Introduction

Health service delivery is an essential element of any health system [1]. The goal of health delivery is to improve the health of the community and respond to the expectations of the people, together with inequality reduction in both cases [2]. In burn injuries, successful service delivery is very important because burn injuries are a major cause of death and infirmity around the world. It is estimated that more than 300,000 people die every year from fire-related burn injuries. Millions suffer from burn injuries, many of which are permanent [3]. Burn injuries result in the imposition of short-term and long-term costs to the victim, families, communities and nations [4]. The mortality rate of burn injuries varies in different parts of the world. Progress in the treatment and care of burn patients has also contributed to reducing the mortality rate in many high-income countries [3]. Burning care costs up to $1000 a day per patient in developed countries [5]. But, in the majority of low and middle-income countries, there is a lack of major surgical infrastructure such as an operating room, high tech instruments and a lack of skilled burn medical and nurse personnel. In addition, they experience an unpredictable supply chain constraints on raw materials and wound dressing [6]. Three WHO regions including Eastern Mediterranean, Southeast Asia and Africa account for almost two third of the total burden of injuries [7].

In Iran, the 2003 global burden of disease study showed that burn injury is the 13th cause of the burden of disease in the general population and the seventh cause in children aged 5 to 14 years old [8]. Trends in burn incidence showed that an increase of burn admissions or burn incidence rates in Iran between 2005–2009 [9]. Moreover, the rate of burn-related mortality was reported 3.8 for every 100 thousand individuals in Iran [10].

The treatment of burns is complex, expensive and time-consuming, because patients need special care, well-equipped medical instruments and trained staff [8]. Currently, the burn delivery system is not clearly defined in Iran’s health system. A small number of specialised burns hospitals (SBHs) located in big provinces provide burn services in which burn patients with more severe conditions are referred to them. Simultaneously, burn units in general hospitals, also, provide primary burn care services.

Since 2013, special measures have been taken to treat burn patients in the form of the Health Evaluation Plan in Iran, including the development of specialised burns sections and hospital emergency equipment, the development and standardisation of burn wards and burn medical care units (BICUs). As more burns occurred in the poor, vulnerable communities and underprivileged districts, treatment deputy of Iran’s Ministry of Health also prioritising burn cares in order to provide fair access to essential burn services for all through scaling up equitable access to burn cares in the society.

Despite the numerous advances, the gap between effective action and demand remains remarkable. Having money and technology is not sufficient for efficiency. Even with more money and better technologies, there remains a major challenge: improving health services [11]. In such a situation, identifying the challenges for delivering burn services is an invaluable field of study. To the best of our knowledge, no comprehensive studies were found in this field in Iran. Nonetheless, in South Asia, a lack of resources at current burn centres, lack of specialised care facilities, overcrowding of centres, delay in follow-up care for burns, lack of funding for low-income and people living in rural areas, and the lack of specialised rehabilitation services for burns were major challenges [12].

Jagnoor et al. (2018) identified a number of barriers to providing burn care services in India. This study showed that the lack of operating standards for burn treatment, different knowledge and skills from health professionals in providing burn care, along with resource shortages, affect the quality of burn care for patients [13]. Jagnoor et al. (2017) identified the challenges of burn and recovery care such as poor communication between health care providers and burn victims, limited rehabilitation services, transportation problems to health centres, and high costs of burn treatment and confirmed the need for long-term rehabilitation [14]. Wang et al. (2018) identified the challenges and improvements in burn wound healing, infection, pain and wound and explained there are challenges in long-term treatment and wound healing, infection, pain and hypertrophic wounds in burn management [15].

Given the importance of the delivering burn services for due treatment of burn patients as well as the significance of burn services for burn victims and their families, the aim of this study was to identify the challenges of delivering burn services in SBHs in Iran. This study will inform policymakers and health authorities to adopt appropriate policy for providing burn services.

Materials and methods

This study received the required ethics approval from Isfahan University of Medical Sciences Research Ethics Committee, Isfahan, Iran with ethics code No. IR.MUI.REC.1395.2.292. Moreover, participants’ informed consent was acquired from all study participant and assured their anonymity and confidentiality of any information they might present.

