.D)(t[r],(function(t,r){var n=e[0];if(r[0]===n){var i=r[1],o=e[3],a=e[2];i.apply(o,a)}}))}},2177:(e,t,r)=>{r.d(t,{c:()=>f,ee:()=>u});var n=r(8632),i=r(2210),o=r(1284),a=r(5763),s="nr@context";let c=(0,n.fP)();var u;function d(){}function f(e){return(0,i.X)(e,s,l)}function l(){return new d}function h(){u.aborted=!0,u.backlog={}}c.ee?u=c.ee:(u=function e(t,r){var n={},c={},f={},g=!1;try{g=16===r.length&&(0,a.OP)(r).isolatedBacklog}catch(e){}var p={on:b,addEventListener:b,removeEventListener:y,emit:v,get:x,listeners:w,context:m,buffer:A,abort:h,aborted:!1,isBuffering:E,debugId:r,backlog:g?{}:t&&"object"==typeof t.backlog?t.backlog:{}};return p;function m(e){return e&&e instanceof d?e:e?(0,i.X)(e,s,l):l()}function v(e,r,n,i,o){if(!1!==o&&(o=!0),!u.aborted||i){t&&o&&t.emit(e,r,n);for(var a=m(n),s=w(e),d=s.length,f=0;fn,p:()=>i});var n=r(2177).ee.get("handle");function i(e,t,r,i,o){o?(o.buffer([e],i),o.emit(e,t,r)):(n.buffer([e],i),n.emit(e,t,r))}},4322:(e,t,r)=>{r.d(t,{X:()=>o});var n=r(5546);o.on=a;var i=o.handlers={};function o(e,t,r,o){a(o||n.E,i,e,t,r)}function a(e,t,r,i,o){o||(o="feature"),e||(e=n.E);var a=t[o]=t[o]||{};(a[r]=a[r]||[]).push([e,i])}},3239:(e,t,r)=>{r.d(t,{bP:()=>s,iz:()=>c,m$:()=>a});var n=r(385);let i=!1,o=!1;try{const e={get passive(){return i=!0,!1},get signal(){return o=!0,!1}};n._A.addEventListener("test",null,e),n._A.removeEventListener("test",null,e)}catch(e){}function a(e,t){return i||o?{capture:!!e,passive:i,signal:t}:!!e}function s(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;window.addEventListener(e,t,a(r,n))}function c(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;document.addEventListener(e,t,a(r,n))}},4402:(e,t,r)=>{r.d(t,{Ht:()=>u,M:()=>c,Rl:()=>a,ky:()=>s});var n=r(385);const i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx";function o(e,t){return e?15&e[t]:16*Math.random()|0}function a(){const e=n._A?.crypto||n._A?.msCrypto;let t,r=0;return e&&e.getRandomValues&&(t=e.getRandomValues(new Uint8Array(31))),i.split("").map((e=>"x"===e?o(t,++r).toString(16):"y"===e?(3&o()|8).toString(16):e)).join("")}function s(e){const t=n._A?.crypto||n._A?.msCrypto;let r,i=0;t&&t.getRandomValues&&(r=t.getRandomValues(new Uint8Array(31)));const a=[];for(var s=0;s {r.d(t,{Bq:()=>n,Hb:()=>o,oD:()=>i});const n="NRBA",i=144e5,o=18e5},7894:(e,t,r)=>{function n(){return Math.round(performance.now())}r.d(t,{z:()=>n})},7243:(e,t,r)=>{r.d(t,{e:()=>o});var n=r(385),i={};function o(e){if(e in i)return i[e];if(0===(e||"").indexOf("data:"))return{protocol:"data"};let t;var r=n._A?.location,o={};if(n.il)t=document.createElement("a"),t.href=e;else try{t=new URL(e,r.href)}catch(e){return o}o.port=t.port;var a=t.href.split("://");!o.port&&a[1]&&(o.port=a[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===a[0]?"443":"80"),o.hostname=t.hostname||r.hostname,o.pathname=t.pathname,o.protocol=a[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var s=!t.protocol||":"===t.protocol||t.protocol===r.protocol,c=t.hostname===r.hostname&&t.port===r.port;return o.sameOrigin=s&&(!t.hostname||c),"/"===o.pathname&&(i[e]=o),o}},50:(e,t,r)=>{function n(e,t){"function"==typeof console.warn&&(console.warn("New Relic: ".concat(e)),t&&console.warn(t))}r.d(t,{Z:()=>n})},2587:(e,t,r)=>{r.d(t,{N:()=>c,T:()=>u});var n=r(2177),i=r(5546),o=r(8e3),a=r(3325);const s={stn:[a.D.sessionTrace],err:[a.D.jserrors,a.D.metrics],ins:[a.D.pageAction],spa:[a.D.spa],sr:[a.D.sessionReplay,a.D.sessionTrace]};function c(e,t){const r=n.ee.get(t);e&&"object"==typeof e&&(Object.entries(e).forEach((e=>{let[t,n]=e;void 0===u[t]&&(s[t]?s[t].forEach((e=>{n?(0,i.p)("feat-"+t,[],void 0,e,r):(0,i.p)("block-"+t,[],void 0,e,r),(0,i.p)("rumresp-"+t,[Boolean(n)],void 0,e,r)})):n&&(0,i.p)("feat-"+t,[],void 0,void 0,r),u[t]=Boolean(n))})),Object.keys(s).forEach((e=>{void 0===u[e]&&(s[e]?.forEach((t=>(0,i.p)("rumresp-"+e,[!1],void 0,t,r))),u[e]=!1)})),(0,o.L)(t,a.D.pageViewEvent))}const u={}},2210:(e,t,r)=>{r.d(t,{X:()=>i});var n=Object.prototype.hasOwnProperty;function i(e,t,r){if(n.call(e,t))return e[t];var i=r();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(e,t,{value:i,writable:!0,enumerable:!1}),i}catch(e){}return e[t]=i,i}},1284:(e,t,r)=>{r.d(t,{D:()=>n});const n=(e,t)=>Object.entries(e||{}).map((e=>{let[r,n]=e;return t(r,n)}))},4351:(e,t,r)=>{r.d(t,{P:()=>o});var n=r(2177);const i=()=>{const e=new WeakSet;return(t,r)=>{if("object"==typeof r&&null!==r){if(e.has(r))return;e.add(r)}return r}};function o(e){try{return JSON.stringify(e,i())}catch(e){try{n.ee.emit("internal-error",[e])}catch(e){}}}},3960:(e,t,r)=>{r.d(t,{K:()=>a,b:()=>o});var n=r(3239);function i(){return"undefined"==typeof document||"complete"===document.readyState}function o(e,t){if(i())return e();(0,n.bP)("load",e,t)}function a(e){if(i())return e();(0,n.iz)("DOMContentLoaded",e)}},8632:(e,t,r)=>{r.d(t,{EZ:()=>u,Qy:()=>c,ce:()=>o,fP:()=>a,gG:()=>d,mF:()=>s});var n=r(7894),i=r(385);const o={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net"};function a(){return i._A.NREUM||(i._A.NREUM={}),void 0===i._A.newrelic&&(i._A.newrelic=i._A.NREUM),i._A.NREUM}function s(){let e=a();return e.o||(e.o={ST:i._A.setTimeout,SI:i._A.setImmediate,CT:i._A.clearTimeout,XHR:i._A.XMLHttpRequest,REQ:i._A.Request,EV:i._A.Event,PR:i._A.Promise,MO:i._A.MutationObserver,FETCH:i._A.fetch}),e}function c(e,t,r){let i=a();const o=i.initializedAgents||{},s=o[e]||{};return Object.keys(s).length||(s.initializedAt={ms:(0,n.z)(),date:new Date}),i.initializedAgents={...o,[e]:{...s,[r]:t}},i}function u(e,t){a()[e]=t}function d(){return function(){let e=a();const t=e.info||{};e.info={beacon:o.beacon,errorBeacon:o.errorBeacon,...t}}(),function(){let e=a();const t=e.init||{};e.init={...t}}(),s(),function(){let e=a();const t=e.loader_config||{};e.loader_config={...t}}(),a()}},7956:(e,t,r)=>{r.d(t,{N:()=>i});var n=r(3239);function i(e){let t=arguments.length>1&&void 0!==arguments[1]&&arguments[1],r=arguments.length>2?arguments[2]:void 0,i=arguments.length>3?arguments[3]:void 0;return void(0,n.iz)("visibilitychange",(function(){if(t)return void("hidden"==document.visibilityState&&e());e(document.visibilityState)}),r,i)}},1214:(e,t,r)=>{r.d(t,{em:()=>v,u5:()=>N,QU:()=>S,_L:()=>I,Gm:()=>L,Lg:()=>M,gy:()=>U,BV:()=>Q,Kf:()=>ee});var n=r(2177);const i="nr@original";var o=Object.prototype.hasOwnProperty,a=!1;function s(e,t){return e||(e=n.ee),r.inPlace=function(e,t,n,i,o){n||(n="");var a,s,c,u="-"===n.charAt(0);for(c=0;c 2?n-2:0),o=2;o {r(A[T],e,w),r(E[T],e,w)})),r(l._A,"fetch",y),t.on(y+"end",(function(e,r){var n=this;if(r){var i=r.headers.get("content-length");null!==i&&(n.rxSize=i),t.emit(y+"done",[null,r],n)}else t.emit(y+"done",[e],n)})),t}const O={},j=["pushState","replaceState"];function S(e){const t=function(e){return(e||n.ee).get("history")}(e);return!l.il||O[t.debugId]++||(O[t.debugId]=1,s(t).inPlace(window.history,j,"-")),t}var P=r(3239);const C={},R=["appendChild","insertBefore","replaceChild"];function I(e){const t=function(e){return(e||n.ee).get("jsonp")}(e);if(!l.il||C[t.debugId])return t;C[t.debugId]=!0;var r=s(t),i=/[?&](?:callback|cb)=([^&#]+)/,o=/(.*)\.([^.]+)/,a=/^(\w+)(\.|$)(.*)$/;function c(e,t){var r=e.match(a),n=r[1],i=r[3];return i?c(i,t[n]):t[n]}return r.inPlace(Node.prototype,R,"dom-"),t.on("dom-start",(function(e){!function(e){if(!e||"string"!=typeof e.nodeName||"script"!==e.nodeName.toLowerCase())return;if("function"!=typeof e.addEventListener)return;var n=(a=e.src,s=a.match(i),s?s[1]:null);var a,s;if(!n)return;var u=function(e){var t=e.match(o);if(t&&t.length>=3)return{key:t[2],parent:c(t[1],window)};return{key:e,parent:window}}(n);if("function"!=typeof u.parent[u.key])return;var d={};function f(){t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}function l(){t.emit("jsonp-error",[],d),t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}r.inPlace(u.parent,[u.key],"cb-",d),e.addEventListener("load",f,(0,P.m$)(!1)),e.addEventListener("error",l,(0,P.m$)(!1)),t.emit("new-jsonp",[e.src],d)}(e[0])})),t}var k=r(5763);const H={};function L(e){const t=function(e){return(e||n.ee).get("mutation")}(e);if(!l.il||H[t.debugId])return t;H[t.debugId]=!0;var r=s(t),i=k.Yu.MO;return i&&(window.MutationObserver=function(e){return this instanceof i?new i(r(e,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype),t}const z={};function M(e){const t=function(e){return(e||n.ee).get("promise")}(e);if(z[t.debugId])return t;z[t.debugId]=!0;var r=n.c,o=s(t),a=k.Yu.PR;return a&&function(){function e(r){var n=t.context(),i=o(r,"executor-",n,null,!1);const s=Reflect.construct(a,[i],e);return t.context(s).getCtx=function(){return n},s}l._A.Promise=e,Object.defineProperty(e,"name",{value:"Promise"}),e.toString=function(){return a.toString()},Object.setPrototypeOf(e,a),["all","race"].forEach((function(r){const n=a[r];e[r]=function(e){let i=!1;[...e||[]].forEach((e=>{this.resolve(e).then(a("all"===r),a(!1))}));const o=n.apply(this,arguments);return o;function a(e){return function(){t.emit("propagate",[null,!i],o,!1,!1),i=i||!e}}}})),["resolve","reject"].forEach((function(r){const n=a[r];e[r]=function(e){const r=n.apply(this,arguments);return e!==r&&t.emit("propagate",[e,!0],r,!1,!1),r}})),e.prototype=a.prototype;const n=a.prototype.then;a.prototype.then=function(){var e=this,i=r(e);i.promise=e;for(var a=arguments.length,s=new Array(a),c=0;c e())),t};function m(e,t){i.inPlace(t,["onreadystatechange"],"fn-",E)}function b(){var e=this,t=r.context(e);e.readyState>3&&!t.resolved&&(t.resolved=!0,r.emit("xhr-resolved",[],e)),i.inPlace(e,f,"fn-",E)}if(function(e,t){for(var r in e)t[r]=e[r]}(o,p),p.prototype=o.prototype,i.inPlace(p.prototype,J,"-xhr-",E),r.on("send-xhr-start",(function(e,t){m(e,t),function(e){h.push(e),a&&(y?y.then(A):u?u(A):(w=-w,x.data=w))}(t)})),r.on("open-xhr-start",m),a){var y=c&&c.resolve();if(!u&&!c){var w=1,x=document.createTextNode(w);new a(A).observe(x,{characterData:!0})}}else t.on("fn-end",(function(e){e[0]&&e[0].type===d||A()}));function A(){for(var e=0;e {r.d(t,{t:()=>n});const n=r(3325).D.ajax},6660:(e,t,r)=>{r.d(t,{A:()=>i,t:()=>n});const n=r(3325).D.jserrors,i="nr@seenError"},3081:(e,t,r)=>{r.d(t,{gF:()=>o,mY:()=>i,t9:()=>n,vz:()=>s,xS:()=>a});const n=r(3325).D.metrics,i="sm",o="cm",a="storeSupportabilityMetrics",s="storeEventMetrics"},4649:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageAction},7633:(e,t,r)=>{r.d(t,{Dz:()=>i,OJ:()=>a,qw:()=>o,t9:()=>n});const n=r(3325).D.pageViewEvent,i="firstbyte",o="domcontent",a="windowload"},9251:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageViewTiming},3614:(e,t,r)=>{r.d(t,{BST_RESOURCE:()=>i,END:()=>s,FEATURE_NAME:()=>n,FN_END:()=>u,FN_START:()=>c,PUSH_STATE:()=>d,RESOURCE:()=>o,START:()=>a});const n=r(3325).D.sessionTrace,i="bstResource",o="resource",a="-start",s="-end",c="fn"+a,u="fn"+s,d="pushState"},7836:(e,t,r)=>{r.d(t,{BODY:()=>A,CB_END:()=>E,CB_START:()=>u,END:()=>x,FEATURE_NAME:()=>i,FETCH:()=>_,FETCH_BODY:()=>v,FETCH_DONE:()=>m,FETCH_START:()=>p,FN_END:()=>c,FN_START:()=>s,INTERACTION:()=>l,INTERACTION_API:()=>d,INTERACTION_EVENTS:()=>o,JSONP_END:()=>b,JSONP_NODE:()=>g,JS_TIME:()=>T,MAX_TIMER_BUDGET:()=>a,REMAINING:()=>f,SPA_NODE:()=>h,START:()=>w,originalSetTimeout:()=>y});var n=r(5763);const i=r(3325).D.spa,o=["click","submit","keypress","keydown","keyup","change"],a=999,s="fn-start",c="fn-end",u="cb-start",d="api-ixn-",f="remaining",l="interaction",h="spaNode",g="jsonpNode",p="fetch-start",m="fetch-done",v="fetch-body-",b="jsonp-end",y=n.Yu.ST,w="-start",x="-end",A="-body",E="cb"+x,T="jsTime",_="fetch"},5938:(e,t,r)=>{r.d(t,{W:()=>o});var n=r(5763),i=r(2177);class o{constructor(e,t,r){this.agentIdentifier=e,this.aggregator=t,this.ee=i.ee.get(e,(0,n.OP)(this.agentIdentifier).isolatedBacklog),this.featureName=r,this.blocked=!1}}},9144:(e,t,r)=>{r.d(t,{j:()=>m});var n=r(3325),i=r(5763),o=r(5546),a=r(2177),s=r(7894),c=r(8e3),u=r(3960),d=r(385),f=r(50),l=r(3081),h=r(8632);function g(){const e=(0,h.gG)();["setErrorHandler","finished","addToTrace","inlineHit","addRelease","addPageAction","setCurrentRouteName","setPageViewName","setCustomAttribute","interaction","noticeError","setUserId"].forEach((t=>{e[t]=function(){for(var r=arguments.length,n=new Array(r),i=0;i 1?r-1:0),i=1;i {e.exposed&&e.api[t]&&o.push(e.api[t](...n))})),o.length>1?o:o[0]}(t,...n)}}))}var p=r(2587);function m(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:{},m=arguments.length>2?arguments[2]:void 0,v=arguments.length>3?arguments[3]:void 0,{init:b,info:y,loader_config:w,runtime:x={loaderType:m},exposed:A=!0}=t;const E=(0,h.gG)();y||(b=E.init,y=E.info,w=E.loader_config),(0,i.Dg)(e,b||{}),(0,i.GE)(e,w||{}),(0,i.sU)(e,x),y.jsAttributes??={},d.v6&&(y.jsAttributes.isWorker=!0),(0,i.CX)(e,y),g();const T=function(e,t){t||(0,c.R)(e,"api");const h={};var g=a.ee.get(e),p=g.get("tracer"),m="api-",v=m+"ixn-";function b(t,r,n,o){const a=(0,i.C5)(e);return null===r?delete a.jsAttributes[t]:(0,i.CX)(e,{...a,jsAttributes:{...a.jsAttributes,[t]:r}}),x(m,n,!0,o||null===r?"session":void 0)(t,r)}function y(){}["setErrorHandler","finished","addToTrace","inlineHit","addRelease"].forEach((e=>h[e]=x(m,e,!0,"api"))),h.addPageAction=x(m,"addPageAction",!0,n.D.pageAction),h.setCurrentRouteName=x(m,"routeName",!0,n.D.spa),h.setPageViewName=function(t,r){if("string"==typeof t)return"/"!==t.charAt(0)&&(t="/"+t),(0,i.OP)(e).customTransaction=(r||"http://custom.transaction")+t,x(m,"setPageViewName",!0)()},h.setCustomAttribute=function(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2];if("string"==typeof e){if(["string","number"].includes(typeof t)||null===t)return b(e,t,"setCustomAttribute",r);(0,f.Z)("Failed to execute setCustomAttribute.\nNon-null value must be a string or number type, but a type of was provided."))}else(0,f.Z)("Failed to execute setCustomAttribute.\nName must be a string type, but a type of was provided."))},h.setUserId=function(e){if("string"==typeof e||null===e)return b("enduser.id",e,"setUserId",!0);(0,f.Z)("Failed to execute setUserId.\nNon-null value must be a string type, but a type of was provided."))},h.interaction=function(){return(new y).get()};var w=y.prototype={createTracer:function(e,t){var r={},i=this,a="function"==typeof t;return(0,o.p)(v+"tracer",[(0,s.z)(),e,r],i,n.D.spa,g),function(){if(p.emit((a?"":"no-")+"fn-start",[(0,s.z)(),i,a],r),a)try{return t.apply(this,arguments)}catch(e){throw p.emit("fn-err",[arguments,this,"string"==typeof e?new Error(e):e],r),e}finally{p.emit("fn-end",[(0,s.z)()],r)}}}};function x(e,t,r,i){return function(){return(0,o.p)(l.xS,["API/"+t+"/called"],void 0,n.D.metrics,g),i&&(0,o.p)(e+t,[(0,s.z)(),...arguments],r?null:this,i,g),r?void 0:this}}function A(){r.e(439).then(r.bind(r,7438)).then((t=>{let{setAPI:r}=t;r(e),(0,c.L)(e,"api")})).catch((()=>(0,f.Z)("Downloading runtime APIs failed...")))}return["actionText","setName","setAttribute","save","ignore","onEnd","getContext","end","get"].forEach((e=>{w[e]=x(v,e,void 0,n.D.spa)})),h.noticeError=function(e,t){"string"==typeof e&&(e=new Error(e)),(0,o.p)(l.xS,["API/noticeError/called"],void 0,n.D.metrics,g),(0,o.p)("err",[e,(0,s.z)(),!1,t],void 0,n.D.jserrors,g)},d.il?(0,u.b)((()=>A()),!0):A(),h}(e,v);return(0,h.Qy)(e,T,"api"),(0,h.Qy)(e,A,"exposed"),(0,h.EZ)("activatedFeatures",p.T),T}},3325:(e,t,r)=>{r.d(t,{D:()=>n,p:()=>i});const n={ajax:"ajax",jserrors:"jserrors",metrics:"metrics",pageAction:"page_action",pageViewEvent:"page_view_event",pageViewTiming:"page_view_timing",sessionReplay:"session_replay",sessionTrace:"session_trace",spa:"spa"},i={[n.pageViewEvent]:1,[n.pageViewTiming]:2,[n.metrics]:3,[n.jserrors]:4,[n.ajax]:5,[n.sessionTrace]:6,[n.pageAction]:7,[n.spa]:8,[n.sessionReplay]:9}}},n={};function i(e){var t=n[e];if(void 0!==t)return t.exports;var o=n[e]={exports:{}};return r[e](o,o.exports,i),o.exports}i.m=r,i.d=(e,t)=>{for(var r in t)i.o(t,r)&&!i.o(e,r)&&Object.defineProperty(e,r,{enumerable:!0,get:t[r]})},i.f={},i.e=e=>Promise.all(Object.keys(i.f).reduce(((t,r)=>(i.f[r](e,t),t)),[])),i.u=e=>(({78:"page_action-aggregate",147:"metrics-aggregate",242:"session-manager",317:"jserrors-aggregate",348:"page_view_timing-aggregate",412:"lazy-feature-loader",439:"async-api",538:"recorder",590:"session_replay-aggregate",675:"compressor",733:"session_trace-aggregate",786:"page_view_event-aggregate",873:"spa-aggregate",898:"ajax-aggregate"}[e]||e)+"."+{78:"ac76d497",147:"3dc53903",148:"1a20d5fe",242:"2a64278a",317:"49e41428",348:"bd6de33a",412:"2f55ce66",439:"30bd804e",538:"1b18459f",590:"cf0efb30",675:"ae9f91a8",733:"83105561",786:"06482edd",860:"03a8b7a5",873:"e6b09d52",898:"998ef92b"}[e]+"-1.236.0.min.js"),i.o=(e,t)=>Object.prototype.hasOwnProperty.call(e,t),e={},t="NRBA:",i.l=(r,n,o,a)=>{if(e[r])e[r].push(n);else{var s,c;if(void 0!==o)for(var u=document.getElementsByTagName("script"),d=0;d {s.onerror=s.onload=null,clearTimeout(h);var i=e[r];if(delete e[r],s.parentNode&&s.parentNode.removeChild(s),i&&i.forEach((e=>e(n))),t)return t(n)},h=setTimeout(l.bind(null,void 0,{type:"timeout",target:s}),12e4);s.onerror=l.bind(null,s.onerror),s.onload=l.bind(null,s.onload),c&&document.head.appendChild(s)}},i.r=e=>{"undefined"!