Intersectoral Expectations for Promoting Mental Health: A Qualitative Case Study of Islamic Republic of Iran.

BACKGROUND: The prevalence of mental diseases is 23.6% in Iran. Taking intersectoral measures is said to be effective in promoting mental health and reducing the burden of the diseases caused by social determinants. The aim of this study was to determine the role of national organizations in promoting mental health in Iran.
METHODS: An applied descriptive qualitative method was used. The data were collected by reviewing the literature, interviewing with experts, and holding focus group discussions. To identify the roles of organization, a two-dimensional matrix was drawn.
RESULTS: The roles of 31 national organizations in five groups were determined. Then, the intersectoral organizational expectations in two key areas were extracted. The key roles determined were mostly related to the Ministry of Education, Islamic Republic of Iran Broadcasting, Ministry of Labor and Social Welfare, and the Ministry of Sports and Youth.
CONCLUSIONS: Due to the growing burden of mental disorders in the country, informing national organizations and attracting their active participation based on intersectoral expectations and developing interaction mechanisms among them can be an effective step in promoting mental health and reducing the environmental factors threatening mental health.

Introduction

Importance of mental health issues

Health systems of different countries are less concerned about mental diseases mainly due to lack of specific symptoms, their widespread and complex risk factors, and their consequences on people and on the environment.[12] About 25% of the world's population is affected by a variety of mental disorders such as schizophrenia, depression, anxiety, suicide, emotional disorders, hopelessness, mood disturbances, drug abuse, alcoholism, etc., in their lifetime.[1] According to the World Health Organization (WHO) in 2009, about 450 million people suffered from mental disorders including schizophrenia, depression, epilepsy, dementia, alcohol dependence and other mental, neurological, and substance-use disorders. This proportion constituted 13% of the global burden of disease, surpassing both cardiovascular disease and cancer and was estimated to reach 15% by 2030.[1345]

In Iran, according to the latest national mental health survey, mental disorders, with a prevalence of 23.6%, have the second highest burden of disease after accidents.[46]

Moreover, about 15.6% of the populations suffer from anxiety disorders, about 14.6% from affective disorders, and 0.55% from primary psychotic disorders. These rates are significantly higher than the global statistics of prevalence of mental health disorders (18.1%–36.1%).[78] Despite higher prevalence of mental health disorders and diseases in Iran, mental health care has not been enjoyed that much attention, and about 65.3% of patients with such disorders do not benefit from any preventive or therapeutic interventions.[7] In the last two decades, all the mental health programs have only covered the population of the rural areas, whereas the urban areas have generally been suffering a lack of services. Interestingly, more than 75% of outpatient mental services is delivered in private clinics and by private psychology and psychiatry; and government sector generally covers the inpatient services. Besides, the cooperative mechanisms between government and private sectors are not clearly defined. Therefore, mental disorders in the country are not adequately diagnosed and treated.[9] According to numerous studies between years 1999 and 2005, the burden of mental diseases has been reported to be second to the unintentional accidents – the same as that of the cardiovascular diseases. On the basis of global trends and the rising trend of Iran's development across different sectors, especially the industrial sector, the comparison between the two recent national surveys (in 2010 and 2011) has demonstrated that the trend in prevalence and burden of mental diseases has been increasing in the past 10 years. More recent studies, including study of justice in the healthcare of urban areas in Tehran in 2009, revealed that the prevalence of suspected mental disorders in residents of Tehran has been 34.2% in average, with significant differences among different areas of Tehran. At the national level, the analysis of the mental health system in general shows that, at the present time, the internal environment (including resource generation and mental health service provision) is in dire straits, and the external environment (players involved in distribution of risk factors for mental health and the environmental factors) is under serious threat; so that improving the present situation requires increasing the capacity of the mental health system internally and expanding the intersectoral collaboration mechanism externally.[4]

The need to develop intersectoral cooperation for reducing social determinants of health

Due to the changing face of diseases in recent decades, the importance of social determinants that threaten health has been more recognized by different countries. Accountability to emerging health needs and ensuring the provision and promotion of public health in the long run is beyond the ability of the health sector alone, thus requiring multisectoral measures in cooperation with stakeholders. So that, it is increasingly recognized that producing positive changes in population health status, including mental health, requires initiatives that go well beyond the confines of the health sector alone.[1011] According to WHO, <28% of the countries worldwide allocate specific budgets to the treatment of mental disorders.[1] Moreover, only 60% of countries have policies, 71% have programs and 59% have laws and regulations for mental health. Since the mid-twentieth century onward, with the identification of the risk factors of mental diseases and the insufficiency of mental hospitals and health services, the governments in global scale have sought more comprehensive and community-oriented approaches. Governmental efforts to develop intersectoral cooperation to establish a health approach in all policies after Alma Ata Declaration in 1978 and the Charter of Ottawa in the 1980s are examples of effective measures to reduce the global burden of diseases attributed to socioeconomic factors.[511] Emerging evidence support the social determinants of mental health emphasizing on the need for collaboration among the involved organizations in terms of formulation/design and implementation of policies by which the determinants are addressed for specific population segments/groups/targets. Unfortunately, the mental health issue has had incomparable share of public health discussions and therefore has been less current in the common agendas for national development sectors/authorities.[1112]

In Iran, with regard to the high burden of mental diseases and due to the lack of mental service coverage for the population covered by the health system, and because of the structural weaknesses of the services provision system and also the content deficit of mental health programs, it is necessary to prepare a common fields for health sector to collaborate with other development sectors that influence the distribution of social determinants of mental health through identifying their potential role in prevention and treatment of mental diseases.