A qualitative study using content analysis approach was designed to investigate the challenges of service delivery in specialised burns hospitals. The study was performed during February 2017 to April 2018 at the national level of the country. The population of study include all key informants related to the burn services delivery in Iran. To identify and select key informants related to the phenomenon of interest, purposeful sampling technique with a maximum variation approach was used. Maximum variation allows us to explore important shared patterns that cut across heterogeneities. The informant participants were recruited at national and provincial levels from Ministry of Health and Medical Education (MoHME) and medical university experts. Also, CEOs, managers, dermatologists, matrons and supervisor nurses that have worked in cities owning SBHs (Tehran, Isfahan, Ahvaz, Shiraz, Bushehr, Mashhad, Tabriz and Yazd) were interviewed. Accordingly, the eligible interviewees were key informants related to burn care delivery across different provinces of Iran. Key informants were excluded for this study if they had an experience <5 years and/or cancelled the interview meeting more than four times.

The required data was gathered through face-to-face, semi-structured interviews with the participants. We developed an interview guide informed by the World Health Organisation’s framework for health system functions [1] and the research objectives (S1 File). Further, to check the validity of the interview guide, at first the questions of interview had been discussed among research team with collaboration of one external expert and revised, accordingly. Later, the interview guide was tested on three non-participants to verify the number and order of the questions in the study.

Interviews were carried out in the interviewee’s office or any places where the participant suggested by one trained member of the study team (MJM). The interviews continued until a saturation point in which no additional data collection was necessary. It is attained with the analysis and comparison of interview contents until no new or relevant data seems to be emerging concerning a theme. Lastly, 21 face-to-face semi-structured interviews were conducted. Each interview time lasted between 30–90 minutes, with an average of 40 minutes. Most interviews were tape-recorded (with participants’ informed consent) and then transcribed verbatim. One of the participants (number 10) did not allow to record his voice, so that interviewer was take field notes.

A thematic analysis with an inductive approach was employed to analysis of transcribed documents assisted by MAXQDA Plus version 12 (Release 12.3.0, VERBI GmbH Berlin). A step-by-step guide proposed by Braun and Clarke [16] was served to conducting thematic analysis. Accordingly, the following steps were done: (1) three of the authors (MAR, FM, and NSZ) as data coders, familiarised with data by immersed themselves in the data by listening to recorded interviews and reading and re-reading transcribed data. (2) the initial list of ideas behind the data was generated and initial codes from the data were produced. In this stage, the most basic segment and repeated interesting patterns were identified and related to each code. (3) after all the data were initially coded and collated, codes were analysed aiming at combining different codes to an inclusive theme. At this stage we also found out sub-themes within themes, viz., essentially themes within a theme. (4) the themes were reviewed and refined during two 3-hour sessions with the main members of the research team in which all the accumulated extracts for each theme were read and coherence of their patterns were considered. (5) at this point, defining and naming of themes was done. Besides paraphrasing the themes, overlaps between themes and sub-themes and their relations to the others were examined carefully. Also, final names were given to the themes and sub-themes. (6) the report as the final opportunity for analysis was produced and scholarly publication wrote-up.

For assessing the quality of current qualitative study, we ensured four trustworthiness criteria suggested by Lincoln and Guba [17]. Credibility was ensured with a prolonged engagement (the study process continued nearly fifteen months) and respondent validation (the process whereby the researchers provided some transcribed interviews to the participants and asked them to ensure that there is a good correspondence between their findings and the perspectives of participants). Further, to improve credibility, opposite issues in findings were discussed among research team to reveal the reasons. Transferability of our qualitative findings was enhanced through purposive sampling technique and thick descriptions. Dependability of the research was adopted by an auditing approach in which the study’s colleagues accompanying by an external auditor engaged in complementary comments in coding process and analysing of interview text as well as cross-checked the data we collected. To increase confirmability, we not openly allowed our personal values to conduct the research and the findings obtaining from it. According to the Hewitt-Taylor [18], we maintained reflexivity by abstractly hypothesizing in a more divorced manner concerning research questions and how the data we gathered gave insight into these, as well we have used field note taking to enrich the data. Moreover, we have tried to shrink the impact of our experiences on different stages of the study process [19].

Results

Interviewees are described in Table 1 (i.e. their organisation affiliation, years of experience and city).

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Table 1. Characteristics of participants.

https://doi.org/10.1371/journal.pone.0216489.t001

Four themes and twelve subthemes on challenges of delivering services in SBHs were extracted. Themes related to challenges of SBHs were as follows: burn care continuum, regionalisation of burning services, costs of providing BRSs, and non-compliance with standardized care (Table 2 and S1 Fig).

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Table 2. Themes, sub-themes, and codes related to the challenges of delivering services at SBHs.

https://doi.org/10.1371/journal.pone.0216489.t002

Discussion

The current study aimed to identify challenges in providing healthcare services in SBHs in Iran, based on a qualitative approach. The results revealed that there are four themes including defects of burn care continuum, regionalization of BRSs, costs related to the burn service provision, non-compliance with standardised care.

Defects of burn care continuum are facing with a variety of challenges in continuum burn care delivery from preventive care and pre-hospital care to home care. The results showed that challenges of preventive care are related to people’s insufficient awareness, inadequate media notification, and particularly, a lack of a national plan for burn prevention. Based on the WHO report, developed countries have substantially reduced burn-related deaths during the past four decades, which most of that can be attributed to the burn prevention. Although, using advanced treatments had a substantial role in this decline [3]. Rode et al. in 2015 have also emphasised the necessity and impact of society education about burn prevention [20]. They showed that implementing prevention strategy results in significant improvement, especially in primary and secondary prevention. Also, some other studies noted that weak performance of burn wards is not due to hospital performance or severity of injuries, but it is mostly due to society’s awareness about burn, primary measures and prevention [13]. A study by Hodgins et al. has also emphasized awareness of burns [21].The study of Atiyeh et al. also showed that low level of family education is a risk factor for burns. In this study the importance of burn prevention programs has been emphasized in burn management protocols [22].

The other important challenge was related to pre-hospital care. Burn patients reside in provinces without a SBH, usually receive poor pre-hospital emergency services and necessarily refer to the SBHs that located in a few number of Iran’s provinces. This leads to some difficulties for the patients. Insufficient skill of ambulance staff and low quality of first aid services usually result in delayed arrival of patients to hospitals, severe consequences, increased hospitalisation, and higher costs for patients and health system. Moreover, physicians in non-SBHs are not fully expert in providing pre-hospital care for burn patient such as oxygen and fluid therapies. As a result, next hospital cares will be accompanied by some side effects including sticky wounds and deformity, which require additional treatments such as plastic surgery. As well as in hospital care, supportive services such as nutritional consultations are not sufficient and generally high calorie and high protein regimes are not served. In hospital care, there is other important challenges which include the provision of out date care that is related to the financial shortages and lack of appropriate training. In hospital, burn patients’ companions often do not have the required knowledge to control infections, mostly due to a low level of health literacy. Various unplanned visits and ignoring sanitary codes by patients’ families, also increase the secondary infections in hospitalised burn patients. Jagnoor et al. showed that lack of society’s awareness on basic burn services can reduce desired consequences [13].

Lack of patients’ follow-up, mainly due to financial barriers, is another import challenge to provide high quality BRSs, which in combination with a shortage of home care, results in consequences such as infection or deformity. In addition, since specialised care is only available in specialised hospitals in big cities, receiving further care can be an important obstacle for patients in small cities. In line with the findings of the current study, Jagnoor has also found that lack of patients’ follow-up is an important challenge in treating burn patients in India. Many of the identified challenges were related to the patients’ socioeconomic status, their literacy level and lack of facilities [13].

Regionalisation of BRSs was another theme in the current study, which include three themes. First, poor access to other specialities and medical services. Due to deliver specialised burn services only in SBHs, burn patients with multi-trauma and co-morbidity that may need cardiovascular, vision, and other specialised cares are exposed with a heavy cost burden, as well it imposes costs on the health system. In addition, this situation usually leads into delayed provision of medical services and patients’ referral to other hospitals. A lack of multi-disciplinary teams along with inadequate access to advanced diagnostic technologies are among other important obstacles to provided BRSs. Jagnoor also has mentioned that inadequate specialised and experienced human resources as important obstacles to provide BRSs. But, because in India BRSs are available in public hospitals, access limitation to specialised services were lesser. Besides, the authors found that insufficient skills of health staff, including physicians with general surgery skills, is an important obstacle to provide high quality BRSs in all healthcare centres [13]. In the study by Atyieh et al, the researchers emphasized on regionalization of burn care and linkage between primary, secondary and tertiary levels. They suggested a registry system for burn services [22]. Also Rode et al proposed a structure for regionalized burn services which include day hospital clinics, primary health care plus district hospital, regional hospital and provincial tertiary hospital [20].

Second, inadequate access to specialised services in provinces without a SBH is another important challenge. Long distances and lack of equipped ambulances, transportation costs, inadequate skills of staff in provinces without a SBH, and a lack of equipment and medicine along with delayed referral due to lack of burn-specialized beds, hinder the provision of high quality services. In many cases the provided services by healthcare facilities were not appropriate, that resulted into consequences such as secondary infections. In addition, delayed referral of patients to equipped healthcare centres increases the treatment period and costs. Gallaher et al. showed that in Africa BRSs are available in the burn department of general hospitals, rather than a SBH, so there are less challenges [6]. Meanwhile, Jagnoor only mentioned to the shortage of equipment and facilities in public sector, including hospital beds, to isolate patients to avoid infection [13]. In India, also, because BRSs are providing through public hospitals, there are less challenges.

Third, a lack of a defined regionalisation system for BRSs is another important challenge. Ignoring regionalisation standards and referral system sometimes lead into refusing to hospitalise patients or delayed hospitalisation, that both can result in severe consequences. Jagnoor et al.’s work is consistent with the results of current study [13]. Holmes et al. investigated the effectiveness of regionalisation from 2000 to 2007, and emphasised on the effectiveness of regionalization of BRSs. They noted that a single healthcare centre cannot provide the best possible services [23]. Literature on standardising care in SBHs show that 24 hours a day and seven days a week access to a specialised team (i.e. physicians, nurses, and other staff) to provide BRSs as well as patients’ follow-up are among basic standards. To achieve this standard, there must be a precise estimation of minimum level of staff [24]. Moreover, studies indicated that patients with major burn injury require a multi-disciplinary team. In this line, services regionalisation can be a useful step [25].

The results also showed that high costs are an important challenge. On one hand, due to the high workload of personnel, and high price of medical equipment and medicine, the cost of provided services is high. On the other hand, public resources are not sufficient to cover these costs. In a study on analysing costs of a burn ward in Africa, high cost was mention as a main challenge. This study has emphasised on possibility of provision of comprehensive BRSs with lower costs in low-and-middle income countries [6].

Finally, another challenge of BRSs’ provision in Iran is non-compliance with international standards. It can be attributed to a lack of clinical guidelines to treat different burned organs, infection control, and using personal ideas in treatment process of burn patients. In addition, defining specific standards on beds per population, intensive care unit beds per burn-related beds, physical and human resources in burn wards had intensified the gap. As interviewees noted, non-compliance with standards had resulted in low quality services. However, non-compliance is mostly the result of financial shortages in low-and-middle income countries [5]. In India, also, standards are not fully complied in which provided interventions and services substantially vary from one hospital to another. Partly it is due to lack of clinical guidelines [14].

Conclusion

The current study showed that Iran has faced with several challenges in terms of delivering BRSs. The results may provide policy actions on improving of BRSs delivery, which include strengthening burn care continuum, burn care regionalisation, allocating sufficient budgets to burn services and formulating burn guidelines. As well, to provide appropriate burn services, intra-sectoral collaborations among MoHME and other organisations and institutions as well as advocacy can be helpful.

Supporting information

Acknowledgments

We would like to thank all interviewees for their kind contribution. Moreover, the authors cordially appreciate Dr. Fereydoon Abedini for his kind help and guidance.