=typeof Symbol&&Symbol.toStringTag&&Object.defineProperty(e,Symbol.toStringTag,{value:"Module"}),Object.defineProperty(e,"__esModule",{value:!0})},i.j=364,i.p="https://js-agent.newrelic.com/",(()=>{var e={364:0,953:0};i.f.j=(t,r)=>{var n=i.o(e,t)?e[t]:void 0;if(0!==n)if(n)r.push(n[2]);else{var o=new Promise(((r,i)=>n=e[t]=[r,i]));r.push(n[2]=o);var a=i.p+i.u(t),s=new Error;i.l(a,(r=>{if(i.o(e,t)&&(0!==(n=e[t])&&(e[t]=void 0),n)){var o=r&&("load"===r.type?"missing":r.type),a=r&&r.target&&r.target.src;s.message="Loading chunk "+t+" failed.\n("+o+": "+a+")",s.name="ChunkLoadError",s.type=o,s.request=a,n[1](s)}}),"chunk-"+t,t)}};var t=(t,r)=>{var n,o,[a,s,c]=r,u=0;if(a.some((t=>0!==e[t]))){for(n in s)i.o(s,n)&&(i.m[n]=s[n]);if(c)c(i)}for(t&&t(r);u {i.r(o);var e=i(3325),t=i(5763);const r=Object.values(e.D);function n(e){const n={};return r.forEach((r=>{n[r]=function(e,r){return!1!==(0,t.Mt)(r,"".concat(e,".enabled"))}(r,e)})),n}var a=i(9144);var s=i(5546),c=i(385),u=i(8e3),d=i(5938),f=i(3960),l=i(50);class h extends d.W{constructor(e,t,r){let n=!(arguments.length>3&&void 0!==arguments[3])||arguments[3];super(e,t,r),this.auto=n,this.abortHandler,this.featAggregate,this.onAggregateImported,n&&(0,u.R)(e,r)}importAggregator(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:{};if(this.featAggregate||!this.auto)return;const r=c.il&&!0===(0,t.Mt)(this.agentIdentifier,"privacy.cookies_enabled");let n;this.onAggregateImported=new Promise((e=>{n=e}));const o=async()=>{let t;try{if(r){const{setupAgentSession:e}=await Promise.all([i.e(860),i.e(242)]).then(i.bind(i,3228));t=e(this.agentIdentifier)}}catch(e){(0,l.Z)("A problem occurred when starting up session manager. This page will not start or extend any session.",e)}try{if(!this.shouldImportAgg(this.featureName,t))return void(0,u.L)(this.agentIdentifier,this.featureName);const{lazyFeatureLoader:r}=await i.e(412).then(i.bind(i,8582)),{Aggregate:o}=await r(this.featureName,"aggregate");this.featAggregate=new o(this.agentIdentifier,this.aggregator,e),n(!0)}catch(e){(0,l.Z)("Downloading and initializing ".concat(this.featureName," failed..."),e),this.abortHandler?.(),n(!1)}};c.il?(0,f.b)((()=>o()),!0):o()}shouldImportAgg(r,n){return r!==e.D.sessionReplay||!1!==(0,t.Mt)(this.agentIdentifier,"session_trace.enabled")&&(!!n?.isNew||!!n?.state.sessionReplay)}}var g=i(7633),p=i(7894);class m extends h{static featureName=g.t9;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];if(super(r,n,g.t9,i),("undefined"==typeof PerformanceNavigationTiming||c.Tt)&&"undefined"!=typeof PerformanceTiming){const n=(0,t.OP)(r);n[g.Dz]=Math.max(Date.now()-n.offset,0),(0,f.K)((()=>n[g.qw]=Math.max((0,p.z)()-n[g.Dz],0))),(0,f.b)((()=>{const t=(0,p.z)();n[g.OJ]=Math.max(t-n[g.Dz],0),(0,s.p)("timing",["load",t],void 0,e.D.pageViewTiming,this.ee)}))}this.importAggregator()}}var v=i(1117),b=i(1284);class y extends v.w{constructor(e){super(e),this.aggregatedData={}}store(e,t,r,n,i){var o=this.getBucket(e,t,r,i);return o.metrics=function(e,t){t||(t={count:0});return t.count+=1,(0,b.D)(e,(function(e,r){t[e]=w(r,t[e])})),t}(n,o.metrics),o}merge(e,t,r,n,i){var o=this.getBucket(e,t,n,i);if(o.metrics){var a=o.metrics;a.count+=r.count,(0,b.D)(r,(function(e,t){if("count"!==e){var n=a[e],i=r[e];i&&!i.c?a[e]=w(i.t,n):a[e]=function(e,t){if(!t)return e;t.c||(t=x(t.t));return t.min=Math.min(e.min,t.min),t.max=Math.max(e.max,t.max),t.t+=e.t,t.sos+=e.sos,t.c+=e.c,t}(i,a[e])}}))}else o.metrics=r}storeMetric(e,t,r,n){var i=this.getBucket(e,t,r);return i.stats=w(n,i.stats),i}getBucket(e,t,r,n){this.aggregatedData[e]||(this.aggregatedData[e]={});var i=this.aggregatedData[e][t];return i||(i=this.aggregatedData[e][t]={params:r||{}},n&&(i.custom=n)),i}get(e,t){return t?this.aggregatedData[e]&&this.aggregatedData[e][t]:this.aggregatedData[e]}take(e){for(var t={},r="",n=!1,i=0;i t.max&&(t.max=e),e 2&&void 0!==arguments[2])||arguments[2];super(e,r,j.t,n),c.il&&((0,t.OP)(e).initHidden=Boolean("hidden"===document.visibilityState),(0,N.N)((()=>(0,s.p)("docHidden",[(0,p.z)()],void 0,j.t,this.ee)),!0),(0,O.bP)("pagehide",(()=>(0,s.p)("winPagehide",[(0,p.z)()],void 0,j.t,this.ee))),this.importAggregator())}}var P=i(3081);class C extends h{static featureName=P.t9;constructor(e,t){let r=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(e,t,P.t9,r),this.importAggregator()}}var R,I=i(2210),k=i(1214),H=i(2177),L={};try{R=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(L.console=!0,-1!==R.indexOf("dev")&&(L.dev=!0),-1!==R.indexOf("nr_dev")&&(L.nrDev=!0))}catch(e){}function z(e){try{L.console&&z(e)}catch(e){}}L.nrDev&&H.ee.on("internal-error",(function(e){z(e.stack)})),L.dev&&H.ee.on("fn-err",(function(e,t,r){z(r.stack)})),L.dev&&(z("NR AGENT IN DEVELOPMENT MODE"),z("flags: "+(0,b.D)(L,(function(e,t){return e})).join(", ")));var M=i(6660);class B extends h{static featureName=M.t;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(r,n,M.t,i),this.skipNext=0;try{this.removeOnAbort=new AbortController}catch(e){}const o=this;o.ee.on("fn-start",(function(e,t,r){o.abortHandler&&(o.skipNext+=1)})),o.ee.on("fn-err",(function(t,r,n){o.abortHandler&&!n[M.A]&&((0,I.X)(n,M.A,(function(){return!0})),this.thrown=!0,(0,s.p)("err",[n,(0,p.z)()],void 0,e.D.jserrors,o.ee))})),o.ee.on("fn-end",(function(){o.abortHandler&&!this.thrown&&o.skipNext>0&&(o.skipNext-=1)})),o.ee.on("internal-error",(function(t){(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,o.ee)})),this.origOnerror=c._A.onerror,c._A.onerror=this.onerrorHandler.bind(this),c._A.addEventListener("unhandledrejection",(t=>{const r=function(e){let t="Unhandled Promise Rejection: ";if(e instanceof Error)try{return e.message=t+e.message,e}catch(t){return e}if(void 0===e)return new Error(t);try{return new Error(t+(0,D.P)(e))}catch(e){return new Error(t)}}(t.reason);(0,s.p)("err",[r,(0,p.z)(),!1,{unhandledPromiseRejection:1}],void 0,e.D.jserrors,this.ee)}),(0,O.m$)(!1,this.removeOnAbort?.signal)),(0,k.gy)(this.ee),(0,k.BV)(this.ee),(0,k.em)(this.ee),(0,t.OP)(r).xhrWrappable&&(0,k.Kf)(this.ee),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}onerrorHandler(t,r,n,i,o){"function"==typeof this.origOnerror&&this.origOnerror(...arguments);try{this.skipNext?this.skipNext-=1:(0,s.p)("err",[o||new F(t,r,n),(0,p.z)()],void 0,e.D.jserrors,this.ee)}catch(t){try{(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,this.ee)}catch(e){}}return!1}}function F(e,t,r){this.message=e||"Uncaught error with no additional information",this.sourceURL=t,this.line=r}let U=1;const q="nr@id";function G(e){const t=typeof e;return!e||"object"!==t&&"function"!==t?-1:e===c._A?0:(0,I.X)(e,q,(function(){return U++}))}function V(e){if("string"==typeof e&&e.length)return e.length;if("object"==typeof e){if("undefined"!=typeof ArrayBuffer&&e instanceof ArrayBuffer&&e.byteLength)return e.byteLength;if("undefined"!=typeof Blob&&e instanceof Blob&&e.size)return e.size;if(!("undefined"!=typeof FormData&&e instanceof FormData))try{return(0,D.P)(e).length}catch(e){return}}}var X=i(7243);class W{constructor(e){this.agentIdentifier=e,this.generateTracePayload=this.generateTracePayload.bind(this),this.shouldGenerateTrace=this.shouldGenerateTrace.bind(this)}generateTracePayload(e){if(!this.shouldGenerateTrace(e))return null;var r=(0,t.DL)(this.agentIdentifier);if(!r)return null;var n=(r.accountID||"").toString()||null,i=(r.agentID||"").toString()||null,o=(r.trustKey||"").toString()||null;if(!n||!i)return null;var a=(0,_.M)(),s=(0,_.Ht)(),c=Date.now(),u={spanId:a,traceId:s,timestamp:c};return(e.sameOrigin||this.isAllowedOrigin(e)&&this.useTraceContextHeadersForCors())&&(u.traceContextParentHeader=this.generateTraceContextParentHeader(a,s),u.traceContextStateHeader=this.generateTraceContextStateHeader(a,c,n,i,o)),(e.sameOrigin&&!this.excludeNewrelicHeader()||!e.sameOrigin&&this.isAllowedOrigin(e)&&this.useNewrelicHeaderForCors())&&(u.newrelicHeader=this.generateTraceHeader(a,s,c,n,i,o)),u}generateTraceContextParentHeader(e,t){return"00-"+t+"-"+e+"-01"}generateTraceContextStateHeader(e,t,r,n,i){return i+"@nr=0-1-"+r+"-"+n+"-"+e+"----"+t}generateTraceHeader(e,t,r,n,i,o){if(!("function"==typeof c._A?.btoa))return null;var a={v:[0,1],d:{ty:"Browser",ac:n,ap:i,id:e,tr:t,ti:r}};return o&&n!==o&&(a.d.tk=o),btoa((0,D.P)(a))}shouldGenerateTrace(e){return this.isDtEnabled()&&this.isAllowedOrigin(e)}isAllowedOrigin(e){var r=!1,n={};if((0,t.Mt)(this.agentIdentifier,"distributed_tracing")&&(n=(0,t.P_)(this.agentIdentifier).distributed_tracing),e.sameOrigin)r=!0;else if(n.allowed_origins instanceof Array)for(var i=0;i 2&&void 0!==arguments[2])||arguments[2];super(r,n,Z.t,i),(0,t.OP)(r).xhrWrappable&&(this.dt=new W(r),this.handler=(e,t,r,n)=>(0,s.p)(e,t,r,n,this.ee),(0,k.u5)(this.ee),(0,k.Kf)(this.ee),function(r,n,i,o){function a(e){var t=this;t.totalCbs=0,t.called=0,t.cbTime=0,t.end=E,t.ended=!1,t.xhrGuids={},t.lastSize=null,t.loadCaptureCalled=!1,t.params=this.params||{},t.metrics=this.metrics||{},e.addEventListener("load",(function(r){_(t,e)}),(0,O.m$)(!1)),c.IF||e.addEventListener("progress",(function(e){t.lastSize=e.loaded}),(0,O.m$)(!1))}function s(e){this.params={method:e[0]},T(this,e[1]),this.metrics={}}function u(e,n){var i=(0,t.DL)(r);i.xpid&&this.sameOrigin&&n.setRequestHeader("X-NewRelic-ID",i.xpid);var a=o.generateTracePayload(this.parsedOrigin);if(a){var s=!1;a.newrelicHeader&&(n.setRequestHeader("newrelic",a.newrelicHeader),s=!0),a.traceContextParentHeader&&(n.setRequestHeader("traceparent",a.traceContextParentHeader),a.traceContextStateHeader&&n.setRequestHeader("tracestate",a.traceContextStateHeader),s=!0),s&&(this.dt=a)}}function d(e,t){var r=this.metrics,i=e[0],o=this;if(r&&i){var a=V(i);a&&(r.txSize=a)}this.startTime=(0,p.z)(),this.listener=function(e){try{"abort"!==e.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==e.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof t.onload)&&"function"==typeof o.end)&&o.end(t)}catch(e){try{n.emit("internal-error",[e])}catch(e){}}};for(var s=0;s 1?e[1]=i:e.push(i)}else e[0]&&e[0].headers&&s(e[0].headers,n)&&(this.dt=n);function s(e,t){var r=!1;return t.newrelicHeader&&(e.set("newrelic",t.newrelicHeader),r=!0),t.traceContextParentHeader&&(e.set("traceparent",t.traceContextParentHeader),t.traceContextStateHeader&&e.set("tracestate",t.traceContextStateHeader),r=!0),r}}function x(e,t){this.params={},this.metrics={},this.startTime=(0,p.z)(),this.dt=t,e.length>=1&&(this.target=e[0]),e.length>=2&&(this.opts=e[1]);var r,n=this.opts||{},i=this.target;"string"==typeof i?r=i:"object"==typeof i&&i instanceof Y?r=i.url:c._A?.URL&&"object"==typeof i&&i instanceof URL&&(r=i.href),T(this,r);var o=(""+(i&&i instanceof Y&&i.method||n.method||"GET")).toUpperCase();this.params.method=o,this.txSize=V(n.body)||0}function A(t,r){var n;this.endTime=(0,p.z)(),this.params||(this.params={}),this.params.status=r?r.status:0,"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var o={txSize:this.txSize,rxSize:n,duration:(0,p.z)()-this.startTime};i("xhr",[this.params,o,this.startTime,this.endTime,"fetch"],this,e.D.ajax)}function E(t){var r=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var o=0;o 2&&void 0!==arguments[2])||arguments[2];super(e,t,we.t,r),this.importAggregator()}}new class{constructor(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:(0,_.ky)(16);c._A?(this.agentIdentifier=t,this.sharedAggregator=new y({agentIdentifier:this.agentIdentifier}),this.features={},this.desiredFeatures=new Set(e.features||[]),this.desiredFeatures.add(m),Object.assign(this,(0,a.j)(this.agentIdentifier,e,e.loaderType||"agent")),this.start()):(0,l.Z)("Failed to initial the agent. Could not determine the runtime environment.")}get config(){return{info:(0,t.C5)(this.agentIdentifier),init:(0,t.P_)(this.agentIdentifier),loader_config:(0,t.DL)(this.agentIdentifier),runtime:(0,t.OP)(this.agentIdentifier)}}start(){const t="features";try{const r=n(this.agentIdentifier),i=[...this.desiredFeatures];i.sort(((t,r)=>e.p[t.featureName]-e.p[r.featureName])),i.forEach((t=>{if(r[t.featureName]||t.featureName===e.D.pageViewEvent){const n=function(t){switch(t){case e.D.ajax:return[e.D.jserrors];case e.D.sessionTrace:return[e.D.ajax,e.D.pageViewEvent];case e.D.sessionReplay:return[e.D.sessionTrace];case e.D.pageViewTiming:return[e.D.pageViewEvent];default:return[]}}(t.featureName);n.every((e=>r[e]))||(0,l.Z)("".concat(t.featureName," is enabled but one or more dependent features has been disabled (").concat((0,D.P)(n),"). This may cause unintended consequences or missing data...")),this.features[t.featureName]=new t(this.agentIdentifier,this.sharedAggregator)}})),(0,T.Qy)(this.agentIdentifier,this.features,t)}catch(e){(0,l.Z)("Failed to initialize all enabled instrument classes (agent aborted) -",e);for(const e in this.features)this.features[e].abortHandler?.();const r=(0,T.fP)();return delete r.initializedAgents[this.agentIdentifier]?.api,delete r.initializedAgents[this.agentIdentifier]?.[t],delete this.sharedAggregator,r.ee?.abort(),delete r.ee?.get(this.agentIdentifier),!1}}}({features:[J,m,S,class extends h{static featureName=oe;constructor(t,r){if(super(t,r,oe,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;const n=this.ee;let i;(0,k.QU)(n),this.eventsEE=(0,k.em)(n),this.eventsEE.on(se,(function(e,t){this.bstStart=(0,p.z)()})),this.eventsEE.on(ae,(function(t,r){(0,s.p)("bst",[t[0],r,this.bstStart,(0,p.z)()],void 0,e.D.sessionTrace,n)})),n.on(ce+ne,(function(e){this.time=(0,p.z)(),this.startPath=location.pathname+location.hash})),n.on(ce+ie,(function(t){(0,s.p)("bstHist",[location.pathname+location.hash,this.startPath,this.time],void 0,e.D.sessionTrace,n)}));try{i=new PerformanceObserver((t=>{const r=t.getEntries();(0,s.p)(te,[r],void 0,e.D.sessionTrace,n)})),i.observe({type:re,buffered:!0})}catch(e){}this.importAggregator({resourceObserver:i})}},C,xe,B,class extends h{static featureName=de;constructor(e,r){if(super(e,r,de,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;if(!(0,t.OP)(e).xhrWrappable)return;try{this.removeOnAbort=new AbortController}catch(e){}let n,i=0;const o=this.ee.get("tracer"),a=(0,k._L)(this.ee),s=(0,k.Lg)(this.ee),u=(0,k.BV)(this.ee),d=(0,k.Kf)(this.ee),f=this.ee.get("events"),l=(0,k.u5)(this.ee),h=(0,k.QU)(this.ee),g=(0,k.Gm)(this.ee);function m(e,t){h.emit("newURL",[""+window.location,t])}function v(){i++,n=window.location.hash,this[ve]=(0,p.z)()}function b(){i--,window.location.hash!==n&&m(0,!0);var e=(0,p.z)();this[pe]=~~this[pe]+e-this[ve],this[ye]=e}function y(e,t){e.on(t,(function(){this[t]=(0,p.z)()}))}this.ee.on(ve,v),s.on(be,v),a.on(be,v),this.ee.on(ye,b),s.on(ge,b),a.on(ge,b),this.ee.buffer([ve,ye,"xhr-resolved"],this.featureName),f.buffer([ve],this.featureName),u.buffer(["setTimeout"+le,"clearTimeout"+fe,ve],this.featureName),d.buffer([ve,"new-xhr","send-xhr"+fe],this.featureName),l.buffer([me+fe,me+"-done",me+he+fe,me+he+le],this.featureName),h.buffer(["newURL"],this.featureName),g.buffer([ve],this.featureName),s.buffer(["propagate",be,ge,"executor-err","resolve"+fe],this.featureName),o.buffer([ve,"no-"+ve],this.featureName),a.