Aim of this study

In this article, with regard to the importance of socioeconomic determinants of mental health, the risk factors pertaining to mental disorders and diseases have been defined in Iran. In addition, as nonhealth sector could have an important role in provision and distribution of such factors along with the health sector, the key functions of each organization in the nonhealth sector have been identified in correlation with those factors and some intersectoral expectations have been raised according to those identified functions.

This paper draws on the finding of a situational analysis conducted by the National Policy of Mental Health Promotion in Iran society (which aims to provide intersectoral policies to reduce the depression burden and all sorts of disability concerned to acute mental disorders in collaboration with all developmental sectors in Iran).

Methods

Study context

The study was carried out in 2011 in Iran where the mental health disorders prevalence is about 23.6%, having the second highest burden of disease after accidents.

Study design

The study identified the intersectoral expectation for promoting mental health in Iran through a progressive plan [Figure 1]. The study employed a qualitative research design using a case study approach and was conducted in three phases: i) preparation, ii) identification, and iii) intervention [Table 1].

Figure 1

The process of the study

Table 1

Timeframe for the development of the study

Phase	Timeframe
Preparation phase	1 month in
Analyzing stakeholders and team building	April 9, 2011, to May 10, 2011
Collecting the data (including scientific resources/reports/national and international documents)	April 21, 2011 to May 10, 2011
Identification phase	2 months in
Identifying the analytical framework of the study	May 11, 2011, to June 10, 2011
Identifying the stakeholder organizations and their functions	June 11, 2011, to July 11, 2011
Intervention phase	3 months in
Determining the expectations	July 12, 2011, to September 11, 2011
Finalizing the expectations	September 12, 2011, to October 12, 2011

Data collection and analysis

Here is provided thick methodological information to elucidate all the research process, step-by-step and address the conformability and transferability.

Preparation phase

Stakeholder analysis

To correctly identify expectations and to increase the possibility of success for the study team in the advocacy stage for identified expectations, an attempt was made to identify key stakeholders in mental health field. For this purpose and to address credibility, we used well-established methods, the four-stages of business network of Business for Social Responsibility, to analysis the stakeholders. First, a list of 60 individual from different stakeholder organization related to different sectors (from inside and outside the health sector) was provided according to their legal responsibility and their extent of influence on mental health promotion. Second, each of the identified individuals’ status was evaluated by five criteria: Legitimacy, contribution, the need for involvement, influence, and willingness to engage. Next, a four-part table map of the stakeholders was prepared using the two dimensions of willingness to contribute and the level of expertise. Finally, those stakeholders with high level of knowledge and expertise plus willingness to cooperate were selected.

Team building

Following the stakeholder analysis, 42 experts from sectors related to mental health were selected at national and provincial levels [Table 2].

Table 2

Summary of participants

Groups	n
Politicians
Commission of Health and Treatment of Parliament	7
Deputies of Health, Treatment, Research and Technology, and Food and Drug organization of MOHME
Public sector policymakers, planners, and experts (from the ministry of health, education, labor, etc.)
Mental and social health office of MOHME	27
Health policymaking secretariat of MOHME
National Committee for Mental and Social Health
Representative of WHO in Iran
Social Studies office of Parliamentary Research Center
Representative of UNICEF in Iran
Welfare Organization
Budget center of MOHME
Psychiatric Institute of Tehran
Central Consultation Office of Ministry of Sciences
United Nations Office for Crime and Drug Misuse Control
Adolescent, Adult and School Health office of MOHME
Drug Control Headquarters
Health Network Management Center of MOHME
Special Education Organization
Civil and Social Education office of Judicial System
Ministry of Labor and Social Welfare
Health and Treatment Office of Imam Khomeini Relief Committee
Health Headquarters of Tehran Municipality
Population, Family, and School Health office of MOHME
Health Education and Promotion office of MOHME
Work, Environment, and Health Center of MOHME
Communicable and Noncommunicable Disease Offices of MOHME
Management Improvement and Administrative Transformation Office of MOHME
Community Nutrition development center of MOHME
Health Technology Assessment, Standards and Tariffs office of MOHME
Hospital Management and Clinical Excellence office of MOHME
Professional associations
Iranian Psychiatric Association	5
Iranian Social Workers Association
Iranian Sociology Association
Iranian Clinical Psychology Association
Iranian Child and Adolescent Psychiatry Association
Universities and Research Institutions
Faculty member of rehabilitation sciences and welfare university	3
Faculty member of Tehran University of Medical Sciences
National Institute of Health Research
Total	42

