Mental Health Priorities in Iranian Women: Overview of Social Determinants of Mental Health

Abstract

Mental health is an essential component for positive adaptation that enables people to cope with adversity to achieve their full potential and humanity. In this study, using a community based approach, the social determinants of mental health in Iranian women were extracted; and in addition, priority setting for interventional programs according to analytical framework of WHO was implemented.
This study was a community based participatory research (CBPR) in district 22 of Tehran (Iran). The target group was married females with age range of 18-65 years. In this study, mental health priorities were extracted by qualitative methods according to Essential National Health Research model (ENHR) and the analytical framework of WHO. Data analysis was done based on content analysis by the open code 3.6 software.
In the quantitative phase, according to secondary data, 1144 individuals (560 females and 584 males) were selected, of whom 41 percent had impaired mental health based on General Health Questionnaire (GHQ) (P<0.05). According to the qualitative phase, the first mental health priority in socioeconomic level was lack of insurance for unattended families, it was unemployment in differential exposure level and it was lack of knowledge and skills related to dealing with stress in the differential vulnerability level; in differential outcome and consequence levels, the priorities were lack of free counseling centers in the study area and lack of facilities for mental health rehabilitation.
Providing training courses to improve the skills to deal with stress is considered one of the most important interventions for mental health promotion in women.

Full text

Birth Order and Sibling Gender Ratio of a Clinical Sample
Iranian J Psychiatry 9:4, October 2014 ijps.tums.ac.ir
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Mental Health Priorities in Iranian Women: Overview of
Social Determinants of Mental Health
Monir Baradaran Eftekhari ,
PhD1,2
Ameneh Setareh Forouzan, MD2
Arash Mirabzadeh, MD2
Homeira Sajadi, MD2
Masoumeh Dejman, PhD 2
Hasan Rafiee, MD2
Mohammad Mahdi Golmakan,
MD3
1 Deputy of Research and
Technology – Ministry of Health
and Medical Education, Tehran,
Iran
2 Social Determinants of Health
Research Center, University of
Social Welfare and Rehabilitation
Science, Tehran, Iran
3 Deputy of Health, Tehran
Municipality,Tehran,Iran
Corresponding author:
Arash Mirabzadeh, Professor of
Psychiatry, Department of
Psychiatry and Social
Determinant of Health Research
Center, University of Social
Welfare and Rehabilitation
Science, Tehran, Iran
Tel: 98-21-88027675
Fax: 98-21- 33401219
Email: aramirab@gmail.com
Objective: Mental health is an essential component for positive
adaptation that enables people to cope with adversity to achieve their full
potential and humanity. In this study, using a community based
approach, the social determinants of mental health in Iranian women
were extracted; and in addition, priority setting for interventional
programs according to analytical framework of WHO was implemented .
Method: This study was a community based participatory research
(CBPR) in district 22 of Tehran (Iran). The target group was married
females with age range of 18-65 years. In this study, mental health
priorities were extracted by qualitative methods according to Essential
National Health Research model (ENHR) and the analytical framework of
WHO. Data analysis was done based on content analysis by the open
code 3.6 software.
Results: In the quantitative phase, according to secondary data, 1144
individuals (560 females and 584 males) were selected, of whom 41
percent had impaired mental health based on General Health
Questionnaire (GHQ) (P<0.05). According to the qualitative phase, the
first mental health priority in socioeconomic level was lack of insurance
for unattended families, it was unemployment in differential exposure
level and it was lack of knowledge and skills related to dealing with stress
in the differential vulnerability level; in differential outcome and
consequence levels, the priorities were lack of free counseling centers in
the study area and lack of facilities for mental health rehabilitation.
Conclusion: Providing training courses to improve the skills to deal with
stress is considered one of the most important interventions for mental
health promotion in women.
Keywords: Social Determinant, Mental Health, Priority Setting, Participatory
Research, Iran
Mental health is an essential component for
positive adaptation that enables people to cope with
adversity to achieve their full potential and humanity
(1). Mental health is also the key to understanding
the impact of inequalities on health (2). The
significance of mental health and its role in health
outcomes confirms the importance of humans in
community, but it does not mean that we should
ignore the mental character and power of the
individual. Mental disorders are responsible for one
third of Years Lived with Disability (YLD) in the
world (3). Also, different studies showed that the
prevalence of mental disorders in women is more
than men (4). In Iran, based on urban HEART study,
the prevalence of mental disorder was 38% in Tehran
in 2008 (twice in females)(5). Understanding the
social determinants of mental health and set their
priorities based on community participation are
essential to design appropriate interventions for
mental health promotion. This process guides the
policy makers to design primary prevention plans for
mental disorders and provide maximum social
welfare (6). In 2007, in the commission on social
determinations of health, World Health Organization
suggested a five-level priority public health
conditions analytical framework that consisted of
socioeconomic context and position, differential
exposure, vulnerability, health care outcomes and
differential consequences to design intervention (7) .
The socioeconomic context has a powerful effect on
societal distribution of health conditions. In 2004,
Bhugra and colleagues investigated the relation
between socioeconomic reform and mental disorders
and found that rapid changes in the configuration of
societies can cause substantial increase in societal
burden of mental disorders (8). Differential
exposures to risk factors such as stressful life events,
Original Article
Iran J Psychiatry 2014; 9:4: 241-247