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"],this.featureName),y(l,me+fe),y(l,me+"-done"),y(a,"new-jsonp"),y(a,"jsonp-end"),y(a,"cb-start"),h.on("pushState-end",m),h.on("replaceState-end",m),window.addEventListener("hashchange",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("load",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("popstate",(function(){m(0,i>1)}),(0,O.m$)(!0,this.removeOnAbort?.signal)),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}}],loaderType:"spa"})})(),window.NRBA=o})(); window.jQuery || document.write(' ') CKEDITOR_BASEPATH='https://f1000research.com/js/vendor/ckeditor/' window.reactTheme = 'research'; window.MathJax = { CommonHTML: { linebreaks: { automatic: true } }, 'HTML-CSS': { linebreaks: { automatic: true } }, SVG: { linebreaks: { automatic: true } }, AuthorInit: function() { MathJax.Hub.Register.MessageHook('End Process', function () { let timeout = false; // holder for timeout id const delay = 250; // delay after event is "complete" to run callback const reflowMath = function() { const dispFormulas = document.querySelectorAll('.disp-formula.panel'); if (!dispFormulas) { return; } for (const dispFormula of dispFormulas) { const child = dispFormula.querySelector('.MathJax_Preview').nextSibling.firstChild; const isMultiline = MathJax.Hub.getAllJax(dispFormula)[0].root.isMultiline; if (dispFormula.offsetWidth < child.offsetWidth || isMultiline) { MathJax.Hub.Queue(['Rerender', MathJax.Hub, dispFormula]); } } }; window.addEventListener('resize', function() { clearTimeout(timeout); // clear the timeout timeout = setTimeout(reflowMath, delay); // start timing for event "completion" }); }); }, }; if (window.location.hash == '#_=_'){ window.location = window.location.href.split('#')[0] } !function(f,b,e,v,n,t,s){if(f.fbq)return;n=f.fbq=function() {n.callMethod? n.callMethod.apply(n,arguments):n.queue.push(arguments)} ;if(!f._fbq)f._fbq=n; n.push=n;n.loaded=!0;n.version='2.0';n.queue=[];t=b.createElement(e);t.async=!0; t.src=v;s=b.getElementsByTagName(e)[0];s.parentNode.insertBefore(t,s)}(window, document,'script','https://connect.facebook.net/en_US/fbevents.js'); fbq('init', '1641728616063202'); fbq('track', "PixelInitialized", {}); (function(h,o,t,j,a,r){ h.hj=h.hj||function(){(h.hj.q=h.hj.q||[]).push(arguments)}; h._hjSettings={hjid:2318163,hjsv:6}; a=o.getElementsByTagName('head')[0]; r=o.createElement('script');r.async=1; r.src=t+h._hjSettings.hjid+j+h._hjSettings.hjsv; a.appendChild(r); })(window,document,'https://static.hotjar.com/c/hotjar-','.js?sv='); search file_upload Submit your research search menu close search Browse Gateways & Collections How to Publish Submit your Research My Submissions Article Guidelines Article Guidelines (New Versions) Open Data, Software and Code Guidelines Open Data and Accessible Source Materials Guidelines (HSS) Open Data, Software and Code Guidelines (PSE) Prepublication Checks Production Process Posters and Slides Guidelines Document Guidelines Article Processing Charges Peer Review Finding Article Reviewers About How it Works For Reviewers Our Advisors Policies Glossary FAQs For Developers Newsroom Contact My Research Submissions Content and Tracking Alerts My Details Sign In file_upload Submit your research { "@context": "https://schema.org", "@type": "ScholarlyArticle", "mainEntityOfPage": { "@type": "WebPage", "@id": "https://f1000research.com/articles/12-350" }, "headline": "In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a...", "datePublished": "2023-03-30T08:16:55", "dateModified": "2025-08-26T14:29:48", "author": [ { "@type": "Person", "name": "Ibrahim Yawer Anwer" }, { "@type": "Person", "name": "Mohammed Jamal Yawuz" }, { "@type": "Person", "name": "Ali Azeez Al-Jumaili" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Background In healthcare settings, specialists from different fields may follow the most well-known, reliable, and easy-to-understand medical guidelines. This study aimed to determine Iraqi physicians’ adherence to treatment guidelines, to specify which treatment guidelines are utilized for each disease and identify their barriers to follow the guidelines. Methods This was qualitative study including face-to-face interviews with specialist physicians from different disciplines. The interviews were conducted between December 2021 and May 2022 in Kirkuk province, Iraq. The qualitative data generated through interviews was analyzed using thematic analysis. Result The study recruited 48 specialists (27 male and 21 female) from seven medical specialties at two large government hospitals. Most physicians 38 out of 48 (79%) revealed that healthcare settings implement treatment guidelines in more than half of cases. American guideline was the most used among the participating physicians. European and British guidelines and textbooks were also used by some specialties. Unfortunately, most 43 out of 48 (89%) physicians were unaware of Iraqi treatment guideline. Most specialist physicians tended to follow the same international guideline within their respective specialties, exhibiting minimal variation in approach. Their adherence was largely shaped by clinical experience and individual flexibility. Nearly all participating physicians identified key barriers to guideline implementation, including shortages in treatment supplies (46 out of 48; 95%), investigation and laboratory materials (45 out of 48; 93%), and low patient adherence (44 out of 48; 91%). Six out of seven specialties experienced shortage in the essential medications that recommended by the guidelines. Conclusions This study highlights systemic and informational barriers to guideline adherence among Iraqi specialists. Addressing these gaps through targeted dissemination and resource allocation may improve clinical consistency and patient outcomes. Enhancing physician awareness of the Iraqi guidelines should be encouraged. Finally, securing essential medicines in public hospitals is pivotal to adopt evidence-based guidelines effectively. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/12-350/v3", "name": "In-depth assessment of Iraqi physicians' adherence to treatment guidelines..." } } ] } Home Browse In-depth assessment of Iraqi physicians' adherence to treatment guidelines... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Anwer IY, Yawuz MJ and Al-Jumaili AA. In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.12688/f1000research.128233.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] Ibrahim Yawer Anwer 1 , Mohammed Jamal Yawuz 1 , Ali Azeez Al-Jumaili https://orcid.org/0000-0003-4691-0280 1 Ibrahim Yawer Anwer 1 , Mohammed Jamal Yawuz 1 , Ali Azeez Al-Jumaili https://orcid.org/0000-0003-4691-0280 1 PUBLISHED 26 Aug 2025 Author details Author details 1 Clinical Pharmacy Department, University of Baghdad College of Pharmacy, Bab-AlMouadhem, Baghdad, 10047, Iraq Ibrahim Yawer Anwer Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Mohammed Jamal Yawuz Roles: Investigation, Methodology, Project Administration, Supervision, Visualization, Writing – Review & Editing Ali Azeez Al-Jumaili Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Health Services gateway. Abstract Background In healthcare settings, specialists from different fields may follow the most well-known, reliable, and easy-to-understand medical guidelines. This study aimed to determine Iraqi physicians’ adherence to treatment guidelines, to specify which treatment guidelines are utilized for each disease and identify their barriers to follow the guidelines. Methods This was qualitative study including face-to-face interviews with specialist physicians from different disciplines. The interviews were conducted between December 2021 and May 2022 in Kirkuk province, Iraq. The qualitative data generated through interviews was analyzed using thematic analysis. Result The study recruited 48 specialists (27 male and 21 female) from seven medical specialties at two large government hospitals. Most physicians 38 out of 48 (79%) revealed that healthcare settings implement treatment guidelines in more than half of cases. American guideline was the most used among the participating physicians. European and British guidelines and textbooks were also used by some specialties. Unfortunately, most 43 out of 48 (89%) physicians were unaware of Iraqi treatment guideline. Most specialist physicians tended to follow the same international guideline within their respective specialties, exhibiting minimal variation in approach. Their adherence was largely shaped by clinical experience and individual flexibility. Nearly all participating physicians identified key barriers to guideline implementation, including shortages in treatment supplies (46 out of 48; 95%), investigation and laboratory materials (45 out of 48; 93%), and low patient adherence (44 out of 48; 91%). Six out of seven specialties experienced shortage in the essential medications that recommended by the guidelines. Conclusions This study highlights systemic and informational barriers to guideline adherence among Iraqi specialists. Addressing these gaps through targeted dissemination and resource allocation may improve clinical consistency and patient outcomes. Enhancing physician awareness of the Iraqi guidelines should be encouraged. Finally, securing essential medicines in public hospitals is pivotal to adopt evidence-based guidelines effectively. READ ALL READ LESS Keywords Guideline, Adherence, physicians, hospitals, Iraq, qualitative study, Interview. Corresponding Author(s) Ali Azeez Al-Jumaili ( [email protected] ) Close Corresponding author: Ali Azeez Al-Jumaili Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Anwer IY et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Anwer IY, Yawuz MJ and Al-Jumaili AA. In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.12688/f1000research.128233.3 ) First published: 30 Mar 2023, 12 :350 ( https://doi.org/10.12688/f1000research.128233.1 ) Latest published: 26 Aug 2025, 12 :350 ( https://doi.org/10.12688/f1000research.128233.3 ) Revised Amendments from Version 2 We have revised the manuscript in accordance with the comments provided by Dr. Anita Silwal (Reviewer No. 2), having previously addressed the feedback from the other two reviewers. As part of this revision, we introduced a new table (Table 4), updated Table 3, and enhanced the manuscript’s language, clarity, and overall flow. We have revised the manuscript in accordance with the comments provided by Dr. Anita Silwal (Reviewer No. 2), having previously addressed the feedback from the other two reviewers. As part of this revision, we introduced a new table (Table 4), updated Table 3, and enhanced the manuscript’s language, clarity, and overall flow. See the authors' detailed response to the review by Alison H Howie READ REVIEWER RESPONSES Introduction According to the Institute of Medicine, Clinical practice guidelines (CPGs) are systematically developed recommendations based on evidence. 1 Their effective application should enhance the quality of care by reducing treatment discrepancies and incorporating innovations into routine practice. Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal. 2 In general, not much is known about how and why physicians change their practices after learning about a guideline. 3 The Agency for Healthcare Research and Quality (AHRQ) guidelines aim to improve clinical decision-making and standardize care to: 1) improve the health of a substantial number of individuals; 2) decrease clinically significant variations in the processes and services offered by physicians; and 3) decrease clinically relevant variations in the results of health care. 1 Private organizations are advancing on multiple fronts in their efforts to set rules. For example, the American College of Physicians and National Institute for Health and Care Excellence (NICE) (UK) have developed specialty-specific guidelines. 4 Emerging are some coordinating mechanisms, but significant problems persist, including unexplained discrepancies across guidelines, overlooked topics, lack of follow-up and inadequate public sharing of the data, participants, and techniques used to develop sets of guidelines. 1 Physician adherence is crucial for transforming suggestions into improved outcomes. However, physician’s adherence to guidelines is impeded by numerous obstacles. Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice. Even if a physician has the right knowledge and attitude, outside factors may make it hard for them or her to follow through on recommendations. The factors that commonly influence physicians’ adherence to treatment guidelines include resource availability, institutional support, and awareness of guidelines. The criteria are well-known and consist of (i) the strength of the data that led to the real treatment recommendations, (ii) comfort with the suggestions, (iii) the physician’s acceptance of the suggestions, (iv) the expected influence of a treatment action on the condition, (v) the patient demographic, and (vi) organizational factors such as workload and the comfort of the suggestions. 5 , 6 The guidelines aim to support physicians and patients in making informed healthcare decisions by establishing a global strategy for the prevention and control of chronic respiratory diseases—particularly in developing countries. They define patient-centered practices, offer a range of widely accepted methods for diagnosis, treatment, and prevention, and promote enhanced coordination across healthcare programs. 1 They are distinct from traditional literature reviews and textbooks by the specific procedures employed in their preparation, which often involve a group of experts (and, increasingly, patients and care givers) who utilize a systematic approach to find and assess the evidence. The experience of the guideline development group is coupled with evidence from secondary research, often in the form of systematic reviews, to produce a set of clinical practice guidelines. 1 Additionally, clinical guidelines should be distinguished from protocols, opinions, and alternatives, in which a synthesis of the data reveals a range of feasible interventions and the evidence that supports each one. For example, the American Psychological Association’s empirically supported treatment approach. 7 Some CPGs are developed by international bodies (e.g., WHO, NICE), while others are country-specific, such as the Iraqi MOH guidelines for chronic diseases. There is substantial diversity across regional guidelines for a single disease, and as a result, their recommendations are frequently inconsistent. This is largely attributable to the diverse approaches employed to develop these guidelines. Therefore, instruments are required to evaluate the quality of guidelines. 1 The methods of guideline formulation should guarantee that patients treated in accordance with the guidelines will achieve the desired outcomes. The dissemination, implementation, and assessment of practice guidelines will be covered in the final piece of this series. 8 Limited information was available about the adherence of Iraqi physicians to treatment guidelines. Participants of both sexes were included in this study, and their answers were comparable. The objectives of this study were to determine Iraqi physicians’ adherence to treatment guidelines, to specify which treatment guidelines are utilized for each disease and identify their barriers to follow the guidelines. Methods 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. Table 1. Interview guide. Demographic Gender, experience years, specialty, degree and hospital name 1 Do you think the concept of medical guideline is applicable by physicians in Iraqi healthcare setting? 2 Which guideline do you follow in your treatment approach of those diseases? 3 Why do you prefer this guideline in those diseases? 4 Are you aware of Iraqi guideline in those diseases? 5 Are all treatments recommended by the guideline in those diseases available in the MOH essential list or in public hospitals? 6 Which treatments recommended by the guideline in those diseases, but not available in public healthcare settings? 7 Do all specialists in this hospital (healthcare setting) follow the same guideline in treatment of these diseases? 8 Do you impose this treatment guideline on your permanents or rotating physicians? 9 Do you rely totally on this guideline, or you may use more than guideline relying on your experience in treatment of a specific disease? why? 10 Do you follow the same guideline in the public setting and private clinic? 11 What do you consider the most important barriers to your implementation of the guideline in your discipline? Barriers in public settings? In private clinic? Which setting has more flexibility? 