MOHME=Ministry of Health and Medical Education, WHO=World Health Organization, UNICEF= United Nations Children’s Fund

Identification phase

Identifying the analytical framework of the study

To identify mental health dimensions and related risk factors (analytical framework of the study), each of the investigators independently review narratively the scientific national databases (database of national publications, Islamic World Science Citation Center, Noor magazine, Academic Jihad Scientific Information Database, Regional Information Center for Science and Technology) and international databases (science direct, PubMed and EBSCO), WHO reports (mental health report 2001, risk factors of mental health report 2004, international mental health report 2008, improving health systems and services for mental health 2009, mental health and development report 2010); then the risk factors related to mental disorders were extracted. To identify the relevant literature, keywords of mental health promotion, mental health, mental disorders, mental diseases, and mental health risk factors were used. Finally, nineteen risk factors of mental health were selected as the base for identifying and analyzing the function of stakeholder organizations and determining the expectations.

Identifying the stakeholder organizations

Following identification of the risk factors, the investigators identified and reviewed the high order national policy documents (including Iran's Vision Policy Document for 2025, the 5th Social and Economic Development Plan, the Health Transformation Plan, annual reports of Mental Health Office of Ministry of Health and Medical Education (MOHME), evaluation reports of the relevant programs, documents from previous strategic programs, supportive notes of mental health programs and relevant studies and statistics) to determining the responsible organizations for distributing the identified risk factors and their related functions. As a result, 31 stakeholder organizations involved in mental health promotion were identified. For classifying the organizations and to address credibility, we used a well-established model, the Thomas Hester's, for classifying mental health-related organizations. He classifies the organizations according to their function and organizational mission in four categories: “policymakers, lawmakers, providers, and allocators of the financial resources,” “organizations providing judicial justice,” “organizations providing health education and social services,” and “advocacy groups.” Another group of organizations were identified in the study, whose indirect role in mental health promotion led us to group them under “partner organizations.“

Identifying organizations’ functions

In this phase, to identify the functions of each stakeholder organization and its relation with each of the 19 identified risk factors, the investigators analyzed a collection of high order and relevant documents including the high order national policy documents, lows pertaining to the organizational structure and functions of identified organization, their electronic portals (annual reports and documents of the organization, operational assessment reports, projects and national programs and plans), and other published documents available to the team, using qualitative content analysis technique.

The intervention phase

Determining expectations

Key informants identified in the preliminary stage interviewed to determine the expectations based on the 19 identified risk factors attributable to mental disorders. The interview schedule was designed based on the general objectives of the study. Major themes in the interviews were: (i) the potential role of the organizations in the prevention of mental diseases/mental health promotion through risk reduction and (ii) the potential role of organizations in removing the barriers to service delivery. Interviews were digitally recorded after obtaining signed informed consent from interviewees then, were carefully transcribed. The potential roles emphasized by interviewees were extracted and linked to each organization according to its function, in the form of a collection of expectations. Qualitative content analysis was undertaken, looking for both manifest and latent content. During the analysis, finding from interview with different key informants were continuously triangulated with results from document reviews and also were checked with themselves to let them change the concepts if they were unhappy with them or because they had been misreported. Interviewees were informed about the purpose of the study, of their rights to participate or not, and that their identities would be protected.

Finalizing the expectations

In this stage, for accrediting and finalizing the extracted expectations from the interviews, five sessions of focused discussion were conducted with all five categorized groups, with the presence of the key representatives from each organization under that classification, based on the principle of homogeneity of the participants in focus group meetings. Then, the identified expectations within two areas of “mental health promotion and prevention” and “barrier removal of service delivery” were discussed.

The investigators functioned as facilitators in the meetings, provided a short introduction, and described the identified functions and relevant expectations from each organization on the basis of the related risk factors; then, each of the participants provided their opinion in confirmation or objection to the identified expectations. After discussion, a roundup of their opinions within each group was identified and finalized for each organization.

Results

Based on the literature review, socioeconomic risk factors associated with mental diseases and disorders are shown in Table 3.

Table 3

Socioeconomic factors attributable to mental diseases and disorders

Socioeconomic risk factors
Poor early childhood development
Unsuccessful marriage and poor fertility
Violence and dissonant and unhealthy behaviors
Violation of civil rights
War
Having mentally ill parents
Lack of parental life skills
Inappropriate and noncaring schools
Low level of social capital
Drug abuse and access to drugs and alcohol
Homelessness
Poor living condition
Social isolation and exclusion from peer groups
Poverty
Unemployment
Occupational stress
Malnutrition
Lack of access to proper transportation
Illiteracy

The summed up opinions of key organizations representatives which were asked to discuss the identified function and roles of each organization in terms of intersectoral expectations for promoting the mental health and eliminating the obstacles toward mental health service provision are shown in Table 4. As it is shown in this table, identified organizations were categorized under five groups based on their mission and roles in the improvement of mental health and relieving mental disorders’ impacts.