Baradaran Eftekhari , Setareh Forouzan, Mirabzadeh, et al
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social conflict, civil unrest, natural disasters and
working environments have strong association with
mental health problems (9). In differential
vulnerability stage, individual characters such as
gender, age, health status, marital status and income
affect mental health (10). Chronic physical ill-health,
female gender and being a young adult can increase
the vulnerability to mental health problems (11).
Lack of mental health literacy and stigma reduce the
ability to use health care services (12). Increased
financial cost of treatment for mental disorders, loss
of job and earning are different consequents of
mental health problems (13) .
In many studies, different interventions for mental
health problems target the five levels of this
analytical framework (14, 15). In Iran, there are some
interventional programs for the promotion of mental
health in different age groups (16, 17), but in the
present study, using community participatory
research approach, the social determinants of mental
disorders were extracted and priority setting for
interventional programs according to analytical
framework of WHO was implemented.
Material and Methods
This was a community based participatory
research(CBPR) conducted for needs assessment and
setting priorities for women’s mental health in district
22 in western part of Tehran. This method was selected
because the CBPR begins with a research topic of
importance to community with the aim of combining
knowledge and action for a social change to improve
the community’s health and eliminate health
disparities. It is a participatory, cooperative and
capacity building process that achieves a balance
between research and action .
The district 22 of Tehran has an approximate
population of 100 thousand, of which , 49% are
women; this district has nine zones and has also special
characteristics such as easy access to the community,
having active humanitarian organizations and hyper
active volunteers that led us to select this district as the
venue of our study. In this area, more than 41% of the
population has impaired mental health (18).
For needs assessment, we used ENHR approach (8)
that has four phases: Stakeholder's analysis,
preparatory phase, needs assessment and priority
setting. In the third phase, gathering the secondary
data was implemented as a quantitative study, and
focus group discussion sessions and in-depth
interviews were carried out as the qualitative part .
A- Stakeholders analysis:
This part has three steps consisting of identifying
stakeholders and prioritizing them based on some
criteria such as influence, power, interest and finally
considering key stakeholders. To implement these
steps, the following actions were taken:
At first, we coordinated with regional stakeholders and
key persons and explained them the aim of the study.
Volunteers were chosen according to some criteria
such as being married, having at least high school
diploma and motivation to participate in activities, and
finally ten candidates were selected. The volunteers
had to do the necessary arrangements in order to carry
out the different steps of the study which were as
follows:
To encourage the community to participate in the needs
assessment process
To carry out the focus group discussion sessions with
married women and conducting in- depth interviews
with key persons.
Knowing different disciplines in the area and forming
the intersectional and multidisciplinary working
groups.
Providing a check list of stakeholders. This check list
consisted of all stakeholders` names which were
prioritized based on some criteria.
B-Preparatory phase:
Doing preparatory work which consisted of awareness
raising and capacity building, reaching agreement
with the stakeholders and planning for needs
assessment and priority setting. One of the most
important parts of this process is capacity building of
the individuals. One training workshop was conducted
for the volunteers.
C-Needs assessment:
C1- Quantitative study:
Gathering secondary data such as demographic
characteristics, executive programs and extracting the
results of the 28-item version of the General Health
Questionnaire (GHQ) from Urban Health Equity
Assessment and Response Tool (Urban HEART). In
Tehran, an improved model incorporates the six
domains of infrastructure, social and humanity
development, economics, governance, health and
nutrition.
GHQ: In 1999, this questionnaire was translated to the
official language of Iran (Farsi), and its validity and
reliability were approved in an independent study by
Noorbala (19). The best cutoff point was 6; and those
participants who scored 6 and above were designated
as possible cases of mental disorder. The sensitivity,
specificity and overall misclassification rate for the
GHQ–28 cut-off score of 6 were 84.7%, 93.8% and
8.2%, respectively (19).
C2- Qualitative study:
A qualitative study was done to extract the mental
health needs and their social determinants in women.
Four focus group discussions (FGD) with married
women and five in- depth interviews with key
stakeholders were conducted to reach data saturation.
The guide questionnaires consisted of three general
questions related to mental health needs, mental health
priorities and appropriate interventions followed by
some probes such as when, who, how, where and so
on. Each interview lasted for almost one hour, and
informed consent was obtained from all the
participants. After each session, the taken notes were
completed with recorded tapes .