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. Results The study recruited 48 specialists (senior physicians) from seven medical specialties (Internal Medicine, Neurology, Cardiology, Rheumatology, Gynecology, Pediatrics, and Nephrology). The participants were 27 (56.3%) male and 21 (43.7%) female. The specialists were from two largest hospitals in the province of Kirkuk (Azadi Teaching Hospital and Kirkuk General Hospital). Their specialist practice experience was 10 years on average and ranged from one to 28 years. The specialists’ academic credentials ranged from High Diploma (14) and MSc (7) to board, clinical degree equivalent to a PhD (27) ( Table 2 ). Table 2. The characteristics of the participating physicians. Physician code Degree/credential Experience years Workplace Gender int1 Consultant 20 College of Medicine/Kirkuk General Hospital Male int2 Consultant 28 College of Medicine/Azadi Teaching Hospital Male int3 High Diploma 28 Kirkuk General Hospital Male int4 Arabic Board 4 Azadi Teaching hospital Male int5 MSc 9 Azadi Teaching hospital Female int6 High diploma 10 Azadi Teaching hospital male int7 Arabic Board 1 Azadi Teaching hospital Female int8 Consultant 24 College of Medicine/Kirkuk General Hospital male int9 Consultant 17 College of Medicine/Kirkuk General Hospital male int10 Arabic Board 20 Azadi Teaching hospital male int11 Board 1 Kirkuk General Hospital Female neu1 Arabic Board 3 Azadi Teaching hospital Male neu2 Arabic Board 2 Azadi Teaching hospital Male neu3 MSc 7 Azadi Teaching hospital Male neu4 MSc 1 Azadi Teaching hospital Male neu5 Arabic Board 3 Kirkuk General Hospital Male neu6 Arabic Board 3 Kirkuk General Hospital Male car1 subspecialty 9 Azadi Teaching hospital Male car2 subspecialty 8 Azadi Teaching hospital Male car3 subspecialty 5 Azadi Teaching hospital Male car4 MSc 6 Azadi Teaching hospital Male car5 subspecialty 5 Azadi Teaching hospital Male rhe1 High Diploma 2 Azadi Teaching hospital Female rhe2 High Diploma 6 Azadi Teaching hospital Female rhe3 High Diploma 25 College of Medicine/Azadi Teaching Hospital Female rhe4 MSc 5 Azadi Teaching hospital Female rhe5 MSc 19 College of Medicine/Azadi Teaching Hospital male rhe6 High Diploma 2 Azadi Teaching hospital Female rhe7 High Diploma 17 Azadi Teaching hospital Female rhe8 High Diploma 1 Azadi Teaching hospital Female gyn1 board 7 College of Medicine/Azadi Teaching Hospital Female gyn2 High Diploma 15 College of Medicine/Azadi Teaching Hospital Female gyn3 High Diploma 12 Azadi Teaching hospital Female gyn4 High Diploma 17 Azadi Teaching hospital Female gyn5 MSc 27 Azadi Teaching hospital Female gyn6 Board 1 Kirkuk General Hospital Female ped1 High Diploma 19 Azadi Teaching hospital male ped2 Board 9 College of Medicine/Azadi Teaching Hospital Female ped3 High Diploma 25 Azadi Teaching hospital Female ped4 Board 10 Kirkuk General Hospital Female ped5 High Diploma 12 Azadi Teaching hospital Female ped6 Board 1 Azadi Teaching hospital Female ped7 Board 20 College of Medicine/Azadi Teaching Hospital Male neph1 Board 2 Azadi Teaching hospital Male neph2 Board 4 Kirkuk General Hospital Male neph3 Board 6 College of Medicine/Azadi Teaching Hospital Male neph4 Board 2 College of Medicine/Azadi Teaching Hospital Male neph5 Board 5 College of Medicine/Azadi Teaching Hospital Male The study’s findings revealed multiple themes ( Table 3 ). Specialists partially adhere to international guidelines (mainly American and European); not all physicians adhere to the same guidelines; essential medicines are unavailable; and most of them are unaware of national guidelines. Table 3. Specialist physicians’ themes, subthemes and example statements. Themes Subthemes Example quotes/statements 1. Partial Implementation of Treatment Guidelines - Estimated adherence to guideline in healthcare settings varies across physicians (≥70%, 50–60%, <50%) - Implementation depends on facility readiness and MOH modifications “Yes, 80% if we follow and obey recommendations.” (Car4) “Not always, according to facilities.” (Int1) “Yes, but only 30–40%.” (Int9) “Yes, if modified by the MOH for our country’s situation — 60%.” (Ped3) 2. Motivations for Guideline Use Ease of use. Based on real world studies. More applicable in our society. Updated. Gives good results/benefits Worldwide use. It has been taught in our post-graduate/specialty program. Required by the MOH “Because it [Nelson] is textbook, easy, updated, more dependable.” (Ped6) “American College of Rheumatology (ACR) is more dependable, evidence-based, and easy for application.” (Rhe2) “American guidelines are easy for our society, more updated, and taught in our post-graduation study.” (Int1) “Royal College of Gynecology is more applicable for our society.” (Gyn4) “Royal College of Gynecology is a worldwide dependable guideline.” (Gyn1) “Nelson textbook and the WHO for GE are more applicable and flexible, and they are obligatory by the MOH.” (Ped1) “GINA for asthma and the WHO for GE get good results, availability of the drugs recommended by guideline, and good compliance by families.” (Ped4) 3. Limited Awareness of National Guidelines - Most (43/48) physicians were unaware of Iraqi treatment guideline. - Perceived lack of official MOH endorsement “I am unaware of, and I think it [Iraqi guideline] is not available.” (Int7) “There is no official guideline obligated by the MOH.” (Int8) “Yes, but it contains a lot of requirements regarding investigations which are not available in hospital.” (Ped3) “For GE, yes — but for asthma, I am not aware of.” (Ped5) 4. Unavailability of Guideline-Recommended Medicines Majority of specialties confirmed unavailability of most guideline-recommended medications. Pediatricians revealed the availability of most guideline-recommended medicines in public hospitals “Most of them [essential medications] are not available.” (Int3,5,9,10,11; Neuro5; Car2; Rhe1,3,6,7; Gyn1,2,4; Neph3). “Most of them [essential medications] are available, yes.” (Ped1,2,3,4,5,7) 5. Inconsistent Guideline Adherence Within Specialties 18 believed that all/most physicians within the same setting/discipline follow the same guideline. 17 believed that not all physicians within the same setting/discipline follow the same guideline. 12 physicians did not know. “I think most of them, yes.” (Int1). “No, every senior physician treats according to his experience and mindset.” (Int7) 6. Hierarchical Enforcement of Guideline Practices - Senior physicians impose guideline preferences on junior staff - Rotating physicians may not always comply Not always due to not all rotators follow instructions. Yes, sure I impose the guideline on the permanent and rotating physicians. 7. Guidelines are the primary reference, supported by clinical experience and textbooks. - Guidelines used alongside clinical experience (32/48). - Some rely on multiple guidelines or external sources (e.g., textbooks, journals) (11/48) “I use a mixture of guideline and self-experience.” (Int2) “No, I use self-experience and other guidelines too.” (Int10) “No, I depend on other guidelines.” (Neu4) “No, many times, we may follow the books, articles in Medline or WebMed, or our college experiences.” (Ped3) “No, I also follow updated articles which are published in high-impact journals.” (Int9) 8. Guideline adherence is perceived to be stronger in private settings. - Majority prefer private sector for guideline adherence (21/48). - Few (only 2) physicians cite public sector advantages “Public settings have more readiness to implement guideline(s) due to governmental supply of investigational and treatment.” (Neph4) “In the public sector, the control of diseases is better.” (Ped4) Partial Implementation of Treatment Guidelines The majority of physicians (38 out of 48; 79%) revealed that treatment guidelines are implemented in less than half of the cases in healthcare settings. “Not always, based on available facilities” (Int1) “Yes, but only by 30-40%” (Int9). International clinical guidelines adopted by Iraqi specialists The American Diabetes Association (ADA) guidelines were most frequently cited, particularly by internal medicine (82%) and gynecology (50%) specialists. AHA/ACC guidelines were used by 55% of internal medicine specialists and all cardiologists. GINA was prominent in pediatrics (71%), internal medicine (45%), and gynecology (33%). Rheumatologists primarily followed ACR (75%), with some referencing EULAR (25%). Neurologists relied entirely on ANA, often supplemented by WHO guidelines (67%), which were also common in pediatrics (71%). Textbook-based approaches were noted in pediatrics (50%) and neurology (33%). All gynecologists used RCOG guidelines, while nephrologists favored AUA (75%) and textbooks (25%) (see Table 4 ). Table 4. The international treatment guidelines used by each medicine specialty in Iraq. Specialty Guideline/Source No. of specialists Used this guideline 1 Internal Medicine (n=11) American Diabetic Association (ADA) 9 American Heart Association (AHA) 5 Global initiative for asthma (GINA) 5 National Institute for Health and Care Excellence (NICE) for hypertension (by UK) 2 Textbooks 2 Global Initiative for Chronic Obstructive Lung Disease (GOLD) for COPD (by WHO) 1 2 Rheumatology (n=8) American College of Rheumatology (ACR) 6 European Alliance of Association for Rheumatology (EULAR) 2 3 Pediatrics (n=7) Global initiative for asthma 3 The WHO for gastroenteritis 6 Nelson textbook of pediatrics 4 4 Gynecology (n=6) Royal College of Gynecology 5 American Diabetes Association (ADA) 2 5 Neurology (n=6) American Neurological Association (ANA) 6 6 Cardiology (n=5) American Heart Association (AHA) and the American College of Cardiology (ACC) 5 European society of cardiology (ESC) 3 7 Nephrology (n=5) AUA (American Urological Association) 3 Textbooks 2 Depending on the disease, each specialty adheres to a different set of guidelines. American guidelines were the most utilized by participating physicians/hospitals. Some specialties also follow European and British guidelines. Five of seven specializations adhere to American guidelines: the American Diabetic Association (ADA), the American Neurological Association (ANA), the American College of Cardiology (ACC), and the American College of Rheumatology (ACR). “They [American guidelines] are easy for our society, more up-to-date, and taught in our post-graduate education” (int1). Nearly all gynecologists followed the guidelines of the Royal College of Gynecology, while some internists relied on those of the National Institute for Health and Care Excellence (NICE, UK). The vast majority of internists and pediatricians follow the Global Initiative for Asthma (GINA). The majority of pediatricians continue to utilize the Nelson textbook. “American College of Rheumatology guideline is more reliable, evidence-based, and straightforward to implement” (Rhe2). “They [GINA for asthma and the WHO for GE] get good results, availability of the drugs suggested by the guidelines, and high family compliance” (Ped4). “Because it is a textbook, simple, up-to-date, and more reliable" (Ped6). The physicians utilized the same guidelines they learned during their board/postgraduate residency programs. Some cardiologists and rheumatologists adhered to European guidelines. The guidelines were put in place for a number of reasons, including their use in clinical settings, their inclusion in postgraduate and specialty programs, and a mandate from the Ministry of Health (MOH). Limited Awareness of National Guidelines Unfortunately, the majority of physicians (43 out of 48) were unaware of the Iraqi treatment guidelines. “I am unaware of [the Iraqi guideline], and I think it is unavailable” (Int7). The MOH does not mandate any official guidelines (Int8). “For GE, yes, but I am unaware of ASHMA” (Ped5). Unavailability of Guideline-Recommended Medicines The necessary medications indicated by the guidelines were in inadequate supply in six out of seven specialties “The vast majority of [essential medications] are unavailable.” Most pediatricians, though, said that needed medicines were easy to find in pediatric hospitals. Yes, the majority of [essential medications] are available (Ped, 1). According to the participating specialists (six out of eight rheumatologists), the majority of hospitals lacked disease-modifying antirheumatic medicines (DMARDs). Several rheumatologists also said that methotrexate, azathioprine, COX-II selective NSAIDs, and biological medications were not available ( Figure 1 ). Figure 1. The missing medications in Rheumatology Department of the public hospital(s). Six neurologists and four out of five cardiologists concurred that anti-thrombolytic medications are in short supply (e.g., actilyse). In addition, the majority of neurologists (four out of six, 66%) recognized that their facilities lacked a specialized stroke unit for treating patients with cerebrovascular accidents (CVA) ( Figure 2 ). Flecainide (antiarrhythmic) and Platelet Glycoprotein IIb/III inhibitor (Eptifibatide) were the most frequently missed cardiovascular medications in hospitals ( Figure 2 ). Figure 2. The Messing medications in Neurology and Cardiology Departments. All gynecologists encountered a shortage of ovulation-inducing medications (such as clomiphene and letrozole) ( Figure 3 ). The majority of pediatricians and internists reported a shortage of cortisone-plus-short-acting beta2-agonist (SABA)-containing combination asthma inhalers ( Figures 3 and 4 ). In addition, seven out of ten internal medicine doctors reported a shortage of innovative oral hypoglycemic medicines ( Figure 4 ). Figure 3. The Messing medications in Neurology, Gynecology and Pediatrics Departments. Figure 4. The messing medications in Internal Medicine Department. There are no ovulation-stimulating drugs (like Letrozole and clomiphene) at the hospital (all 6 gynecologists: Gyn 1,2,3,4,5,6). There is a shortage of inhalers containing both SABA and cortisone (Ped 7). Barriers hinder guideline implementation in public healthcare Several barriers hinder physicians from implementing guidelines in public healthcare settings. Key challenges include shortages of medications (45 out of 48; 93%), limited availability of diagnostic and laboratory materials (44 out of 48; 91%), and low patient adherence (44 out of 48; 91%) ( Figure 5 ). Figure 5. The challenges facing full implementation of the guidelines in the public sector. “Lack of investigational tools and treatment, absence of a stroke unit, restricted availability of MRI and CT scans” (Neu 9). There isn’t enough medicine, testing, and catheterization equipment; there isn’t a stroke center; and hospitals are too full (Neu 2). “Ignorance of individuals, untrained substaff, equipment shortages, and resistance to change” (Ped 3). Most physicians agreed that there are two main problems with putting guidelines into practice in private settings: high prescription costs (47 out of 48; 98%), and it’s hard to keep track of patients (21 out of 48; 43%) ( Figure 6 ). Figure 6. The challenges facing full implementation of guidelines in the private sector. “High costs and difficult patient follow-up” (Gyn 3, Ped 2). “High cost and low patient education” (Int 4). Discussion 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. Conclusions This study underscores the presence of systemic and informational barriers that hinder guideline adherence among Iraqi specialists. In our public healthcare settings, specialists from seven fields utilized the most well-known and universally accepted guidelines. The majority of physicians (38 out of 48) revealed that healthcare settings implement treatment guidelines in more than half of cases. American guideline was the most commonly used among the participating physicians. European and British guidelines and textbooks were also used by some specialties. Unfortunately, most physicians were unaware of Iraqi treatment guideline. Most senior physicians often followed the same guidelines for one branch, with little variation in approach based on their experience and flexibility. Almost all participating physicians believed that shortages in treatment and investigation/lab materials and low patient adherence are major barriers to implement the guideline(s). Six out of seven specialties experienced shortage in the essential medications that recommended by the guidelines. Enhancing physician awareness of the Iraqi guidelines should be encouraged. Finally, securing essential medicines in public hospitals is pivotal to adopt evidence-based guidelines effectively. Data availability Underlying data Figshare: In-depth Assessment of Iraqi physicians’ Adherence to Treatment Guidelines for Different Diseases: A Qualitative Study. https://doi.org/10.6084/m9.figshare.21624327.v1 . 12 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments The authors extend their sincere gratitude to all participating healthcare providers at Kirkuk General Hospital and Azadi Teaching Hospital in Kirkuk Province, Iraq, for generously sharing their experiences. References 1. Medicine Io: Clinical Practice Guidelines: Directions for a New Program. Field MJ, Lohr KN, editors. Washington, DC: The National Academies Press; 1990. p. 168. 2. Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients‘ care. The Lancet. 2003; 362 (9391): 1225–1230. Publisher Full Text 3. Gundersen L: The effect of clinical practice guidelines on variations in care. 2000; 133 . : 317. American College of Physicians. Publisher Full Text 4. Qaseem A, Forland F, Macbeth F, et al. : Guidelines International Network: toward international standards for clinical practice guidelines. Annals of Internal Medicine. 2012; 156 (7): 525–531. PubMed Abstract | Publisher Full Text 5. Cabana MD, Rand CS, Powe NR, et al. : Why don‘t physicians follow clinical practice guidelines?: A framework for improvement. JAMA. 1999; 282 (15): 1458–1465. 6. Carlsen B, Glenton C, Pope C: Thou shalt versus thou shalt not: a meta-synthesis of GPs‘ attitudes to clinical practice guidelines. The British Journal of General Practice. 2007; 57 (545): 971–978. PubMed Abstract | Publisher Full Text | Free Full Text 7. Chambless DL: Task Force on Promotion and Dissemination of Psychological Procedures: A Report Adopted by the Division 12 Board-October 1993.1993. 8. Feder G, Eccles M, Grol R, et al. : Using clinical guidelines. BMJ. 1999; 318 (7185): 728–730. PubMed Abstract | Publisher Full Text | Free Full Text 9. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough? Field Methods - FIELD METHOD. 2006 02/01; 18 : 59–82. 10. Braun V, Clarke V: Using thematic analysis in psychology.Qualitative Research in Psychology.2006 2006/01/01; 3 (2): 77–101. Publisher Full Text 11. Heidari S, Babor TF, De Castro P, et al. : Sex and gender equity in research: rationale for the SAGER guidelines and recommended use. Research Integrity and Peer Review. 