How Iranian women conceptualize mental health: an explanatory model.

BACKGROUND: In Iran, more than 25% of women suffer from mental disorders. Mental disorders and subclinical problems are associated with socioeconomic problem. At the community level, mental health promotion can reduce social damage. The aim of this study as a part of community based mental health promotion intervention was to explore how mental health in Iranian women is viewed.
METHODS: According to a qualitative method in 2012, participants were selected by purposeful sampling from married women 18 to 65 years who are residents in Tehran. Fifteen in depth individual interviews were conducted with regard to the concept of mental health, causal pathway and help-seeking behavior according to explanatory model.
RESULTS: Mental health was perceived as the same of emotional well-being. It conceptualized not only lack of mental disorder but also sense of satisfaction and healthy functioning. According to participant's view, the causal pathway of mental health problems were classified to individual, familial and social factors. Physical and behavioral problems were related to individual factor, Lack of marital adjustment was one of the most important issues in familial item and in social factor, cultural context and socio-economic problems were extracted. In help seeking process, all of the participants believed that the religion has important effect in mental health.
CONCLUSION: Marital adjustment is an important stage in process of mental health in women.

Introduction

According to World Health Organization's definition, mental health is a state of well being that individuals can recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities. In fact, the mental health is more than the absence of clinical mental illness (1).

In 2004, 1.2% of deaths in men and 2.2 %of deaths in women have been due to psychological disorders. These diseases are responsible for one third of Years Lived with Disability (2).

In Iran, in 2004, according to Noorbala and colleagues survey, using the General Health Questionnaire, 21 %of the total population (25.9% of women and 14.6% of men) suffered from mental illness (3). In 2008, this percent has been increased to 36% in Tehran (2 to 1 in women than men) (4).

Considering the importance and high prevalence of mental health problems, especially among women and also its greatest impact in causing other diseases and complications (5), it is needed to be designed the interventional programs to promote mental health. Different studies indicated that mental health promotion at the community level can reduce social damage at this level (6, 7).

There are a lot of interventional programs in mental health. In 2012, Francesca and colleagues using the qualitative method studied the role of peer support within the Clubhouse model. Through this study, four levels of peer support emerged and emphasize that Peer support facilitates recovery (8). Also, in 2012, through the interventional project, the mental health needs assessment in elderly care givers was be done and some interventions such support groups, training for caregivers and other community members were be implemented (9).

In Iran, in 2010, in three ethnic groups, the concept of depression was extracted by qualitative method (10). The results of this study were used for interventions planning.

In this study, as a part of community based mental health promotion intervention, we explore how mental health in Iranian women is viewed. For achieving this purpose, we used frame work of explanatory model (11) which is a way of looking at the process with regard to the concept of mental health, cause and help-seeking behavior. This model is used to explain, organize, and manage particular episodes of impaired well-being and is strongly shaped by the context (12).

Materials and Methods

A qualitative approach was selected for this study because the use of qualitative methods can provide an in-depth understanding of the issues and barriers related to women mental health and can help to inform the planning of health promotion programs and interventions (13).

Data collection started in December 2011 and ended in July 2012. In this study, participants were selected by purposeful sampling from married women 18 to 65 years who are residents in District 22 of Tehran Municipality. This area is located in the western part of Tehran, Iran. District Characteristics such as, having active groups and humanitarian organizations related to Tehran Municipality, easy access to the community and its population, having demographic information led us to select it as the venue of our study .

Individual in-depth interviews were used for data gathering, because this tool can provide an in-depth understanding of the issues and it is quite flexible (14).

Number of interviews was based on data saturation. Each interview lasted 1-1.5 hours, and ended when no new issues seemed to arise. In cases, that there was ambiguity or a question was raised, the interview was repeated. The place of Interview was chosen based on the interviewee.

In each interview, the moderator started the interview by presenting the aim of the study. The Participant was also informed about confidentiality, that participation was voluntary and informed of her right to withdraw from the study at any time during the interview. The nature and purpose of the study were explained to each participant before her consent, which was confirmed by a signature or a left thumb-print. Permission to audiotape the interview session was sought orally prior to the interviews. The discussion started with how the mental health might be defined and described. Then respondent was asked to define a stressful day. During the interview the appropriate probes with words as where, when, how and why were done. Probes were used to confirm concepts mentioned and to explore new areas.

The study protocol was approved by the ethical committees in University of Social Welfare and Rehabilitation Sciences.