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The analysis of health situation consisted of health
status and health system in the study area.
Different techniques such as brainstorming and
nominal group (20) with stakeholders were used to
assign the scoring system.
D-Priority setting:
Using the bottom up approach or ENHR model (6), the
mental health priorities were extracted by stakeholders’
participation; and then based on the public health
analytical framework of WHO, five levels of social
determinants, priorities and interventional programs
were determined. (Figure 1)
Data analysis: Data analysis in the qualitative study
was done based on conventional content analysis. In
this method of analysis, coding categories are derived
directly from the text data (21). In order to increase the
reliably of the data, all codes and classes were cross-
checked by the research team. To address
conformability, we shared the summarized interview
findings with the key persons at the end of the
interview (respondent validation) to get find the
participants’ recognition of the finding (22). To assess
dependability, peer checking was done by an
experienced colleague to re-analyze some of the data
was performed. Team consistency checks between
colleagues were also performed throughout the coding
process (23).
Ethical Considerations
In this study, ethical issues were considered. Informed
consent was obtained from all the participants. They
were assured that the data would be managed in line
with regulations in the law of confidentiality and
anonymity. The Local Ethics Committee of Welfare
and Social Science University approved the study
design.
Results
Based on the ENHR model, four steps were
implemented. In this part, we presented the result of the
three steps. The preparatory work consisted of some
actions which were explained in the method’s section .
A- StakeholdersAnalysis:
Based on the stakeholder’s analysis, the five categories
are as follows:
1- Team researchers
2-Decision makers on provincial and district levels
3-Health service providers at the district level
4-Charitable actions
5- The most important category is community.
B-Needs Assessment:
This phase has two sections. In the quantitative phase,
the status of mental health was extracted by GHQ via
Urban HEART developed by the WHO office (5)
(Table 1).
In the qualitative study, four FGD and five in-depth
interviews were implemented. The characteristics of
the participants in the FGD are as follows:
The participants in the individual interviews consisted
of the representatives from the municipality, health
centers, two of volunteers and one member from of the
NGO related to women’s health in the district .
Based on data saturation, and according to the
analytical framework of WHO in mental health
condition, five categories and twenty sub categories
related to social determinants of mental disorders are
extracted as follows:
- Socioeconomic and position: this category was
presented by key persons. It seems that these
needs were related to the national level. There are
four sub- categories in this level consist of:
including instability on policy and planning, social
gradient, lack of insurance for unattended family
families and income inequality.
Member of NGO said: “Instability on of policy can
cause mental health problems, because you cannot have
any plans for your life. Today you are wealthy, but
tomorrow you will may be poor.”
- Differential Exposure: Based on the views of the
majority of participants` view, there are some
exposures leading to impaired mental health such
as unemployment, income insecurity and increased
living costs that can lead cause to a decrease in
social welfare.
Married women in FGD said: “when you are poor and
cannot pay the rent, you will be depressed ."
Representative A representative from municipality:
commented, "Income insecurity as much as
unemployment can create mental disorders”.
Globalization, internet access and changing changes in
the cultural norms, despite some benefits, can make
cause complex problems especially particularly for the
youth. In addition, in the opinions of the majority of the
participants tobacco use and addiction could in
opinion`s majority of participants destroy the capacities
of the community.
- Differential vulnerability: in this regard, two
important needs were expressed by most of the
women, : at first lack of mental health literacy and
then lack of knowledge and skills related to
dealing with stress .
Most of married women in the FGD: said," we don’t
know how to manage the techniques of our stress
management and or how to dealing deal with daily
stress pressure ."
- Differential health outcome: In this category, three
important sub- categories were presented as
follows:
- lack of free counseling centers in the study
area
- stigma and delay in help seeking
- lack of access to mental health services
Representative from a health center said:"To promote
mental health, having access to mental health services
and free counseling centers in the district are needed to
mental health promotion ."