2016; 1 (1): 2. PubMed Abstract | Publisher Full Text | Free Full Text 12. McKinlay JB, Link CL, Freund KM, et al. : Sources of variation in physician adherence with clinical guidelines: results from a factorial experiment.Journal of General Internal Medicine.2007 Mar; 22 (3): 289–96. PubMed Abstract | Publisher Full Text | Free Full Text 13. Zaki AM, Kheder SI: A survey of patterns, attitudes, and beliefs of house staff physicians concerning antibiotic use in Khartoum state hospitals.2012. 14. Nassrullah Z, Al-Jumaili AA: Professional challenges facing pharmacists working at public hospitals in an Iraqi province: A qualitative study.Iraqi Journal of Pharmaceutical Sciences.2023; 32 (Suppl.): 204–13. Publisher Full Text 15. Ali MM, Al-Jumaili AA: Through the Eyes of Healthcare Providers, the Necessity and Challenges of Implementing Medication Reconciliation at Hospital Discharge: A Qualitative Study. Al-Kindy College Medical Journal. 2024; 20 (2): 122–129. Publisher Full Text 16. Antonaci F, Dumitrache C, De Cillis I, et al. : A review of current European treatment guidelines for migraine. The Journal of Headache and Pain. 2010; 11 (1): 13–19. PubMed Abstract | Publisher Full Text | Free Full Text 17. Al-Jumaili AA, Al-Rekabi MD, Doucette W, et al. : Factors influencing the degree of physician-pharmacist collaboration within Iraqi public healthcare settings.International Journal of Pharmacy Practice.2017 Dec; 25 (6): 411–417. Epub 2017/02/10. eng. PubMed Abstract | Publisher Full Text 18. Al-Jumaili AA, Jabri AMH, Al-Rekabi MD, et al. : Physician Acceptance of Pharmacist Recommendations about Medication Prescribing Errors in Iraqi Hospitals. INNOVATIONS in Pharmacy. 2016; 7 (3): 1–9. Publisher Full Text 19. Mosca L, Linfante AH, Benjamin EJ, et al. : National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines.Circulation.2005 2005/02/01; 111 (4): 499–510. Publisher Full Text 20. Gupta N, Coates MM, Bekele A, et al. : Availability of equipment and medications for non-communicable diseases and injuries at public first-referral level hospitals: a cross-sectional analysis of service provision assessments in eight low-income countries.BMJ Open.2020 Oct 10; 10 (10): e038842. Epub 20201010. eng. PubMed Abstract | Publisher Full Text | Free Full Text 21. Fahmi HL, Al-Jumaili AA, Younus MM: The whole experience of public hospital physicians from several specialties with biopharmaceutical effectiveness, safety, adverse drug reactions and interchangeability: A qualitative study.Exploratory Research in Clinical and Social Pharmacy.2022 2022/09/01/; 7 : 100162. PubMed Abstract | Publisher Full Text | Free Full Text 22. Ali Azeez Al-Jumaili MMY, Kannan YJA, Nooruldeen ZE, et al. : Pharmaceutical regulations in Iraq: from medicine approval to post-marketing. Eastern Mediterranean Health Journal. 2021; 27 : 1007–1015. Publisher Full Text 23. Layla Abdullah Mahdi DJK, Al-Jumaili AA: Knowledge, perception and attitude regarding generic medicines among Iraqi physicians. Innovations in Pharmacy. 2020; 11 (1): 10. 24. Heselmans A, Donceel P, Aertgeerts B, et al. : The attitude of Belgian social insurance physicians towards evidence-based practice and clinical practice guidelines. BMC Family Practice. 2009; 10 (1): 64. PubMed Abstract | Publisher Full Text | Free Full Text 25. Woo B, Woo B, Cook EF, et al. : Screening procedures in the asymptomatic adult: comparison of physicians‘ recommendations, patients‘ desires, published guidelines, and actual practice. JAMA. 1985; 254 (11): 1480–1484. Publisher Full Text 26. Fischer F, Lange K, Klose K, et al. , editors. Barriers and strategies in guideline implementation—a scoping review.Healthcare. 2016: MDPI. 27. Religioni U, Barrios-Rodríguez R, Requena P, et al. : Enhancing Therapy Adherence: Impact on Clinical Outcomes, Healthcare Costs, and Patient Quality of Life.Medicina.2025; 61 (1): 153. PubMed Abstract | Publisher Full Text | Free Full Text 28. British Thoracic Society NAC, Royal College of Physicians of London: The British Guidelines on Asthma Management: 1995 Review and Position Statement. Thorax. 1995 (52): S1–S21. 29. Roumie CL, Elasy TA, Greevy R, et al. : Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Annals of Internal Medicine. 2006; 145 (3): 165–175. PubMed Abstract | Publisher Full Text 30. Guldberg TL, Lauritzen T, Kristensen JK, et al. : The effect of feedback to general practitioners on quality of care for people with type 2 diabetes. A systematic review of the literature.BMC Family Practice.2009 2009/05/06; 10 (1): 30. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 30 Mar 2023 ADD YOUR COMMENT Comment Author details Author details 1 Clinical Pharmacy Department, University of Baghdad College of Pharmacy, Bab-AlMouadhem, Baghdad, 10047, Iraq Ibrahim Yawer Anwer Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Mohammed Jamal Yawuz Roles: Investigation, Methodology, Project Administration, Supervision, Visualization, Writing – Review & Editing Ali Azeez Al-Jumaili Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) version 3 Revised Published: 26 Aug 2025, 12:350 https://doi.org/10.12688/f1000research.128233.3 version 2 Revised Published: 22 Aug 2024, 12:350 https://doi.org/10.12688/f1000research.128233.2 version 1 Published: 30 Mar 2023, 12:350 https://doi.org/10.12688/f1000research.128233.1 Copyright © 2025 Anwer IY et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Anwer IY, Yawuz MJ and Al-Jumaili AA. In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.12688/f1000research.128233.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 22 Aug 2024 Revised Views 0 Cite How to cite this report: Silwal A. Reviewer Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.170252.r320469 ) The direct URL for this report is: https://f1000research.com/articles/12-350/v2#referee-response-320469 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 20 Sep 2024 Anita Silwal , Oklahoma State University, Stillwater, Oklahoma, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.170252.r320469 This paper addresses an important topic related to clinical guidelines. The manuscript needs proper editing and revision and needs to address several concerns, as stated below. ABSTRACT: In the result section, the authors mentioned they ... Continue reading READ ALL This paper addresses an important topic related to clinical guidelines. The manuscript needs proper editing and revision and needs to address several concerns, as stated below. ABSTRACT: In the result section, the authors mentioned they recruited 48 specialists, but the results only say out of 47. Need to explain why one specialist is missing in the result. Instead of 38/44, recommend writing 38 out of 44. Or may write in % too. What do authors mean by “…in more than half of cases” in the result section? What do authors mean by “…followed the same guidelines for one branch…?” Need to explain what does this mean. Delete and add comma: “…shortages in treatment (46/47), and investigation/lab materials (45/47), and low…” The first three sentences of the conclusion read like results and are repetitive from the results section. Please consider rewriting the conclusion. Please adhere to capitalizing first letter of each keyword. INTRODUCTION: Consider deleting “that are made on purpose” The CPGs are recommendations and are based on evidence-based practices. “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal” – authors are making claims that need to be cited. Consider deleting “should” in the first sentence in paragraph two. “Private organizations are advancing on multiple fronts in their efforts to set rules” – authors are making claims that need to be cited. I encourage authors to add an example, it would be helpful for readers to understand. “Even if a physician has the right knowledge and attitude, outside factors may make it hard for him or her to follow…” Do the authors mean attitude toward the guidelines? If yes, please mention to be clear. Also, consider replacing “him or her” with them. “The factors that commonly influence physicians’ adherence to treatment guidelines…” Incomplete sentence: what are the factors? "The intent of the guidelines was to..." Are authors looking into the guidelines that are no longer valid or used? If not, I believe it should be is instead of was. Are authors referring to specific guidelines or to some specific health conditions? The first sentence is also very long. Consider rewriting. “Some CPGs are developed by organizations. Others are produced by regional groupings and are country specific.” Recommend adding some examples. Additionally, I recommend rewording the paragraph, e.g., mentioning examples and specific guidelines; it is confusing and hard to follow. I suggest reviewing literature reviews on clinical guidelines adherence. Is there any specific reason why the authors are listing ten health organizations? I think this paragraph and paragraph 4 could be merged—authors could include the names of a few associations as an example under paragraph 4. "The methods of guideline formulation should guarantee that patients treated in accordance with the guidelines will achieve the desired outcomes." As per my understanding, guidelines are not fixed protocols, “Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”(Institute of Medicine, 1990). So, the guidelines do not guarantee the outcome. This section examines the five steps involved in the creation of an evidence-based guideline. The dissemination, implementation, and assessment of practice guidelines will be covered in the final piece of this series.” This is unclear and confusing. This paragraph does not reflect the details. What do authors mean by “final piece of this series.?” The last paragraph, the first sentence, sounds like that belongs in the limitation section, and the final section belongs to the discussion. METHODS: This section needs editing and rewriting – reorganization and removing repetitive sentences. “…crucial feature of these types of investigations.” Please reconsider rewriting. Plain language is important in helping readers understand the research method. The list of specialties is repeated under study design and eligibility criteria. The abstract mentions virtual interviews; no details are mentioned in the study design. Under “Settings,” “Almost all interviews were performed face-to-face…” Be specific. How many participants were contacted, and how many in-person and virtual interviews? Study design says purposive sampling, but under-sampling, two different sampling methods are written. What are authors referring to – “Optional audio recording was available because it could deter potential interviewers from participating. The physicians who rejected the recording given handwritten responses in addition to notes taking by the interviewer during the interview.” Unclear how those data were used – the handwritten notes. This section needs a major editing. “The data was coded with two data codes. The author failed to provide a description of coding trees.” I could not follow what the authors were trying to say. RESULTS: It would be helpful to add percentages in descriptive results. For example, “…according to gender as 56.25% male ( n =27). For Table 2, please be consistent with capitalization under Gender. “Specialists partially adhere to international guidelines (mainly American and European); not all physicians adhere to the same guidelines; essential medicines are unavailable; and most of them are unaware of national guidelines.” It would be helpful to provide data for each of these, both in percentage and number. Under quotes, for the first theme, I do not think they are actual quotes but the names of the associations. If correct, consider removing it. Please be consistent with numbering or the use of symbols in the quotes and subthemes, respectively, in Table 3. Table 3, needs to be edited to properly ensure that the themes, subthemes and quotes are represented correctly. Themes are written as a sentence. Authors need to develop themes – for example: instead of “The vast majority of the participating physicians were unaware of Iraqi treatment guidelines” authors can rewrite this as “Lack of awareness of national treatment guidelines.” “Nearly all gynecologists followed the guidelines of the Royal College of Gynecology, while some internists relied on those of the National Institute for Health and Care Excellence (NICE, UK). The vast majority of internists and pediatricians follow the Global Initiative for Asthma (GINA). The majority of pediatricians continue to utilize the Nelson textbook.” Please consider adding percentages as well as numbers for the reader to understand. It is hard to comprehend when terms such as some and majority are used, and specific details are not provided. MOH? Please ensure you have spelled all acronyms. The results sound repetitive in the Table and text. Ensure results are not written repeatedly. “The majority of hospitals (six out of eight rheumatologists) lacked…” Does six out of eight refer to participants' expertise or the hospitals? Unclear. For Figure 1, the authors used the term “missing medication.” What does that mean? Or do they mean “medication shortage?” Again in Figure 2, Figure 3, Fig 4 caption, it says, “messing medication.” Please rewrite. DISCUSSION: Under demographics, authors write, “guidelines; thus, the findings may not be representative of all physicians.” This actually should be under limitation. Under unavailability of Iraqi treatment guidelines for various disease, authors have expanded on the results, it would be helpful to explain if there is any specific guidelines in the country? And if yes, possibly could explain the lack of awareness about it and lack of effort to educate physician about the guidelines. What does this mean – “There were good connections and discussions between specialist physicians and permanents and rotators regarding diseases and guidelines…” What is the connection about? Unclear and hard to follow? Please rewrite. Overall, the discussion should not be the expansion of the result itself but shall offer an interpretation. I highly encourage authors to rewrite the section focusing on analyzing and interpreting results. Conclusion is well written. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public Health, Health communication, Policy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Silwal A. Reviewer Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.170252.r320469 ) The direct URL for this report is: https://f1000research.com/articles/12-350/v2#referee-response-320469 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 30 Mar 2023 Views 0 Cite How to cite this report: Q.B. Allela O. Reviewer Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.140803.r176786 ) The direct URL for this report is: https://f1000research.com/articles/12-350/v1#referee-response-176786 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Sep 2024 Omar Q.B. Allela , Pharmacy Department, Alnoor University College, Nineveh, Iraq Approved VIEWS 0 https://doi.org/10.5256/f1000research.140803.r176786 Physician adherence is very important, so this article will add a good idea and clear picture for this important problem (non-adherence to guideline). But also so important to add a quantitative study to be completed study. Regarding conclusion, ... Continue reading READ ALL Physician adherence is very important, so this article will add a good idea and clear picture for this important problem (non-adherence to guideline). But also so important to add a quantitative study to be completed study. Regarding conclusion, need to list more points to apply for the area in future. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Clinical pharmacy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Q.B. Allela O. Reviewer Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.140803.r176786 ) The direct URL for this report is: https://f1000research.com/articles/12-350/v1#referee-response-176786 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Howie AH. Reviewer Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.140803.r205712 ) The direct URL for this report is: https://f1000research.com/articles/12-350/v1#referee-response-205712 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 13 Oct 2023 Alison H Howie , University of Ottawa, Ontario, Canada; Epidemiology and Biostatistics, Western University, London, Ontario, Canada Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.140803.r205712 This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be ... Continue reading READ ALL This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. Introduction: 1. I suggest removing “on purpose” from the first sentence. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. 3. Suggest including the mean number of years of experience in addition to the range. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). 