The clients' readiness to use mental health care services: Experiences and perceptions from Iranian context.

BACKGROUND: Underutilization of mental health care services has been a challenge for the health care providers for many years. This challenge could be met in part by improving the clients' readiness to use such services. This study aimed to introduce the important aspects of the clients' readiness to use mental health services in the Iranian context.
MATERIALS AND METHODS: A thematic analysis of in-depth interviews was undertaken using a constant comparative approach. Participants (11 health professionals consisting of 3 physicians, 7 nurses, 1 psychologist, and 5 patients/their family members) were recruited from educational hospitals affiliated with Isfahan University of Medical Sciences, Iran. The credibility and trustworthiness was grounded on four aspects: factual value, applicability, consistency, and neutrality.
RESULTS: The study findings uncovered two important aspects of the clients' readiness for utilizing mental health care services. These are described through two themes and related sub-themes: "The clients' awareness" implies the cognitive aspect of readiness and "the clients' attitudes" implies the psychological aspect of readiness, both of which have perceived to cultivate a fertile context through which the clients could access and use the mental health services more easily.
CONCLUSIONS: For the health care system in Isfahan, Iran to be successful in delivering mental health services, training programs directed to prepare service users should be considered. Improving the clients' favorable attitudes and awareness should be considered.

INTRODUCTION

Although various effective mental health care services (MHCS) are available,[1] majority of people do not get even adequate services.[123] Apart from some limitations in the provision of MHCS, many people in developing countries[45] such as Iran[6] do not receive even the available care services.

History and current context of mental health services in Iran

Modern mental health care system in Iran was established in the 1940s. In the 1960s, new university hospitals and psychiatric departments were built; and in the 1970s, comprehensive community-based mental health care was achieved[7] that was aimed to decentralize MHCS and decrease hospitalization rate. After the Islamic revolution in 1979, the “Teheran Psychiatric Institute” was formed. In 1985, “National Mental Health Program” was drafted.[8] Now, mental health services in Iran are delivered mainly by governmental and some nongovernmental as well as private organizations.

Review of the literature

Many have tried to uncover and describe the causes of service utilization gaps. Some researchers have tried to depict various factors that may be influencing MHCS utilization, namely financial,[2] cultural,[1] stigma,[9] access to services,[10] individual, and family factors, type of symptoms exhibited,[11] severity of the health problem,[12] etc. However, particular attention have been paid to high-risk population instead of all health clients in mental health care settings[123].

Now, there is an increasing attention to the critical roles of service users in utilizing MHCS. Some researchers have focused on service user involvement as an important factor.[1314] But there is a scarcity of documents about the clients’ role in the state of MHCS utilization. Particularly there is no published document specified to explore clients’ readiness as an important factor to use MHCS in the context of Iran. Therefore, this study was aimed to explore and describe the important aspects of the clients’ readiness to use MHCS in the Iranian context.

MATERIALS AND METHODS

Design

In order to describe the participants’ perceptions and experiences of the clients’ readiness to use mental health education services, a thematic analysis method[15] is followed. Qualitative method of inquiry is the appropriate way to study this phenomenon in a natural context.[16]

Setting, sample, and procedures

This study was conducted in three educational hospitals affiliated to Isfahan University of Medical Sciences, Iran. Purposive sampling was used to recruit 16 participants, including 11 health professionals who consisted of 3 physicians, 7 nurses, 1 psychologist, and 5 clients. Participants were selected purposefully to ensure a range of participants.[17]

Initially the main interviewer met the managers of medical centers to get written consent to conduct the interviews. They were informed about the purpose and procedures of the study and asked to introduce some informant professionals who have work experience in the field of MHCS. Then the interviewer met potential participants in order to inform them about the purpose of the study, get some information about their work position, and invite them to the study. Other participants were selected considering their specific knowledge and experiences and based on the data that emerged from each of the previous interviews. Similar method was followed by the researchers to select the clients. The potential participants were marked by the health professionals based on the clients’ experiences of getting MHCS and their ability to participate in the study. They were verbally informed about the study purpose and how they could be helpful. Also, all participants signed written informed consent document that included some information about the sponsor institution, legal permission, and the study purpose.