Data analysis was performed using content analysis (15). All of the individual in depth interviews were transcribed. The transcribed interviews were analyzed manually. The transcripts were read with the intention of deriving ‘meaning units. The coding scheme was derived theoretically according to the framework of the study, with regard to the concept of mental health, cause and help-seeking behavior. On the other hand, the themes and subthemes were extracted from transcripts, providing the basis for generating new codes or modifying the codes by induction. The inductive codes were sorted into meaningful categories within the theoretical themes (16).

In this study, various aspects of trustworthiness have been observed. Sharing the summarized interview findings with the participants at the end of the group discussion (respondent validation). Attempting to clearly detail methods of data collection, analysis, added quotes, and meaning units (Transferability), peer checking by an experienced colleague (dependability), and Consistency checks between colleagues were also performed throughout the analysis process (team consistency) (17).

Results

In this study, the total number of 15 interviews was conducted. Demographic characterization of participants is shown in Table 1. The participants' views were analyzed within the three themes, Under these themes, subthemes were identified as follows:

Table 1

Description of demographic characterization of participants

Age (yr):	Max:59	Min:23	Mean:34.6	SD:10.5
Sex:	Female :14		Male:1
Education:	Under diploma:1	Diploma:4	Master:5	MSC:5
Job status	Employment:9		Housewife:6
Marriage status	Married:11	Divorced:2		Single:2
Duration of marriage (year)	Max:45	Min:0	Mean:8.2	SD:13.7
Number of children	Max:5	Min:0

1-Definition of mental health:

The majority of participants believed that the Mental health is emotional – well being.

They expressed that; sense of satisfaction is one of the most important causes of emotional-well being. According to participant's view, people who have high self-esteem, realistic beliefs, sense of control, essence or spirituality are satisfied. Based on women's experiences, healthy functioning is another meaning of mental health. It includes lack of stress and has some skills as coping, problem solving and stress management. These components provide means that promote healthy functioning. Also, based on participant's opinion, mental health can be identified by absence of mental disorder such as depression, anxiety and so on.

2- Causal pathway of mental health problems:

The subthemes of cause of mental health problems were classified to social, familial and individual factors.

a- Social factors :

This factor consists of socioeconomic situation and cultural context.

The majority of participants expressed that Poverty is an important factor in mental health problem. Unemployment, especially in married men, job insecurity which raises stress in work place and financial problem are effective in this regards. But they believed that be too wealthy is also not good and money is Double-edged sword.

“If you're poor, you should be concerned about the rental house or living expenses. You should think about your education expenses of your kids and so on. When you are rich, after a while, you will come to be absurd and you have no thing to be happy “.

Also social problems such as addiction, divorce and social stigma can cause to mental health problems.

“If you're a widow or have an addiction you cannot live with peace of mind because they all deal with different and you'll be disappointed”.

In relation to the cultural context, some of the participants believed that the ethnic difference has role in creating argument in family, especially in new married couples, and therefore these differences can cause mental health problems in the family.

“I had argument with my husband because he was Turk and I was Fars . He hadn't understood me and finally I got divorced and now I has mental problem”

b- Familial factors:

This factor is comprised of two stages, before and after marriage as follow:

Some of the participants believed that, parental irresponsibility, familial adversity such as inter-parental violence can cause emotional difficulties and behavioral problem in children. Also, parental divorce has negative effect and its aftermath in adult mental health. In these families, the absence of the father and great responsibility of mother can cause the children actually lost both of them, because, maternal duties such as upbringing of children are not done completely.

“My mother had to go to work to manage our lives. When she back to home, she was very tired and she didn't any time to express her love. I lost all of them, father and mother”.

Authority of parents is also effective in mental health. Patriarchy, female democracy or participatory decision making are three main kinds of authority in families based on participant's view.

“In our family, all decisions are made in consultation with family members and I learned it from childhood”

“In our family, all of the decisions made by my father and we hadn't any role in this regard. Now I am married but I think I must be obedient to my husband's decisions and it bothers me”

In after marriage stage, marital adjustment includes age of marriage, choice of spouse, male – female roles and cultural conflicts are important in Wives' mental health. The majority of participants believed that, the choice of spouse is very important in mental health process and the age of marriage has effect on it.

“My mother was put under pressure to get married because of my age” .”I was scared because I had lost all chance of marriage”. “I married with high expectation. I had though all shortcomings should be resolved with marriage. But it was wrong”.

c- Individual factors:

According to some of the participant's opinion, behavioral characteristics such as aggression, lying, egoism, jealousy, vanity, irresponsibility are important in mental health problems.