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The above mentioned categories are related to the
prevention of mental disorders, but the following
themes are related to harm reduction.
- Differential Consequences: the most important
need in this part is Lacking of facilities for
mental health rehabilitation is an important
issue needing attention, and. Failure to
response to satisfy this need may be create
social exclusion and reduce the ability to
work.
C-Priority Setting:
During the nominal group and brain storming sessions
with participation of the key persons and research
team, some criteria (Table 3) for setting the priorities
were extracted. These criteria consisted of three main
categories and seven sub-categories. Based on the
participants` view, for each subcategory, scores 0-3
was considered.
After a score was given to each of the social
determinants of mental disorders in each level, the first
important priority was determined (Table 4).
Table 1: The Status of Different Domains of Mental Health Based on GHQ
Table 2: The Demographic Characteristics of the Participants in FGD
Demographic Characteristic
Status
Age
Max :59
Min:23
Mean:24.6
SD:10.5
Education
Non Academic Education :30%
Academic Education :70%
Employment status
Employed :30%
Unemployed:70%
Number of Children
Max:5
Min: 0
Number of Participants
30
Table 3: Mental Health Priority Setting Criteria
Main Category
Sub- category
Appropriateness
- Ethical and Moral Issues
Relevancy
- Community Demands
- Trend of the Problems
- Urgency
- Severity of the Problems
Chance of Success
- Capacity of the Project to Undertake the Interventional Program
- Cost Justification
Table 4: The Most Important Priority of Women’s Mental Health
Level of Conceptual Framework
First Priority in Each Level
Authorities for Intervention
Socioeconomic Status and Position
lack of Insurance for Unattended Families
Policy Makers in National Level
/Legislation
Differential Exposures
Unemployment
GOs and NGOs in the District such as
Municipality
Differential Vulnerability
Lack of Knowledge and Skills to Deal with
Stress
Training Positive Coping Mechanisms
by Projects
Differential Health Outcome
Lack of Free Counseling Center in the
Study Area
Ministry of Health and Medical
Education
Differential Consequences
Lack of Facilities for Mental Health
Rehabilitation
Social Welfare Organization
Indicator
District 22
(%)
Tehran
(%)
Anxiety
38.6
38
somatization
36.6
37
Impaired social function
22.7
26
depression
35.2
36
Impaired mental health
41.01
41

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context
exposure
position
vulnerability
outcome
consequence
Figure 2: Public Health Conditions Analytical Framework of WHO
Discussion:
In this study, three main approaches have been used
simultaneously (CBPR, ENHR and Analytical
framework of WHO) to design the interventions of
public health condition. In the CBPR approach,
community participation can improve the positive
health behaviors, human resource mobilization,
community empowerment and finally mental health
promotion (24). ENHR model is a bottom up approach
that set the priorities based on stakeholders` opinion
(6), and then determines the stage of the intervention
based on the analytical framework of WHO.
In our study, stakeholders' analysis was essential to
start the project. In this analysis, the role and function
of each stakeholder is important, and not the personal

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identity (25). In our society, with rapid changes in the
political positions, the sustainability of the stakeholders
was not enough and this was one of the limitations of
our project.
Interventions that address the socioeconomic context
are at the national level. Providing insurance coverage
for unattended families is one of the policies in this
level. According to the result of this project, secure
employment is important in differential exposure level,
but at the vulnerability level, training the positive
coping mechanism has been considered. In 2009, the
result of the study of the regional office for the Eastern
Mediterranean of WHO showed that in this region, the
interventions related to the above levels, consist of
reducing risk behaviors such as tobacco use, unsafe
sex, improving access to basic health care and
reducing social problems such as school drop-outs and
domestic violence(26). It seems that the first priorities
in our study are not completely compatible with this
study. In Iran, during the recent years, access to basic
health care has been facilitated, but the development of
free counseling centers and providing coping
mechanisms trainings are necessary. Considering the
differential consequences, the majority of the
interventions cannot evaluate these consequences,
because they are frequently distal to the intervention.
Furthermore, given the multiple, interacting nature of
the social determinants, it may be difficult to identify
which aspect of the intervention “caused” the mental
health outcome (26). Also, it is necessary to recognize
that mental health as a determinant can help explain
outcomes for individuals and communities (1), and as
an outcome it has multi-factorial etiologies consisting
of genetic, biological, psychological and social
determinants, with social determinants having
particular salience (27). For sustainability of all the
interventions targeting social determinants, existing
political will, strong community partnerships,
availability of financial and human resources are broad
requirements (28).
Conclusions
Improving the coping skills to deal with stress is one of
the most important interventions for mental health
promotion in women.
Acknowledgment
The authors wish to thank all the volunteers in district
22 of Tehran for assistance in data collection and
cooperation.
This project was extracted from a PhD thesis supported
by National Health Research Institute.
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