Data collection and interviews

Data collection methods included unstructured in-depth interviews conducted over a 6-month period in 2010 (from February to October). All questions, whether to health professionals or from patients/their family members, explored the same phenomenon: “utilizing mental health services.”

Questions to health professionals included: Tell me about your experiences of providing MHCS for patients and their family members; tell me about any problems you faced in giving the MHCS for patients and their families; and how do you usually deal with the obstacles you find in giving MHCS. Questions to the clients included: Tell me about your experiences of receiving MHCS; how did you get your needed information and training; and can you tell me about any problems you faced with fulfilling your mental health needs. Some other questions also were asked at the time of need and based on the previous information gained from the interviewee, aimed to collect more information.

The interviews were all conducted by one main interviewer who was accompanied by an assistant. Two pilot interviews were completed, audio-recorded, transcribed verbatim, and reviewed by an independent researcher to ensure that the phenomenon under study is fully explored.

Each interview took approximately 1 h to complete. Some notes were also taken during the interviews that were useful in clarifying the meaning of information collected. All interviews were conducted in a private, previously agreed place (often in the participants’ work setting for professionals and in a private room in hospital for the patients and family members), and participants were advised that they could cease the interview at any time. The interviews were audio-taped with the participants’ permission. Taped interviews were transcribed verbatim as soon as possible after each interview during the first week.

The interviews continued until data saturation was reached and ceased once no more new information could be obtained from the interviews.[18]

Analysis

Data analysis was undertaken simultaneously with data collection. A thematic analysis method[15] was used to analyze the data obtained from the transcripts. Thematic analysis is used to identify explicit and implicit themes, essences, or patterns within the text in relation to the study aims and objectives.

The transcribed interviews were systematically reviewed by the two principal researchers independently who manually coded, identified, and categorized themes. Their works were assessed on a subset of transcripts in terms of ensuring consistency.

During the analysis process, texts were manually coded and common codes were combined to identify related themes. After analyzing each participant's interview (and related notes), sections of text coded to a particular theme were examined across the datasets and then overall themes were developed using constant comparative analysis. Theme choices were collectively discussed and the final result report was reviewed and agreed by the research team.

Quality assurance of data analysis and interpretation

Trustworthiness of the study was supported through including adequate number of subjects, accomplishing the analytical process actively, and reaching a level of saturation. Also, audio recordings were used to collect data and taped interviews were transcribed verbatim to prevent missing any information. Some participants were asked back to confirm a brief description of each analyzed interview. Text coding and data analysis were performed by the two researchers independently to ensure following consistent trend and getting similar results. Furthermore, we tried to strengthen the study by using peer-checking of the themes.

RESULTS

The findings emphasized on two important aspects of clients’ readiness for utilizing MHCS that are described through two themes and related sub-themes: “The clients’ awareness” implies the cognitive aspect of readiness and “the clients’ attitudes” implies the psychological aspect of readiness, both of which have perceived to be a potential context through which the clients could seek and use the educational services more easily. Some of the sample preliminary codes that the sub-themes and themes have originated from are listed in Table 1.

Table 1

Sample preliminary codes that the sub-themes and themes have originated from

Theme 1: The clients’ awareness

Awareness of services

Based on the findings, the first aspect of the clients’ readiness for utilizing MHCS is awareness of existence as well as nature of such services. The participants’ experiences showed that one of the barriers to utilizing services is insufficient awareness. It is evident from a participant who said:

“I think my lack of awareness or insufficient awareness … causes me that, for example, although I know my need, I don’t know how to meet it.” (No. 11)

Some participants believed that introducing these services to the clients may pave the way for improving services. For instance, a client said:

“Announcement about the available facilities and their benefits may be helpful.” (No. 14)