Table 4

Matrix of intersectoral functions and expectations for promoting the community mental health in Iran

Organization type	Organization	Main function(s)	Organization role	Role type
				MHPP	PASD
Policymakers/law makers/providers and allocators of financial resources	Office of the Supreme Leader	Determining the mega policies of the Islamic Republic of Iran	Inviting official bodies and the community to make efforts to reduce risk factors of mental diseases	✓
	Expediency Council	Advising the supreme leader in setting mega policies of the Islamic Republic of Iran to solve public problems	Formulating, communicating and monitoring megapolicies in the management of risk factors of mental diseases in line with the country’s 20-year vision	✓
	Supreme Council for National Security	Setting the country`s security-defense policies	Enacting effective policies to protect national security with respect to its effects on mental and social health	✓
	Guardian Council	Supervising the legislation process and its outcomes	Supporting legislations in accordance with health equity	✓	✓
	Parliament	Legislation	Enacting bills related to mental health and monitoring the implementation of health attachments of approved laws	✓
	Presidential Institution of Islamic Republic of Iran	Implementing the constitution	Implementing the attachments of health policies, preparing the bills, and strategic plans of the government	✓	✓
	Supreme Council of Cultural Revolution	Setting the goals, developing the policies, and planning for cultural and scientific affairs	Enacting intersectoral cooperation policies for mental health promotion	✓	✓
	Drug Control Headquarters	Determining the policies and programs for addiction prevention and fighting drug trafficking	Developing policies and monitoring the interventions to reduce supply and demand effectively	✓
Suppliers of justice and trial	Judicial System of Iran	Protecting public rights and promoting justice and public freedom	Health-oriented training of judiciary staff and judges	✓	✓
			Providing voluntary or mandatory education for judges and clients	✓
			Promoting the mental health of the staff working in prisons	✓	✓
			Preventing the unwarranted imprisonment of people with mental disorders	✓	✓
			Treating behavioral and mental disorders in prisons		✓
			Reducing the impact of imprisonment on mental health		✓
			Establishing offices for protection of children and women in all provinces	✓	✓
			Providing psychological support for the families of prisoners	✓
	Ministry of interior	Providing security as a judicial bailiff (drugs, trafficking, corruption, crime prevention, arresting offenders, and preventing them from escaping and hiding)	Developing community health promotion programs in cooperation with the MOHME	✓
			Attracting the cooperation of and empowerment of Urban and Rural Islamic Councils, municipalities, and Village Administrations to improve the health status of their residents	✓
			Licensing the NGOs active in mental health and supporting their performance	✓	✓
			Informing provincial governors and technical work groups about mental health promotion and attracting their cooperation in this way	✓
			Protecting and supporting social, political, and legal freedoms of citizens within the constitution	✓
	Ministry of Justice	Administrating the prisons affairs and health violations Implementing governmental penalties	Establishing a monitoring system for mental and social health regulations, including laws for mental health, child abuse, and domestic violence	✓	✓
Service providers	Ministry of Education	Providing public educationProviding literacy servicesTraining teachers and instructors	Assessing and improving the mental health status of the teachers and instructors	✓
			Empowering PTA to promote mental health programs in schools	✓
			Assessing and reviewing the content of textbooks in terms of coverage of mental health and life skills at all educational levels periodically	✓
			Providing and training health workers for schools	✓	✓
			Participating in and supporting the establishment of health-promoting schools	✓
			Supporting the equipment of schools’ physical space	✓
			Assessing the mental health status of dropouts	✓
			Developing effective policies for managing dropouts		✓
			Introducing anti-discrimination policies in schools	✓
			Addressing the needs of children with special needs, including children with learning disabilities		✓
			Assessing the mental health status of exceptional students and their families	✓
	Ministry of Science, Research and Technology	Providing academics and students with health care servicesDeveloping the applied and technical skills training	Assessing the mental health status of students and staffs	✓
			Establishing the mental health advisory centers in universities		✓
			Providing students with relevant courses to improve their mental health literacy	✓
			Establishing programs to improve happiness among academic community	✓
			Reducing the stresses of periodic examinations	✓
			Unifying the curriculums of psychology majors and considering their teaching possibility in universities	✓
			Supplying the required human resources for community mental health promotion		✓
			Addressing the psychological consequences of students failing in university entrance exams	✓
	Ministry of Labor and Social Welfare	Creating jobs and reducing unemployment	Creating a positive work environment free of discrimination and violence	✓
		Providing safe work environments (reducing occupational accidents and using workplace opportunity for health promotion)	Preventing social damages	✓
		Providing opportunities to access trade unions and employers	Training social welfare staff about mental health	✓
		Creating job opportunities for women	Supervising the quality of services delivered in kindergartens	✓
			Assessing the mental health status of Imam Khomeini support seekers/clients	✓
			Increasing the employment rate of the vulnerable groups, especially mentally ill ones		✓
			Addressing policies promoting high levels of employment, maintaining people as workforce and helping unemployed people		✓
			Paying pension to mentally handicapped people and those with psychiatric disease	✓	✓
			Supporting the orphans, homeless children, help-seeking, and socially damaged women and girls and one parent families	✓	✓
			Supporting and empowering people being in risk of social harms		✓
			Providing social and professional rehabilitation facilities for mentally and physically disabled people and educating social deviants		✓
			Supporting and caring of the orphans, the disabled and elderly people		✓
			Including the presence and severity of mental diseases as a factor in receiving social welfare benefits		✓
			Providing benefits for mental patients` family members if they are primary caregivers		✓
			Establishing a center to address occupational violations and abuse of workers		✓
			Supporting low-income people to start small business units		✓
			Strengthening the rehabilitation services provided to psychiatric patients		✓
			Organizing homeless psychiatric patients		✓
			Covering all kinds of pharmacological and nonpharmacological treatment services including hospitalization, psychiatry, psychotherapy, counseling, occupational therapy, para clinic and laboratory (ECT, MRI, X-rays, EEG, and CT) by the health insurances for psychiatric patients		✓
			Providing health services (outpatient, hospitalization, paraclinic) covered by governmental insurances in public and private hospitals		✓
	Ministry of Roads and Urban Development	Providing secure and accessible housingProviding of urban facilities for health promotionDetermining future location of cities and population centersManaging and controlling urbanizationPromoting Iranian architecture, culture and Islamic values in architecture and urban developmentRenewing and reconstructing old neighborhoods, reorganizing old buildings and urban margins with the aim of empowering their residents	Monitoring the rate of rent and mortgage and preventing their uncontrolled increase	✓
			Giving priority to housing of people with psychiatric diseases		✓
			Assigning residential centers for psychiatric patients (such as temporary homes)		✓
			Avoiding discrimination in providing housing services for psychiatric patients and separating them geographically		✓
Advocacy groups	NGOs	Providing voluntary advocacy in various social and political fields	Advocacy with policy makers	✓
			Observing the mental health status of patients and those at risk and supporting them		✓
Partner organizations	Headquarter of Armed Forces	Making policies and commanding all armed forces	Assessing mental health status of armed forces	✓
			Implementing mental health promotion programs for armed forces	✓
	Department of Environment	Protecting the environment and ensuring proper and continuous utilization of the environment considering sustainable development requirements	Preventing environmental pollutions harmful to mental health	✓
			Performing EIA	✓
	Crisis Management Council	Preparing for and preventing crises and managing them through first aids provision	Preparing for unexpected disasters resulting from social psychosocial increased burden		✓
	Islamic Republic of Iran Broadcasting	Producing and broadcasting radio and television programs in three areas of informing, behavioral modification, and advocacy for high-risk behaviors , diseases, and public policies	Implementing joint programs for promoting community mental health in national and provincial levels	✓
			Developing, adopting, and promoting the Charter of Protection and Promotion of Mental Health	✓
	Ministry of Sport and Youth	Developing sport facilities	Planning and managing the community entertainment in all age groups	✓
		Developing promotional policies to promoting public and championship sports	Developing public sport, especially for vulnerable people	✓
Partner organizations	Ministry of Industry, Mining, and Commerce	Ensuring the health of the cycle of maintenance, distribution and utilization of basic goods/productsImporting healthy productsPreventing harmful drugs traffickingProducing healthy goods and materialsPreventing of environmental pollution due to good production processes	Providing workers with mental health services		✓
			Attracting employers, trade unions, and businessmen’s commitment to maintaining and improving the mental health of consumers through providing proper products and services		✓
	Ministry of Agriculture	Providing health care and disease management services for cattle, poultry, fish, and plantsAddressing rural and tribal developmentEnsuring the health of forests, pastures, and watershedsProviding food security, especially adequate production to reduce waste material and improve the quality of productsEnsuring the sanitation of slaughterhousesControlling the use of pesticides and chemicals and developing the processing industries	Providing farmers and tribes with mental health services		✓
			Attracting practical commitment of all food production owners to ensure the maintenance and improvement of the consumers’ mental health	✓
	Ministry of Culture and Islamic Guidance	Producing the cultural products (books, periodicals and audio-visual) that affecting the health risky behaviorsDeveloping policies addressing recreation development and the impact of tourism on happiness, music and artDeveloping policies addressing news agencies’ advocacy in health fieldProviding pilgrims with health servicesDeveloping charity policies addressing health promotionPromoting spiritual health based on the teachings of the Koran, the Prophet Mohammad and his householdPromoting cultural beliefs affecting health and self-confidence, hope, social, and individual happinessPromoting social capital	Supporting books, publications, and artistic products addressing mental health promotion and encouraging best products in this area	✓
			Developing traditional Iranian music	✓
			Developing tourism and community recreation specifically for vulnerable social classes	✓
Partner organizations	Ministry of Economics and Finance	Monitoring the receiving and fair distribution of taxesCooperating with and taking part in joint venture investments with foreign countries with regards to its effect on employment and per capita incomeDeveloping policies addressing banks and insurancesMonitoring the customs performance	Admitting policies addressing economic reform capable of reducing relative and absolute poverty	✓
			Eliminating any potential negative impact of economic reforms on unemployment status	✓
	Ministry of Communication and Technology	Establishing e-government and reducing household expenditures and unnecessary travel within and outside the cities	Allocating communicational and technological facilities to provide mental health literacy	✓
			Assessing and limiting the harmful effect of radiation on mental health	✓
	Ministry of Defense	Defending the country in special conditionsProviding the military force with health care services, especially during military service period	Planning comprehensively for improving the mental health status of soldiers and armed forces	✓
	Ministry of Petroleum	Providing the staff with health and safety services	Providing and promoting mental health status of workers in industries and special economic zones	✓
	Ministry of Foreign Affairs	Health diplomacy (reducing sanctions effects)Providing health and related protective laws for immigrants and foreigners	Cooperating in improving the mental health status of Iranians living abroad	✓
			Establishing effective health diplomacy by setting up an office or related system in ministry of foreign affaires	✓
	Ministry of energy	Providing permanent and healthy water supplyProviding fair access to electricity and gasPreserving water and energy resources and their transmission to the future generationsDeveloping policies addressing “new energies”	Paying attention to the mental health promotion of its personnel	✓
	Ministry of information	Providing security services to protect people against terrorism attacks	Paying attention to the mental health status of its personnel	✓

MOHME=Ministry of Health and Medical Education, NGOs=Nongovernmental organizations, PTA=Parents and Teachers Associations, EEG=Electroencephalogram, CT=Computed tomography, MRI=Magnetic resonance imaging, ECT=Electroconvulsive therapy, EIA=Environmental impact assessment, MHPP=Metal Health Promotion and Prevention, PASD=Providing Access to Service Delivery

The first group was those involved in the formulation of laws, macro policies, and decisions on financial provision and resource allocation through which they could play an important role in the promotion of the community mental health.

The second group of the organizations was those involved in judicial affairs and justice policymaking that could play an important role in promoting mental health and removing barriers faced by vulnerable and mentally disordered groups to access the necessary services.

The third group was those organizations that provided mental patients with services in the areas of education, employment, and housing.

The fourth group was those nongovernmental organizations (NGOs) and nonfor-profit communities that were institutionalized, especially at the local level, to meet some specific needs and seek support for vulnerable groups.

The fifth group which was categorized as “partner organizations” could play a significant indirect role in promoting the community mental health in cooperation with other organizations.

Some organizations, especially those categorized under the first and fifth groups in Table 4 including the Office of the Supreme Leader, the Expediency Council, Supreme Council for National Security, Guardian Council, Parliament, Presidential Institution, Supreme Council of Cultural Revolution, drug control headquarters, armed forces headquarters, Organization of Environmental Protection, Crisis Management Council, Islamic Republic of Iran Broadcasting (IRIB), and the Ministries of Industry, Mining and Commerce, Agriculture, Information, and Communication Technology, Information, Defense, Justice, Petroleum, and Foreign Affairs, can play a significant role in preventing the spread of the mental diseases and disorders and promoting mental health.

Other organizations such as the Judicial System of Iran, the Ministries of Education, Science, Research and Technology, Labor and Social Welfare (including Imam Khomeini Relief Committee, Welfare Organization, Social Security Organization, Health Insurance Organization, and Center for Research, Education, Technical Protection, and Occupational Health), Youth and Sport, Culture and Islamic Guidance, Economics, and Finance, in addition to possessing the necessary capacities to prevent mental diseases and disorders and promote the mental health, had an effective role in facilitating the access of the vulnerable groups to the services required.

Based on the functions and expectations identified in Table 4, the key roles were related to the Ministry of Internal Affairs, Ministry of Education, IRIB, Ministry of Labor and Social Welfare, and Ministry of Sports and Youth.

Discussion

This study was conducted to identify four main topics with regard to mental health. They include the attributing risk factors to mental disorders and diseases, the function and role of the involved organizations in distribution of these factors together with the potential expectations from them in terms of mental health prevention and promotion, and finally, facilitating access to mental healthcare services.

The role of 31 responsible national organizations in five groups of “policy makers/legislators/suppliers and the allocators of financial resources“, “suppliers of judicial justice,” “providers of health care, education, and social security services“, “advocacy groups/coalitions,” and “partner organizations” were determined. Then, the intersectoral organizations expectations in two areas of “mental health promotion” and “removing obstacles to providing services to patients with mental disorders” were extracted. The key roles were related to the Ministry of Education, IRIB, Ministry of Labor and Social Welfare, and Ministry of Sports and Youth.

Today, ignoring the role of national organizations outside the health sector in the promotion of mental health and eliminating barriers to access mental health services, especially for vulnerable groups and those with mental disorders, is one of the major causes of the failure of health systems to provide and promote the public health.[13]

Although the health sector is known to be responsible for public health, the cooperation of other national and international organizations is required to achieve this goal.[1314] Therefore, determining the intersectoral expectations of national organizations in promoting mental health can play an important role in informing them about their role in prevention of mental diseases, promotion of mental health, and removing the obstacles to access mental health services, and involving them in reducing the burden of mental diseases.[151617]

The situational analysis study in 2011 and the mental health system status in Iran showed that the stewardship in mental health sector, financing, human resources allocation, information, and medication and also the status of mental services provision in the healthcare system, had serious shortfalls. Despite the numerous plans and high-level rulings in the context of mental health, and the activities of mental health promotion office in the Ministry of Health and Medical Education, the mental health policies have never been a priority, and there has never existed a defined system for cooperation or intersectoral activities inside or outside of the MOHME. In addition, there has never been a defined system for attracting cooperation of the civil society. In the resource generation, despite availability of professional human resources in this field and allocation of 10% of the general hospitals’ bed to mentally ill patients, the country is faced with budget deficiency allocated to mental health, lack of professional human resources, weakness in national medical education system in stressing the community-based mental health and training the specialist workforce, and weakness in attraction of participation and maintenance of private centers for care and rehabilitation of mentally ill patients. In service provision, despite the integration of mental health in the Primary Health Care (PHC) system and outpatient service coverage, especially in rural areas, there are still numerous problems in insurance coverage for mentally ill patients; health provision by private sector; coverage of the urban population by PHC system; provision of inpatient services; the quality of services; and proportion of the preventive and promotional services compared to the therapeutic and rehabilitative once.

From the external environment point of view, the level of participation of nonhealth sectors involved in mental health promotion, and the social, economic, and cultural environment conditions are threatening. Despite the presence of numerous health-centered media and the collaboration between several different organizations and the Health Promotion Office in MOHME and the involvement of NGOs and scientific institutions in the field of mental health, the mental health issue has not been sufficiently addressed by nonhealth sectors’ policymakers, and it seems that these sectors are not aware of their roles and organizational decisions’ potential impacts on the society mental health status. In addition, the capacity of the nonhealth sectors is limited for participating in mental health field. In the large countrywide scale, mental health promotion has been repeatedly addressed in the national Constitution, general health policies, and 5-year social and economic development plans; and a social approach to health along with the development of structures for intersectoral collaboration and issuing the global statements is being institutionalized. Nevertheless, due to a number of reasons this issue has been neglected, for example, relevant large-scale operations suffer from a poor culture of teamwork (poor collaborative culture), and economic crises in the last few decades have exacerbated the shortage of resources, therefore, political attention has been focused on higher priority matters leading the mental health to the sideline. In the same study, it has been emphasis on two key strategies of internally empowering the health system and promoting intersectoral collaboration in short-term, and promoting health literacy and investment in mental health risk factor reduction in long term, to exit from the present situation.[4]

Despite of about 37 years of integration of mental services in PHC system in Iran, the increasing prevalence and rising trends of the mental diseases burden indicates that comprehensive management of mental health issues is impossible by the health sector alone, and the control and management of mental disease risk factors and the noncommunicable diseases (NCDs) require the collaboration of nonhealth sectors.

Since 1978, the WHO has stressed the need to develop intersectoral cooperative strategies in the management of public health by reducing the impact of social determinants of health in several statements (including the Alma Ata Declaration in 1978, the Adelaide Declaration in 2010, the United Nations political declaration in 2011, the Rio Political Declaration of 2011 and the Declaration of Helsinki in 2013.[131819]

Therefore, in this study, after identifying the risk factors attributed to mental diseases and disorders, the role of the nonhealth organizations was determined in terms of intersectoral expectations according to their legal function.

According to WHO report (2014), although many governments have benefited from the participation of other organizations outside the health sector in their communities’ health promotion since the Alma Ata Declaration, very little systematic evidence is available on the successful experience of these countries.[19] One study conducted by the WHO between 2011 and 2013 regarding the experiences of the countries in the development of interdisciplinary collaboration, showed that each of the countries studied (19 countries) benefited from this strategy in tackling various problems (including noncommunicable diseases such as obesity and physical activity, communicable diseases, environment, and waste management, housing, etc.). From a total of 25 studies, some national stakeholder organizations, including the Ministry of Labor and Social Welfare, Ministry of Culture, and Ministry of Sports (48%), Ministry of Education (44%), Department of Environment (40%), Ministry of Interior (32%), Ministry of Roads and Urban Development (28%), municipalities (32%) and support-seeking groups, and NGOs (80%) had the highest contribution to designing and implementation of intersectoral interventions.[19]

Rantala et al. have emphasized the influential role of the nonhealth organizations in their study. They identified facilitating and restrictive factors toward intersectoral collaboration in promoting public health including national and international influences, local political context, public participation, and use of support mechanisms such as coordination structures; the structure, processes, and mechanisms of cofinancing, the possibility of developing legal resolutions, and facilitating the information flow between stakeholders from other sectors, monitoring, and evaluation, and equity considerations.[1920]

In the mental health field, there have been few countries to attempt reporting results and achievements from attracting participation of nonhealth organizations in promoting mental health or identifying their share and role in prevention and promotion of mental health or facilitating access to mental health services. Skin et al. have conducted a study in South Africa (2010), mentioning the role of intersectoral collaboration in promotion of mental health, have investigated the progress trend of intersectoral collaboration for mental health and identified roles and responsibilities of different sectors. Not only they have mentioned education, employment, social development, police services, educational and correctional services, judiciary, accommodation, local government, and transportation but also identified each sectors role in “preventing and promoting of mental health” and “facilitating access to mental health services“.

Regarding the infrastructural requirements of the development of intersectoral cooperation for mental health, the experience of South Africa showed that institutionalization of this approach in the field of mental health required the reinforcement of the leadership role of the health sector through developing regulatory and incentive mechanisms, attracting the political commitment of the politicians, developing collaborative policy and decision-making networks, and developing interaction mechanisms with stakeholders outside the health sector in the field of mental health.[11]

Several countries have attempted to integrate the mental health services into their PHC system (Argentina, Australia, Brazil, Chile, India, Saudi Arabia, Uganda, and the United Kingdom) showing their attention and consideration to invest on mental health prevention and promotion plans within the healthcare system. In spite of this, they have rarely moved towards intersectoral controlling and managing social determinants of mental health through non health organizations.

Although some countries like Pakistan have moved toward attracting the participation of private sector, health-oriented NGOs and Ministry of Education to provide educational and consultation services, no considerable intervention has yet been taken to utilize nonhealthcare sectors’ capacity to promote mental health and facilitate access to essential services to target groups.[2122]

However, Iran is one of the countries that has taken significant steps toward the promotion and expansion of intersectoral collaboration for mental health in the last decade. Having established structures and mechanisms facilitating intersectoral participation in problem definition and policymaking for intersectoral problems has laid the ground for participation of the nonhealth organizations in prevention and promotion of mental health and removing the barriers to mental health delivery. Some important achievements of above-mentioned strategy in Iran are developing an intersectoral policy document for mental health promotion, piloting numerous intersectoral projects in different towns within different provinces of Iran with participation of nonhealth organizations, signing several items of memoranda for intersectoral participation between MOHME and nonhealth organizations based on their mutual roles in mental health promotion, and facilitating access to mental services for vulnerable groups.

Limitations of the study

There were some limitations in this study that should be noted. In the preliminary phase, analysis of the stakeholders was performed by targeted sampling based on two criteria including legal responsibility and the extent of influence on mental health promotion. However, there might be entities whose opinions have not completely been reflected through the selected groups. Besides, in selection of the stakeholders, NGOs and civil society were not included. It is recommended that, in the future studies, such stakeholders be included by the researchers with a view to possibility of attracting maximal participation of the interested parties and society as a whole.

Conclusions

Due to the growing burden of mental disorders in the country, informing national organizations and attracting their active participation based on intersectoral expectations and developing interaction mechanisms among national organizations can be an effective step in promoting the mental health and reducing the environmental factors threatening the mental health of the public.

In addition, to utilize the capacity and abilities of nonhealth sectors, the government, with the MOHME in the center, should be actively following the strategies such as signing memorandum with organizations involved in prevention or promotion of mental health facilitating access to mental services for intersectoral collaborations, selecting, and training of health volunteers in those organizations to follow-up intersectoral demands and expectations; establishing a monitoring system for the agreed issues, defining joint projects and promote advocacy mechanism for mental health issues through the formation of coalitions. Moreover, active follow-up of health-oriented demands from nonhealth organizations by the highest executive authority of the country and also conducting national and provincial surveys to determine the status of happiness, utilization of consultation services, behavioral change, mental health literacy, availability of social support, and also the prevalence of mental illnesses, could all provide the policymakers of the health domain with valuable information on the extent of success with intersectoral programs. Ranking and introducing the superior organizations and entities that have succeeded in the field of prevention and promotion of mental health and facilitation of access to mental services, can to be an effective strategy to encourage nonhealth organizations to participate in mental health promotion in the country.

Since we determined intersectoral expectations based on the role of national organizations in prevention of mental diseases, promotion of mental health, and removing the barriers to access to mental health services, it is suggested that the quantitative share of each organization and their ranking based on their effective contribution be determined in another study _ considering the effect of changes in the macroenvironment within a certain period, for example, in accordance with national development plans. In addition, it is recommended that research priorities of intersectoral actions be extracted to enhance mental health. In addition, it is recommended to extract research priorities for intersectoral actions to enhance mental health. Finally, it is proposed to identify the requirements to accomplish intersectoral expectations of each national stakeholder organization considering the contextual conditions and characteristics of the research country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.