5. Suggest defining “MOH” 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Epidemiology, physician adherence to guideline recommendations I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Howie AH. Reviewer Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.140803.r205712 ) The direct URL for this report is: https://f1000research.com/articles/12-350/v1#referee-response-205712 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 22 Aug 2024 Ali Azeez Al-Jumaili , Clinical Pharmacy Department, University of Baghdad College of Pharmacy, Bab-AlMouadhem, 10047, Iraq 22 Aug 2024 Author Response This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, ... Continue reading This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. The authors would thank the reviewer (Dr. Alison H Howie ) for her valuable comments to enhance the quality of the manuscript. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? - Agree with reviewer, the number of participants was 48, so we fixed the numbers in the denominator. What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. - Yes, branch is used in Iraq. However, we replaced it with specialty instead per the reviewer request. Introduction: 1. I suggest removing “on purpose” from the first sentence. - Removed per the reviewer request. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) - Reviewed. 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. - Agency refers to the “Agency for Healthcare Research and Quality" (AHRQ)”. We fixed it. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” - Sorry, we fixed it . 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. Removed the patients per the reviewer request. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. Deleted the 2 nd sentence to avoid duplication. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). Agree with the reviewer, so we fixed and shortened them to the following: Guidelines for chronic diseases are followed by physician’s worldwide could fall into the following categories: European Society of Cardiology, American Heart Association, American College of Cardiology, Global Initiative to Combat Asthma (GINA), the American Diabetes, the American Neurological Association (ANA), the European Urological Association (EAU) , the American Rheumatology Association and the European Alliance of Rheumatology Associations (EULAR) and the British Royal College of Obstetricians and Gynecologists. 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Agree, the last sentence was deleted. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. - The method section has been revised per the reviewer request. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” - Agree with the reviewer, we moved the first section to the thematic analysis section. In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. - Revised to “before administering the interview questions”. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” We removed the results from the method section per the reviewer request. 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). Removed. 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” Agree, interviewee. 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” Revised. 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” Done. 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Revised to “ in addition to notes taking by the interviewer during the interview”. It means we had transcripts including both hand-written from the interviewee and notes from the interviewer. Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. We tried to put number of participants who mentioned the same theme and subtheme, so the readers would understand the portion of agreement on each theme. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. Done. 3. Suggest including the mean number of years of experience in addition to the range. The mean of experience year was added. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). We fixed these denominators to be 48. 5. Suggest defining “MOH” The Iraqi Ministry of Health 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. They used very similar words. Per the reviewer request, we kept two participant pseudo names who said exactly the same answer. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Done Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. The discussion has been revised per the reviewer request. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. Agree. It is done. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. Removed to avoid redundancy. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Done We highly appreciate the reviewer’s valuable comments to enhance the quality of our manuscript. Best regards, Ali Azeez Al-Jumaili, MPH, PhD Corresponding author This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. The authors would thank the reviewer (Dr. Alison H Howie ) for her valuable comments to enhance the quality of the manuscript. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? - Agree with reviewer, the number of participants was 48, so we fixed the numbers in the denominator. What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. - Yes, branch is used in Iraq. However, we replaced it with specialty instead per the reviewer request. Introduction: 1. I suggest removing “on purpose” from the first sentence. - Removed per the reviewer request. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) - Reviewed. 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. - Agency refers to the “Agency for Healthcare Research and Quality" (AHRQ)”. We fixed it. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” - Sorry, we fixed it . 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. Removed the patients per the reviewer request. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. Deleted the 2 nd sentence to avoid duplication. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). Agree with the reviewer, so we fixed and shortened them to the following: Guidelines for chronic diseases are followed by physician’s worldwide could fall into the following categories: European Society of Cardiology, American Heart Association, American College of Cardiology, Global Initiative to Combat Asthma (GINA), the American Diabetes, the American Neurological Association (ANA), the European Urological Association (EAU) , the American Rheumatology Association and the European Alliance of Rheumatology Associations (EULAR) and the British Royal College of Obstetricians and Gynecologists. 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Agree, the last sentence was deleted. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. - The method section has been revised per the reviewer request. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” - Agree with the reviewer, we moved the first section to the thematic analysis section. In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. - Revised to “before administering the interview questions”. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” We removed the results from the method section per the reviewer request. 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). Removed. 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” Agree, interviewee. 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” Revised. 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” Done. 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Revised to “ in addition to notes taking by the interviewer during the interview”. It means we had transcripts including both hand-written from the interviewee and notes from the interviewer. Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. We tried to put number of participants who mentioned the same theme and subtheme, so the readers would understand the portion of agreement on each theme. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. Done. 3. Suggest including the mean number of years of experience in addition to the range. The mean of experience year was added. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). We fixed these denominators to be 48. 5. Suggest defining “MOH” The Iraqi Ministry of Health 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. They used very similar words. Per the reviewer request, we kept two participant pseudo names who said exactly the same answer. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Done Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. The discussion has been revised per the reviewer request. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. Agree. It is done. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. Removed to avoid redundancy. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Done We highly appreciate the reviewer’s valuable comments to enhance the quality of our manuscript. Best regards, Ali Azeez Al-Jumaili, MPH, PhD Corresponding author Competing Interests: No competing interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 22 Aug 2024 Ali Azeez Al-Jumaili , Clinical Pharmacy Department, University of Baghdad College of Pharmacy, Bab-AlMouadhem, 10047, Iraq 22 Aug 2024 Author Response This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, ... Continue reading This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. The authors would thank the reviewer (Dr. Alison H Howie ) for her valuable comments to enhance the quality of the manuscript. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? - Agree with reviewer, the number of participants was 48, so we fixed the numbers in the denominator. What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. - Yes, branch is used in Iraq. However, we replaced it with specialty instead per the reviewer request. Introduction: 1. I suggest removing “on purpose” from the first sentence. - Removed per the reviewer request. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) - Reviewed. 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. - Agency refers to the “Agency for Healthcare Research and Quality" (AHRQ)”. We fixed it. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” - Sorry, we fixed it . 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. Removed the patients per the reviewer request. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. Deleted the 2 nd sentence to avoid duplication. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). Agree with the reviewer, so we fixed and shortened them to the following: Guidelines for chronic diseases are followed by physician’s worldwide could fall into the following categories: European Society of Cardiology, American Heart Association, American College of Cardiology, Global Initiative to Combat Asthma (GINA), the American Diabetes, the American Neurological Association (ANA), the European Urological Association (EAU) , the American Rheumatology Association and the European Alliance of Rheumatology Associations (EULAR) and the British Royal College of Obstetricians and Gynecologists. 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Agree, the last sentence was deleted. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. - The method section has been revised per the reviewer request. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” - Agree with the reviewer, we moved the first section to the thematic analysis section. In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. - Revised to “before administering the interview questions”. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” We removed the results from the method section per the reviewer request. 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). Removed. 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” Agree, interviewee. 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” Revised. 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” Done. 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Revised to “ in addition to notes taking by the interviewer during the interview”. It means we had transcripts including both hand-written from the interviewee and notes from the interviewer. Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. We tried to put number of participants who mentioned the same theme and subtheme, so the readers would understand the portion of agreement on each theme. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. Done. 3. Suggest including the mean number of years of experience in addition to the range. The mean of experience year was added. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). We fixed these denominators to be 48. 5. Suggest defining “MOH” The Iraqi Ministry of Health 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. They used very similar words. Per the reviewer request, we kept two participant pseudo names who said exactly the same answer. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Done Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. The discussion has been revised per the reviewer request. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. Agree. It is done. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. Removed to avoid redundancy. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Done We highly appreciate the reviewer’s valuable comments to enhance the quality of our manuscript. Best regards, Ali Azeez Al-Jumaili, MPH, PhD Corresponding author This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. The authors would thank the reviewer (Dr. Alison H Howie ) for her valuable comments to enhance the quality of the manuscript. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? - Agree with reviewer, the number of participants was 48, so we fixed the numbers in the denominator. What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. - Yes, branch is used in Iraq. However, we replaced it with specialty instead per the reviewer request. Introduction: 1. I suggest removing “on purpose” from the first sentence. - Removed per the reviewer request. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) - Reviewed. 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. - Agency refers to the “Agency for Healthcare Research and Quality" (AHRQ)”. We fixed it. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” - Sorry, we fixed it . 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. Removed the patients per the reviewer request. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. Deleted the 2 nd sentence to avoid duplication. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). Agree with the reviewer, so we fixed and shortened them to the following: Guidelines for chronic diseases are followed by physician’s worldwide could fall into the following categories: European Society of Cardiology, American Heart Association, American College of Cardiology, Global Initiative to Combat Asthma (GINA), the American Diabetes, the American Neurological Association (ANA), the European Urological Association (EAU) , the American Rheumatology Association and the European Alliance of Rheumatology Associations (EULAR) and the British Royal College of Obstetricians and Gynecologists. 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Agree, the last sentence was deleted. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. - The method section has been revised per the reviewer request. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” - Agree with the reviewer, we moved the first section to the thematic analysis section. In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. - Revised to “before administering the interview questions”. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” We removed the results from the method section per the reviewer request. 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). Removed. 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” Agree, interviewee. 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” Revised. 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” Done. 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Revised to “ in addition to notes taking by the interviewer during the interview”. It means we had transcripts including both hand-written from the interviewee and notes from the interviewer. Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. We tried to put number of participants who mentioned the same theme and subtheme, so the readers would understand the portion of agreement on each theme. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. Done. 3. Suggest including the mean number of years of experience in addition to the range. The mean of experience year was added. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). We fixed these denominators to be 48. 5. Suggest defining “MOH” The Iraqi Ministry of Health 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. They used very similar words. Per the reviewer request, we kept two participant pseudo names who said exactly the same answer. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Done Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. The discussion has been revised per the reviewer request. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. Agree. It is done. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. Removed to avoid redundancy. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Done We highly appreciate the reviewer’s valuable comments to enhance the quality of our manuscript. Best regards, Ali Azeez Al-Jumaili, MPH, PhD Corresponding author Competing Interests: No competing interests Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 30 Mar 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 3 (revision) 26 Aug 25 Version 2 (revision) 22 Aug 24 read Version 1 30 Mar 23 read read Alison H Howie , University of Ottawa, Ontario, Canada; Western University, London, Canada Omar Q.B. Allela , Alnoor University College, Nineveh, Iraq Anita Silwal , Oklahoma State University, Stillwater, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Silwal A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 20 Sep 2024 | for Version 2 Anita Silwal , Oklahoma State University, Stillwater, Oklahoma, USA 0 Views copyright © 2024 Silwal A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This paper addresses an important topic related to clinical guidelines. The manuscript needs proper editing and revision and needs to address several concerns, as stated below. ABSTRACT: In the result section, the authors mentioned they recruited 48 specialists, but the results only say out of 47. Need to explain why one specialist is missing in the result. Instead of 38/44, recommend writing 38 out of 44. Or may write in % too. What do authors mean by “…in more than half of cases” in the result section? What do authors mean by “…followed the same guidelines for one branch…?” Need to explain what does this mean. Delete and add comma: “…shortages in treatment (46/47), and investigation/lab materials (45/47), and low…” The first three sentences of the conclusion read like results and are repetitive from the results section. Please consider rewriting the conclusion. Please adhere to capitalizing first letter of each keyword. INTRODUCTION: Consider deleting “that are made on purpose” The CPGs are recommendations and are based on evidence-based practices. “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal” – authors are making claims that need to be cited. Consider deleting “should” in the first sentence in paragraph two. “Private organizations are advancing on multiple fronts in their efforts to set rules” – authors are making claims that need to be cited. I encourage authors to add an example, it would be helpful for readers to understand. “Even if a physician has the right knowledge and attitude, outside factors may make it hard for him or her to follow…” Do the authors mean attitude toward the guidelines? If yes, please mention to be clear. Also, consider replacing “him or her” with them. “The factors that commonly influence physicians’ adherence to treatment guidelines…” Incomplete sentence: what are the factors? "The intent of the guidelines was to..." Are authors looking into the guidelines that are no longer valid or used? If not, I believe it should be is instead of was. Are authors referring to specific guidelines or to some specific health conditions? The first sentence is also very long. Consider rewriting. “Some CPGs are developed by organizations. Others are produced by regional groupings and are country specific.” Recommend adding some examples. Additionally, I recommend rewording the paragraph, e.g., mentioning examples and specific guidelines; it is confusing and hard to follow. I suggest reviewing literature reviews on clinical guidelines adherence. Is there any specific reason why the authors are listing ten health organizations? I think this paragraph and paragraph 4 could be merged—authors could include the names of a few associations as an example under paragraph 4. "The methods of guideline formulation should guarantee that patients treated in accordance with the guidelines will achieve the desired outcomes." As per my understanding, guidelines are not fixed protocols, “Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”(Institute of Medicine, 1990). So, the guidelines do not guarantee the outcome. This section examines the five steps involved in the creation of an evidence-based guideline. The dissemination, implementation, and assessment of practice guidelines will be covered in the final piece of this series.” This is unclear and confusing. This paragraph does not reflect the details. What do authors mean by “final piece of this series.?” The last paragraph, the first sentence, sounds like that belongs in the limitation section, and the final section belongs to the discussion. METHODS: This section needs editing and rewriting – reorganization and removing repetitive sentences. “…crucial feature of these types of investigations.” Please reconsider rewriting. Plain language is important in helping readers understand the research method. The list of specialties is repeated under study design and eligibility criteria. The abstract mentions virtual interviews; no details are mentioned in the study design. Under “Settings,” “Almost all interviews were performed face-to-face…” Be specific. How many participants were contacted, and how many in-person and virtual interviews? Study design says purposive sampling, but under-sampling, two different sampling methods are written. What are authors referring to – “Optional audio recording was available because it could deter potential interviewers from participating. The physicians who rejected the recording given handwritten responses in addition to notes taking by the interviewer during the interview.” Unclear how those data were used – the handwritten notes. This section needs a major editing. “The data was coded with two data codes. The author failed to provide a description of coding trees.” I could not follow what the authors were trying to say. RESULTS: It would be helpful to add percentages in descriptive results. For example, “…according to gender as 56.25% male ( n =27). For Table 2, please be consistent with capitalization under Gender. “Specialists partially adhere to international guidelines (mainly American and European); not all physicians adhere to the same guidelines; essential medicines are unavailable; and most of them are unaware of national guidelines.” It would be helpful to provide data for each of these, both in percentage and number. Under quotes, for the first theme, I do not think they are actual quotes but the names of the associations. If correct, consider removing it. Please be consistent with numbering or the use of symbols in the quotes and subthemes, respectively, in Table 3. Table 3, needs to be edited to properly ensure that the themes, subthemes and quotes are represented correctly. Themes are written as a sentence. Authors need to develop themes – for example: instead of “The vast majority of the participating physicians were unaware of Iraqi treatment guidelines” authors can rewrite this as “Lack of awareness of national treatment guidelines.” “Nearly all gynecologists followed the guidelines of the Royal College of Gynecology, while some internists relied on those of the National Institute for Health and Care Excellence (NICE, UK). The vast majority of internists and pediatricians follow the Global Initiative for Asthma (GINA). The majority of pediatricians continue to utilize the Nelson textbook.” Please consider adding percentages as well as numbers for the reader to understand. It is hard to comprehend when terms such as some and majority are used, and specific details are not provided. MOH? Please ensure you have spelled all acronyms. The results sound repetitive in the Table and text. Ensure results are not written repeatedly. “The majority of hospitals (six out of eight rheumatologists) lacked…” Does six out of eight refer to participants' expertise or the hospitals? Unclear. For Figure 1, the authors used the term “missing medication.” What does that mean? Or do they mean “medication shortage?” Again in Figure 2, Figure 3, Fig 4 caption, it says, “messing medication.” Please rewrite. DISCUSSION: Under demographics, authors write, “guidelines; thus, the findings may not be representative of all physicians.” This actually should be under limitation. Under unavailability of Iraqi treatment guidelines for various disease, authors have expanded on the results, it would be helpful to explain if there is any specific guidelines in the country? And if yes, possibly could explain the lack of awareness about it and lack of effort to educate physician about the guidelines. What does this mean – “There were good connections and discussions between specialist physicians and permanents and rotators regarding diseases and guidelines…” What is the connection about? Unclear and hard to follow? Please rewrite. Overall, the discussion should not be the expansion of the result itself but shall offer an interpretation. I highly encourage authors to rewrite the section focusing on analyzing and interpreting results. Conclusion is well written. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health, Health communication, Policy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Silwal A. Peer Review Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.170252.r320469) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-350/v2#referee-response-320469 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Q.B. Allela O. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Sep 2024 | for Version 1 Omar Q.B. Allela , Pharmacy Department, Alnoor University College, Nineveh, Iraq 0 Views copyright © 2024 Q.B. Allela O. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Physician adherence is very important, so this article will add a good idea and clear picture for this important problem (non-adherence to guideline). But also so important to add a quantitative study to be completed study. Regarding conclusion, need to list more points to apply for the area in future. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Clinical pharmacy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Q.B. Allela O. Peer Review Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.140803.r176786) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-350/v1#referee-response-176786 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Howie A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13 Oct 2023 | for Version 1 Alison H Howie , University of Ottawa, Ontario, Canada; Epidemiology and Biostatistics, Western University, London, Ontario, Canada 0 Views copyright © 2023 Howie A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. Introduction: 1. I suggest removing “on purpose” from the first sentence. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. 3. Suggest including the mean number of years of experience in addition to the range. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). 5. Suggest defining “MOH” 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Epidemiology, physician adherence to guideline recommendations I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (1) Author Response 22 Aug 2024 Ali Azeez Al-Jumaili, Clinical Pharmacy Department, University of Baghdad College of Pharmacy, Bab-AlMouadhem, 10047, Iraq This paper describes a qualitative study of physician adherence to guideline recommendations within hospitals in Iraq. I believe the study was well-conducted and is an important addition to the literature, however, I have several concerns that I believe must be addressed before publication, as described below. The authors would thank the reviewer (Dr. Alison H Howie ) for her valuable comments to enhance the quality of the manuscript. Abstract: You say there were 48 participants but the results use 44 or 47 as the denominator. Could you include one sentence acknowledging/explaining the missing data? - Agree with reviewer, the number of participants was 48, so we fixed the numbers in the denominator. What is meant by “branch”? Is it synonymous with specialty? This is not a well-known term; I suggest re-wording or clarifying. - Yes, branch is used in Iraq. However, we replaced it with specialty instead per the reviewer request. Introduction: 1. I suggest removing “on purpose” from the first sentence. - Removed per the reviewer request. 2. Several sentences make claims that are not referenced. I suggest reviewing the introduction for these sentences, including: “Despite widespread dissemination, the impact of guidelines on physician conduct has been minimal.” (para 1) “Private organizations are advancing on multiple fronts in their efforts to set rules.” (para 2) “Regarding physician attitudes, other potential obstacles include disagreement, identity, outcome expectancies, and the inertia of previous practice.” (para 3) - Reviewed. 3. What is meant by “the agency” in the first sentence of the second paragraph? I suggest elaborating/clarifying. - Agency refers to the “Agency for Healthcare Research and Quality" (AHRQ)”. We fixed it. 4. The following sentence is unfinished: “The factors that commonly influence physicians’ adherence to treatment guidelines” - Sorry, we fixed it . 5. The fourth paragraph sounds like it’s referring to a specific guideline regarding respiratory diseases, but it is not clear which. Suggest explicitly mentioning and referencing the guideline. It also introduces the idea that guidelines are meant for physicians and patients, but the rest of the introduction focuses on physicians. Adding patients here without explanation feels out of place. Removed the patients per the reviewer request. 6. The second sentence in the fourth paragraph repeats what is already said in the previous sentence - suggest merging the two sentences. Deleted the 2 nd sentence to avoid duplication. 7. Paragraphs 5 and 6 could use some editing. There are unfinished sentences and perhaps too many examples. Suggest only including a handful of examples (with references). Agree with the reviewer, so we fixed and shortened them to the following: Guidelines for chronic diseases are followed by physician’s worldwide could fall into the following categories: European Society of Cardiology, American Heart Association, American College of Cardiology, Global Initiative to Combat Asthma (GINA), the American Diabetes, the American Neurological Association (ANA), the European Urological Association (EAU) , the American Rheumatology Association and the European Alliance of Rheumatology Associations (EULAR) and the British Royal College of Obstetricians and Gynecologists. 8. The last sentence of the introduction, “Participants of both genders were included in this study, and their answers were comparable.” belongs in the results/discussion. Agree, the last sentence was deleted. Methods: Overall comment: several sentences are repeated in multiple sections of the methods, and several sentences include results from the study and do not belong in the methods. The whole methods section needs to be reviewed carefully and duplicate sentences and results-based sentences need to be removed. - The method section has been revised per the reviewer request. The first paragraph about the analysis of the data is misplaced. Suggest moving it to the thematic analysis section at the end of methods and removing duplicate sentences, e.g., “Thematic analyses were performed to analyze interview-generated qualitative data.” - Agree with the reviewer, we moved the first section to the thematic analysis section. In the ethical approval section, it says, “before administering the questionnaire”. This is the first mention of a questionnaire. Was it a mixed-methods study? If not, suggest re-wording this as it may confuse readers. - Revised to “before administering the interview questions”. Any mention of results does not belong in the methods, including the number of participants in the study. The following sentences should be removed as they are repeated in the results: “There were 48 participants in this study. This study includes both male and female specialists, who were selected using a purposive sampling method. Two physicians refused to participate because they were not interested.” “Almost all interviews (N = 48) were performed face-to-face at Kirkuk province’s public hospitals.” For this one, you could just say “Interviews were performed face-to-face at Kirkuk province’s public hospitals” without including the number of participants. “In fact, most physicians refused to record the session.” “Most interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency).” We removed the results from the method section per the reviewer request. 