Awareness of the professionals

As the majority of MHCS are met by the health professionals directly, it is important that service users be aware of the professionals’ roles and responsibilities. Hereby they could get the needed appropriate services from professionals. Some participants of the study were uncertain about the professionals’ roles and responsibilities, which have been followed by avoiding expression of their own educational needs. For example, a client who had experienced stress said:

“If I talk to nurses about my stress, they may say that they couldn’t do anything because they are not counselors … maybe they only have responsibility to do my physical care.” (No. 9)

We found that some of the health professionals had given their own services based on the level of the clients’ expectations and wish, rather than scientific evidences as well as their own competencies. The favorite side of the coin is that such professionals are sensitive to the clients’ needs and wants. The unfavorable side of the coin is that they may adopt an inactive role against the clients who have not expressed their own needs, as evidenced in a nurse participant's quote:

“Almost all people expect a nurse to do only physical care for the clients. Expectations from us are limited to that. I think you should follow what is expected from you.” (No. 5)

Awareness of their own rights

For the effective use of MHCS, the clients need to be aware of their own rights as users of such services. The finding revealed that the clients, who had considered the services as their own rights, had expressed their expectations to use the services more than others. It is evident in a client's quote who said:

“They should take care of me, whether physically or mentally. I think they are capable and they have to do that. Doctors or everyone who works here should help me to be relaxed. I think they are responsible and they must do that.” (No. 11)

The professionals’ experiences also revealed the same finding, although they expressed the clients’ insufficient awareness as one of the current challenges of MHCS utilization:

“Laymen are really neglected; they think it is supposed to be like this; they think they should be neglected. They unfortunately accept such neglectful behaviors.” (No. 12)

“The people are not trained about their own rights, so they don’t expect anything more than it is.” (No. 3)

Theme 2: The clients’ attitudes

Attitude to effectiveness of services

Findings showed that the clients’ perceptions about whether the services are right and appropriate for improving their own health play a great role in their approaches toward the services. For example, a client who had negative attitudes about the counseling services pointed out thus:

“I have experiences from other professionals, which sometimes lead me to distrust counseling services.” (No. 11)

A nurse connected the clients’ negative attitudes with the professionals’ faults in delivering services:

“A problem that I always see is that the people have poor beliefs about MHCS; sometimes the psychologists and psychiatrists are stigmatized as being crazy.” (No. 4)

Attitudes toward service providers

Besides the importance of the clients’ attitudes toward the services, the findings predominated the importance of the clients’ attitudes toward “the service providers” as well. The clients’ perceived characteristics of the professionals as being active or passive people, expert or inexpert, client oriented or task oriented, and finally effective or ineffective, affect their decisions to use the services.

“I have not found the professionals as excellent, because I think they themselves have distresses that have not been resolved yet… when I see that my care givers are depressed or tired, certainly he or she couldn’t work as backer.” (No. 8)

“We are the professionals’ customers; they do like us to be patients.” (No. 13)

Attitude to their own needs

Findings revealed that the clients’ perceptions of their needs to MHCS have been influenced by their tendency to utilize such services. It means that the clients who had not perceived the services as important had not attempted to utilize the services.

“Majority of the clients is not interested in getting information …” (No. 1)

“I’ve never got to health centers to get education service; often I’ve tried to help myself to overcome my problems.” (No. 11)

DISCUSSION

This study aimed to introduce the important aspects of the clients’ readiness to use MHCS in the Iranian context. The findings revealed that the clients’ awareness was a key aspect of their readiness. We found that it had been challenging for some clients to find the services appropriate for their mental health needs. Therefore, some of them have los t their opportunities to meet their mental health needs. Wang et al.[19] have related the unmet mental health needs of the clients with some conditions such as being a member of traditionally underserved groups, elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas.

Findings emphasized the importance of the clients’ awareness of the professionals’ roles and responsibilities in their attempt to use MHCS. Therefore, it may be helpful to establish training programs or planned experiences to improve the clients’ awareness. This finding is in line with Teng and Friedman's finding who report an appropriate service use in older Chinese Americans and a significant increase in intention to consult a mental health professional for psychiatric symptoms after increasing mental health awareness.[20]

The study findings also uncovered the clients’ awareness of their own rights to receive appropriate care as an important aspect of their readiness to use the services. Now, the right to receive appropriate MHCS has been well recognized as human rights of all communities. Particularly in terms of health system clients, it is established as a main aspect of the clients’ health services.[21]

Based on the findings, it is worthwhile to suggest training programs directed to improve the mental health clients’ awareness in order to improve MHCS utilization. Recently, some studies have demonstrated higher education level as an important variable which is associated with an increased likelihood of MHCS use.[22]

Moreover, consumer-directed care through which the clients have increased decision-making responsibilities to increase self-care and self-efficacy[23] may be a helpful way of improving the clients’ readiness to use MHCS.

The main theme “the clients’ attitudes” implies the clients’ psychological readiness to see certain things in a positive or negative way. The study findings identified the clients’ attitudes as an important element of their readiness to use MHCS. We found that the clients’ attitude to effectiveness of services plays an important role in their decisions to engage in mental health services and to seek help to meet their own education needs. Jang et al.,[24] who examined the attitudes toward mental health services in their study, pointed out that culture-influenced beliefs such as cultural misconceptions have a substantial contribution in the clients’ attitudes toward MHCS. Some of our participants had negative attitudes that had hindered them in seeking help for services. Similarly, Eisenberg et al.[25] have identified the stigma related to mental illness and mental health services as an important barrier to use mental health services.

Moreover, we found that the clients’ attitudes toward the service providers have been perceived as an important factor in service utilization. The findings showed that the clients’ negative attitudes to the health professionals hindered the use of the MHCS. Lee et al.[26] related this challenge with the clients’ relationship with the mental health professionals, the level of professionalism of the professionals, and the effects of the treatment. They found that communication with mental health professionals was frequently problematic, and so, their study participants expressed feeling like being ignored and misunderstood. Also, more than half of the parents who participated in the study conducted by Starr et al.[27] were concerned that the health professionals would not care for their child. It is also pointed out in the study of Irajpour et al.[28] who identified the challenge of medical-oriented approach of the mental health professionals in the Iranian context. So, it may be helpful to design planned experiences of the clients-professionals relationships through which the mental health clients could perceive the mental health professionals as friendly and helpful. This idea has been supported by Ishikawa et al.[29] who pointed out that the clients’ prior help-seeking experiences work as a key motivational factor for seeking mental health services.

The findings also showed that another important aspect of the clients’ readiness to receive MHCS is their attitudes to their own needs. Ishikawa et al.[29] also demonstrated perceived need for treatment to have an important effect on the clients’ help-seeking behaviors. Similarly, Sareen et al.,[30] who studied the pattern of reported barriers to mental health service utilization, found that attitudinal barriers (thoughts that the problem would get better on its own) were more prevalent than structural barriers (inability to get an appointment). Moreover, Thoits[31] reported a positive relationship between severity of the clients’ mental conditions and, therefore, the perceived needs and the probability of mental health utilization.

In brief, the study findings emphasized on the clients’ critical role in mental health services. It is congruent with the findings of Alavi et al.[32] They introduced the clients as the center of MHCS that can bring the mental health professionals together in order to meet the clients’ mental health needs.

CONCLUSION

This study uncovered some important aspects of the clients’ readiness to use MHCS. Nevertheless, limited number of the study participants would limit the transferability of the findings to other context. This problem could be met by conducting other large-scale studies on this topic.

The study findings emphasized on the clients’ critical role in mental health services. For the health care system in Isfahan, Iran to be successful in delivering mental health services, training programs directed to prepare service users should be considered. Improving the clients’ favorable attitudes and awareness should be considered.