To identify the main drivers of low-value medical imaging in Iran and explore potential strategies to reduce its use.

Qualitative study using semistructured interviews.

Public and private healthcare settings in Iran.

34 physicians, including general practitioners, radiologists and non-radiology specialists, selected using purposive and snowball sampling.

Semistructured interviews were conducted between October 2023 and February 2024 through face-to-face, telephone and video calls. Data were analysed using thematic content analysis with a hybrid inductive–deductive approach and organised using the five control knobs framework.

Participants identified multiple drivers of low-value medical imaging across five domains: organisation, financing, payment, behaviour and regulation. Key drivers included weaknesses in the referral system, limited oversight, financial incentives, defensive medical practice, patient demand and misconceptions about diagnostic value. Suggested mitigation strategies included public education, physician training, stronger referral pathways, improved insurance oversight, use of evidence-based guidelines and better regulatory monitoring.

Low-value medical imaging in Iran is sustained by interacting weaknesses in referral pathways, financial incentives, professional practice and oversight. Efforts to reduce overuse should therefore combine physician and public education with stronger referral systems, insurer monitoring and regulatory action.