5. In the settings section, suggest removing the second sentence (“Internists, nephrologists, gynecologists, neurologists, cardiologists, rheumatologists, and pediatricians.”) as it is unfinished and repeated in the next section (Eligibility). Removed. 6. I believe the following sentence should use the term “interviewee” instead of “interviewer”: “Optional audio recording was available because it could deter potential interviewers from participating.” Agree, interviewee. 7. The following sentences are conflicting and also should be in the results section: “In fact, most physicians refused to record the session.” and “Several individuals were interviewed using an audio recorder.” Revised. 8. Missing a word from the following sentence, “Notes taken during and following interviews.” I believe it should say “Notes were taken during and following interviews.” Done. 9. You explain that participants who refused to record were given a handwritten page to fill out. It is unclear how these data were incorporated into the analysis. In the thematic analysis section, you just talk about transcripts. How was the other data used? Revised to “ in addition to notes taking by the interviewer during the interview”. It means we had transcripts including both hand-written from the interviewee and notes from the interviewer. Results: 1. Overall comment: the results are heavily focused on quantitative findings - reporting the number of participants whose responses fell under each theme when the purpose is to conduct a qualitative analysis. I’m not sure that all of these numbers belong to the results of a qualitative analysis. We tried to put number of participants who mentioned the same theme and subtheme, so the readers would understand the portion of agreement on each theme. 2. Including gender information in the first sentence is out of place. Suggest including a separate sentence for gender. Done. 3. Suggest including the mean number of years of experience in addition to the range. The mean of experience year was added. 4. You say there were 48 participants, but several results use other numbers as denominators (i.e., 44). Please explain the reason for missing data (e.g., did you run out of time to ask some participants some of the questions? Did they refuse to answer some?). We fixed these denominators to be 48. 5. Suggest defining “MOH” The Iraqi Ministry of Health 6. You include direct quotations and reference multiple participants for some of them (e.g., “The vast majority of [essential medications] are unavailable.” (Int 3,5,9,10,11, neuro5, car2, Rhe1,3,6,7, Gyn1,2,4, Neph3).” I find it hard to believe that all these participants said the same thing. I believe only the interviewee who said the quote should be named. They used very similar words. Per the reviewer request, we kept two participant pseudo names who said exactly the same answer. 7. Sometimes quotation marks are used to indicate a participant's direct quote, other times they are not. The results need to be carefully reviewed for consistency here. Done Discussion:​​​​​ 1. A lot of information is repeated from the results. The discussion should be an interpretation of the findings at large and a comparison to other studies in the literature. The discussion needs to be reviewed and edited to provide an interpretation of the results. The discussion has been revised per the reviewer request. 2. In the section entitled, “Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals”, you mention “patient education” for the first time. What is meant by this? Avoid introducing new findings in the discussion that were not mentioned in the results. Agree. It is done. 3. I don’t know what is meant by the following sentence, “All of these things make older people rely on rules and follow each update.” Suggest re-wording or elaborating on this point. Removed to avoid redundancy. 4. Suggest adding a “Limitations” section at the end of the discussion (there are currently two sentences that refer to limitations within the “Follow the recommendations of the guidelines in both public and private settings” section. Done We highly appreciate the reviewer’s valuable comments to enhance the quality of our manuscript. Best regards, Ali Azeez Al-Jumaili, MPH, PhD Corresponding author View more View less Competing Interests No competing interests reply Respond Report a concern Howie AH. Peer Review Report For: In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved] . F1000Research 2025, 12 :350 ( https://doi.org/10.5256/f1000research.140803.r205712) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-350/v1#referee-response-205712 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Stay Updated Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with F1000Research Already registered? Sign in Not now, thanks close PLEASE NOTE If you are an AUTHOR of this article, please check that you signed in with the account associated with this article otherwise we cannot automatically identify your role as an author and your comment will be labelled as a “User Comment”. If you are a REVIEWER of this article, please check that you have signed in with the account associated with this article and then go to your account to submit your report, please do not post your review here. If you do not have access to your original account, please contact us . All commenters must hold a formal affiliation as per our Policies . The information that you give us will be displayed next to your comment. User comments must be in English, comprehensible and relevant to the article under discussion. We reserve the right to remove any comments that we consider to be inappropriate, offensive or otherwise in breach of the User Comment Terms and Conditions . Commenters must not use a comment for personal attacks. When criticisms of the article are based on unpublished data, the data should be made available. I accept the User Comment Terms and Conditions Please confirm that you accept the User Comment Terms and Conditions. Affiliation ✕ refresh Please enter your institution. Note: To add your institution or organisation, start typing the name and then select the correct name from the list. Where applicable, the name will appear in both the original language and in English. Do not paste in the name. If the name does not appear in the drop-down list, we will display the information you have entered. ✕ refresh Country/Region * USA UK Canada China France Germany Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo (Serbia and Montenegro) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Minor Outlying Islands of the United States Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Is South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Gambia The Netherlands Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UK USA Uganda Ukraine United Arab Emirates United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna West Bank and Gaza Strip Western Sahara Yemen Zambia Zimbabwe Please select your country/region. You must enter a comment. Competing Interests Please disclose any competing interests that might be construed to influence your judgment of the article's or peer review report's validity or importance. Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Please state your competing interests The comment has been saved. An error has occurred. Please try again. Cancel Post var lTitle = "In-depth assessment of Iraqi physicians\'...".replace("'", ''); var linkedInUrl = "http://www.linkedin.com/shareArticle?url=https://f1000research.com/articles/12-350/v3" + "&title=" + encodeURIComponent(lTitle) + "&summary=" + encodeURIComponent('Read the article by '); var deliciousUrl = "https://del.icio.us/post?url=https://f1000research.com/articles/12-350/v3&title=" + encodeURIComponent(lTitle); var redditUrl = "http://reddit.com/submit?url=https://f1000research.com/articles/12-350/v3" + "&title=" + encodeURIComponent(lTitle); linkedInUrl += encodeURIComponent('Anwer IY et al.'); var offsetTop = /chrome/i.test( navigator.userAgent ) ? 4 : -10; var addthis_config = { ui_offset_top: offsetTop, services_compact : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_expanded : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_custom : [ { name: "LinkedIn", url: linkedInUrl, icon:"/img/icon/at_linkedin.svg" }, { name: "Mendeley", url: "http://www.mendeley.com/import/?url=https://f1000research.com/articles/12-350/v3/mendeley", icon:"/img/icon/at_mendeley.svg" }, { name: "Reddit", url: redditUrl, icon:"/img/icon/at_reddit.svg" }, ] }; var addthis_share = { url: "https://f1000research.com/articles/12-350", templates : { twitter : "In-depth assessment of Iraqi physicians\' adherence to treatment.... Anwer IY et al., published by " + "@F1000Research" + ", https://f1000research.com/articles/12-350/v3" } }; if (typeof(addthis) != "undefined"){ addthis.addEventListener('addthis.ready', checkCount); addthis.addEventListener('addthis.menu.share', checkCount); } $(".f1r-shares-twitter").attr("href", "https://twitter.com/intent/tweet?text=" + addthis_share.templates.twitter); $(".f1r-shares-facebook").attr("href", "https://www.facebook.com/sharer/sharer.php?u=" + addthis_share.url); $(".f1r-shares-linkedin").attr("href", addthis_config.services_custom[0].url); $(".f1r-shares-reddit").attr("href", addthis_config.services_custom[2].url); $(".f1r-shares-mendelay").attr("href", addthis_config.services_custom[1].url); function checkCount(){ setTimeout(function(){ $(".addthis_button_expanded").each(function(){ var count = $(this).text(); if (count !== "" && count != "0") $(this).removeClass("is-hidden"); else $(this).addClass("is-hidden"); }); }, 1000); } close How to cite this report {{reportCitation}} Cancel Copy Citation Details $(function(){R.ui.buttonDropdowns('.dropdown-for-downloads');}); $(function(){R.ui.toolbarDropdowns('.toolbar-dropdown-for-downloads');}); $.get("/articles/acj/128233/186687") new F1000.Clipboard(); new F1000.ThesaurusTermsDisplay("articles", "article", "186687"); $(document).ready(function() { $( "#frame1" ).on('load', function() { var mydiv = $(this).contents().find("div"); var h = mydiv.height(); console.log(h) }); var tooltipLivingFigure = jQuery(".interactive-living-figure-label .icon-more-info"), titleLivingFigure = tooltipLivingFigure.attr("title"); tooltipLivingFigure.simpletip({ fixed: true, position: ["-115", "30"], baseClass: 'small-tooltip', content:titleLivingFigure + " " }); tooltipLivingFigure.removeAttr("title"); $("body").on("click", ".cite-living-figure", function(e) { e.preventDefault(); var ref = $(this).attr("data-ref"); $(this).closest(".living-figure-list-container").find("#" + ref).fadeIn(200); }); $("body").on("click", ".close-cite-living-figure", function(e) { e.preventDefault(); $(this).closest(".popup-window-wrapper").fadeOut(200); }); $(document).on("mouseup", function(e) { var metricsContainer = $(".article-metrics-popover-wrapper"); if (!metricsContainer.is(e.target) && metricsContainer.has(e.target).length === 0) { $(".article-metrics-close-button").click(); } }); var articleId = $('#articleId').val(); if($("#main-article-count-box").attachArticleMetrics) { $("#main-article-count-box").attachArticleMetrics(articleId, { articleMetricsView: true }); } }); var figshareWidget = $(".new_figshare_widget"); if (figshareWidget.length > 0) { window.figshare.load("f1000", function(Widget) { // Select a tag/tags defined in your page. In this tag we will place the widget. _.map(figshareWidget, function(el){ var widget = new Widget({ articleId: $(el).attr("figshare_articleId") //height:300 // this is the height of the viewer part. [Default: 550] }); widget.initialize(); // initialize the widget widget.mount(el); // mount it in a tag that's on your page // this will save the widget on the global scope for later use from // your JS scripts. This line is optional. //window.widget = widget; }); }); } close Error Close Add Reset F1000.MICROSERVICES.AFFILIATION = ''; $(document).ready(function () { $('.js-affiliations-form').each((index, form) => { new AffiliationForm({ formId: form.id, institutionErrorSelector: '.comment-enter-institution', departmentErrorSelector: '.comment-enter-department', placeSelector: '.js-add-comment-place', stateSelector: '.js-add-comment-state', zipCodeSelector: '.js-add-comment-zipcode', countrySelector: '.js-add-comment-country', countryErrorSelector: '.comment-enter-country', }); }); }); $(document).ready(function () { var reportIds = { "292102": 0, "292103": 0, "212775": 0, "212779": 0, "212778": 0, "212777": 0, "212776": 0, "212783": 0, "316201": 0, "212782": 0, "212781": 0, "212780": 0, "316980": 0, "182322": 0, "316981": 0, "182323": 0, "316982": 0, "316983": 0, "212784": 0, "182321": 0, "198455": 0, "182326": 0, "198454": 0, "182327": 0, "198453": 0, "182324": 0, "316979": 0, "182325": 0, "316988": 0, "198459": 0, "182330": 0, "198458": 0, "198457": 0, "182328": 0, "198456": 0, "182329": 0, "316984": 0, "316985": 0, "198462": 0, "316986": 0, "198461": 0, "316987": 0, "198460": 0, "327052": 0, "376205": 0, "205707": 0, "294540": 0, "327053": 0, "376204": 0, "205706": 0, "294541": 0, "327054": 0, "376207": 0, "327055": 0, "376206": 0, "205711": 0, "168590": 0, "205710": 0, "168591": 0, "327050": 0, "376203": 0, "205709": 0, "294538": 0, "327051": 0, "205708": 0, "294539": 0, "168589": 0, "176786": 6, "205715": 0, "376212": 0, "205714": 0, "205713": 0, "168592": 0, "205712": 27, "327056": 0, "376209": 0, "327057": 0, "376208": 0, "327058": 0, "376211": 0, "327059": 0, "376210": 0, "221107": 0, "221106": 0, "221105": 0, "221111": 0, "312753": 0, "221110": 0, "221109": 0, "221108": 0, "221114": 0, "221113": 0, "221112": 0, "320468": 0, "387797": 0, "320469": 11, "320470": 0, "320471": 0, "387798": 0, "320464": 0, "320465": 0, "320466": 0, "387795": 0, "320467": 0, "387794": 0, "320472": 0, "320473": 0, "409316": 0, "409314": 0, "387809": 0, "409315": 0, }; $(".referee-response-container,.js-referee-report").each(function(index, el) { var reportId = $(el).attr("data-reportid"), reportCount = reportIds[reportId] || 0; $(el).find(".comments-count-container,.js-referee-report-views").html(reportCount); }); var uuidInput = $("#article_uuid"), oldUUId = uuidInput.val(), newUUId = "c0d63667-2bb5-4c10-92f0-1f0723916235"; uuidInput.val(newUUId); $("a[href*='article_uuid=']").each(function(index, el) { var newHref = $(el).attr("href").replace(oldUUId, newUUId); $(el).attr("href", newHref); }); }); An innovative open access publishing platform offering rapid publication and open peer review, whilst supporting data deposition and sharing. Browse Gateways Collections How it Works Contact For Developers Cookie Notice Privacy Notice RSS Submit Your Research Follow us © 2012-2026 F1000 Research Ltd. ISSN 2046-1402 | Legal | Partner of Research4Life • CrossRef • ORCID • FAIRSharing R.templateTests.simpleTemplate = R.template(' $text $text $text $text $text '); R.templateTests.runTests(); var F1000platform = new F1000.Platform({ name: "f1000research", displayName: "F1000Research", hostName: "f1000research.com", id: "1", editorialEmail: "[email protected]", infoEmail: "[email protected]", usePmcStats: true }); $(function(){R.ui.dropdowns('.dropdown-for-authors, .dropdown-for-about, .dropdown-for-myresearch');}); // $(function(){R.ui.dropdowns('.dropdown-for-referees');}); $(document).ready(function () { if ($(".cookie-warning").is(":visible")) { $(".sticky").css("margin-bottom", "35px"); $(".devices").addClass("devices-and-cookie-warning"); } $(".cookie-warning .close-button").click(function (e) { $(".devices").removeClass("devices-and-cookie-warning"); $(".sticky").css("margin-bottom", "0"); }); $("#tweeter-feed .tweet-message").each(function (i, message) { var self = $(message); self.html(linkify(self.html())); }); $(".partner").on("mouseenter mouseleave", function() { $(this).find(".gray-scale, .colour").toggleClass("is-hidden"); }); }); Sign In Remember me Forgotten your password? Sign In Cancel Email or password not correct. Please try again Please wait... $(function(){ // Note: All the setup needs to run against a name attribute and *not* the id due the clonish // nature of facebox... $("a[id=googleSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("GOOGLE"); $("form[id=oAuthForm]").submit(); }); $("a[id=facebookSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("FACEBOOK"); $("form[id=oAuthForm]").submit(); }); $("a[id=orcidSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("ORCID"); $("form[id=oAuthForm]").submit(); }); }); If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here . If you still need help with your Google account password, please click here . You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here . If you still need help with your Facebook account password, please click here . Code not correct, please try again Reset password Cancel Email us for further assistance. Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait... Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });