Barriers to Successful Healing Landscape Initiatives in Iran: A Multi-Criteria Decision Analysis

Introduction: Healing landscapes (HL) are increasingly recognised for their psychological, physiological, and social benefits. Despite these advantages, HL project implementation in Iran has been inconsistent, with many initiatives failing to achieve their intended outcomes due to systemic barriers, including inadequate financial resources, shortages of skilled personnel, weak project governance, and insufficient maintenance infrastructure. This study examines how the absence of codified regulatory standards, fragmented institutional governance, and underutilised innovative procurement and risk-management technologies constitute primary barriers, highlighting the tension between static regulatory environments and the need for innovation in Iran's healthcare construction sector.

Methods: A descriptive, analytic approach integrated a two-round Delphi process with Analytic Hierarchy Process (AHP). Round 1 employed semi-structured interviews to elicit failure factors; Round 2 used a 5-point Likert scale for refinement. Consensus criteria (≥75% agreement, SD < 1.0) confirmed 8 main criteria and sub-criteria. AHP established relative weights via a three-level hierarchy (Goal, 8 Criteria, Sub-criteria) and pairwise comparisons on Saaty's 9-point scale, processed with Expert Choice software (mean CR = 0.07). Ninety-four technical experts participated across diverse disciplines.

Results: Project delays (16%), inadequate financial resources (15%), and institutional discord among stakeholders (14%) were the predominant perceived barriers. Absence of therapeutic quality frameworks contributed 11%, while risk management received 6%. The expert panel was predominantly composed of design, engineering, and project management professionals, with limited clinical input. The AHP weights reflect expert perceptions of immediate project-level barriers rather than objective causal measurements.

Conclusion: Institutional coordination and governance weaknesses, particularly in time and cost management, are perceived as primary barriers. Policy interventions should prioritise strengthening governance, funding structures, and cross-sector collaboration. Future research should validate these priorities against empirical data and incorporate end-user perspectives.