“Jealous people compare themselves with others constantly and they are not at all comfortable”.

“People who are lying, they are anxious and worried constantly, because they are afraid to reveal their lies.”

Some of participants said that, Physical disabilities and serious injuries due to accidents and so on can facilitate mental health problems

“Healthy mind in a healthy body”

3- Help- seeking process :

This process consists of “reinforcement of faith in God”, help from others and counseling.

All of the participants believed that the religion has important effect in gaining the peace of mind. They noted that belief in God as a safe harbor can cause to escape from loneliness.

“When I'm sad, I'm just talking with God. I feel, there is a super natural power that helps me”

Friends and close family members especially spouse in new couple and children in old couple were expressed as the main source of support. Changing the living conditions such as traveling, entertaining activities, provision of a cheerful environment were the suggested strategies for changing the monotonous rhythm of life and dealing with the problem. Peers are particularly important in this process.

“Whenever I'm sad, I go with my friends. They understand me and try to help me.”

The majority of educated participants recommended consultation with a family counselor or psychologists. They pointed that, speaking with an expert in comfortable situation causes the person to relax. Learning the life skills as stress management, problem solving and so on were other strategies for mental health promotion. Using the herbal medicine, relaxation exercise and different ways of coping mechanisms were the other strategies that be mentioned by some of participants.

“I think, it is needed to learn how to manage daily stress, how to say no, how to solve our problems “. “Family counselor can help us very much”

Some of the participants believed that despite of advantages of counseling, due to high cost and social stigma; many people do not go to a counselor and it can cause much more psychological problem.

“I want to go to counselor but I am afraid, others will think I'm crazy”

Discussion

This is one of the qualitative studies about perceptions of female related to mental health carried out in Tehran. A majority of the study participants considered that the mental health is the same of emotional well-being. According to results, there are three main causes consisting of social, individual and familial factors in mental health problems. Based on participant's view, mental health problem could be managed in a first stage with the help of religion, family, and friends and consultation to control of daily stress.

Definition of mental health highlights emotional well-being. It means the capacity to live a full and creative life, the flexibility to deal with life's inevitable challenges (18, 19). Also There are two dimensions of ‘wellbeing', that consist of Hedonic (positive feelings or positive affect) and Eudemonic dimensions (positive functioning) (20)

The results of this study indicate that many participants tried to explain two dimensions of positive mental health or well being. Subjective wellbeing, life satisfaction and happiness for hedonic dimension, sense of meaning and social wellbeing for eudemonic.

Regarding to causes of mental health problem, there is a relationship between mental health and economic condition. Unemployed people feel stress about finding a new job and employed feel less secure about being able to keep one (21). Based on the COS-RGO project on Mental Health and Economic Development, the increase in certain types of mental health problems can be related to changes in the economy, especially in the nature of work and the increase in work-related stress accompanying this change (22). According the participants view, social problem such as addiction and social stigma can cause the mental health problem.

The study in New York showed that the social stigma can effect on psychological well-being, cognitive functioning, and interactions with non-stigmatized individuals (23).

In related to behavioral factors, bad habits such as Jealousy have linked to aggression and low self-esteem. These habits refer to the negative thoughts and feelings of insecurity, fear, and anxiety (24).

Besides, According to Mental Health Foundation, there is inextricably link between the Physical health and mental health. Activities are needed to improve the physical health of people with mental health problems, and to make mental health a key public health priority (25).

In related to familial factors, parental divorce has an effect on mental health. A longitudinal, multi-method survey in Great Britain showed that parental divorce had moderate, long-term negative impact on adult mental health (26). Also in children exposed to early severe deprivation due to parental divorce, there are more attachment disturbances and mental disorders (27). In opposite that, marriage can improve the mental health and the risk of mental disorders reduced for both men and women (28). In our study, marital adjustment is a key stage in mental health process.

The results show that the help-seeking pathway begins with daily stress and some of resources such as God, friends, family and psychologists facilitate this process. In this pathway, reinforcement of faith in God is one of the most important resources for gaining piece of mind. The study of Levin and colleges in 2005 on African Americans showed that religion has identifying effects on both physical and mental health outcomes (29).

Conclusion

In Iran, familial factors such as marital adjustment have essential roles in women mental health process.

Ethical consideration

All Ethical issues (such as conflict of interest, plagiarism, misconduct, co-authorship, double submission, etc.) have been considered carefully.