Interventions for Decreasing Drug Abuse and Social Problem in Iran's Comprehensive Mental and Social Health Services.

Objective: Social problems and drug abuse, especially addiction, divorce, poverty, crime, violence, alcohol consumption, and substance abuse, have increased in Iran over the past two decades. The present study aims to determine an approach to decrease drug abuse and social ‎problems in the Islamic Republic of Iran. Method : A national program on providing comprehensive social and mental health services, entitled "SERAJ", was developed and piloted in three districts of Iran. To compile this study, three types of data collection have been used: (1) review of the literature, (2) an in-depth interview with experts and stakeholders, (3) focused group discussions.
Results: In our proposed model for decreasing drug abuse and social ‎problems, comprehensive mental and social health service are provided. Social care is integrated into the primary health care and six types of services, including social health education, screening for risk factors of social problems, and drug abuse, identifying underlying psychiatric, psychological, or social causes, short consultations, referral to social workers, and follow-up.
Conclusion: Theoretically, if mental disorders are reduced, social harm and addiction will also be reduced because it is one of the important risk factors for divorce, violence, crime, drug abuse, and alcohol consumption. SERAJ reduces mental disorders; therefore, it can reduce social problems and addiction.

The 2008 WHO report (1) highlights four key features of successful PHC systems: regular entry, service integrity, service sustainability, and people-centered development. Corresponding to these characteristics, social services in Iran have serious weaknesses:

There is no regular entry for people to receive social services; in other words, the level of services is not evident, the citizens do not know where to receive the social services they need. Such services are not categorized at the basic or specialized level.

The comprehensiveness of services is not observed; in other words, physical, psychological, and social services are not provided side by side in a holistic approach. A person with hypertension may be facing a divorce issue which the physician is not aware of, thus, the management of hypertension may fail.

There is no sustainability of service, clients' problems are not continually monitored to obtain optimal results, such as a visit for a person with major depression, and the patient may receive his/ her medication monthly due to lack of follow-up and problems.

The second has interrupted or does not reach the level of self-reliance on the client's social problems, and is frequently plagued with issues that we see in the treatment of drug addicts

Provided services are not people-centered, and people are not transparently aware of their diagnosis, management, community-based interventions, and follow-up.

Resources are spent by different organizations and their efficiency and effectiveness are unknown.

In such circumstances, syndical principles are not observed, and the set of efforts done by various uncoordinated community organizations will be in vain, and eventually, resources will be wasted and improvements in physical, mental, and social health indicators will be slow.

According to the latest study conducted in Iran (2), 1.1 million people (14%) are marginal settlers. Also, ‎30 000 000 (12.7%) females are the head of households. There are 181 000 divorced couples throughout the country, meaning that about one in four recent marriages is likely to end in divorce. Moreover, ‎11500 children workers in the street are registered on the State Welfare Organization. There were more than five million school dropouts‎, among whom ‎142 000 students were in primary school. At least 100 000 births occur to adolescent girls per year. There are 240 000 prisoners throughout the country with an entrance rate of 460 000 inmates ‎per year. ‎Also, 77 000 women refer to family forensic examinations per year complaining of domestic violence. The rate of successful suicide in Iran is 4560 ‎per 100 000 people (5.7%). Besides the social problems, ‎2.85 million people (5%) aged 15-64 years are reported to have substance abuse. Three million people (‎‎6.3%) are reported with recreational alcohol consumption and 2% with chronic ‎consumption.

In practice, interventions are taken in Iran to reduce physical and mental disorders, social problems, and drug abuse, but such interventions are poorly coordinated and separately implemented by different departments.

For instance, interventions taken for contagious and noncommunicable physical disorders (such as hypertension, cancer, diabetes) are coordinated by the Ministry of Health and Medical Education (MOHME). Moreover, interventions for social problems are coordinated by the State Welfare Organization, municipalities, Imam Khomeini Relief Committee, Social Security, Law Enforcement, and other organizations. Furthermore, mental disorders are jointly intervened by the MOHME and State Welfare Organization. The improvement of each condition depends on implementing the principle of syndemic or intersectionality theory.

The present study aims to determine an approach to decrease drug abuse and social ‎problems in the Islamic Republic of Iran.

Materials and Methods

A national program on providing comprehensive social and mental health services, entitled “SERAJ”, was developed and piloted in three districts of Iran, including Bardsir, Quchan, and Osco. To compile this study, 3 types of data collection were used:

(1) review of the literature, (2) an in-depth interview with experts and stakeholders, (3) focused group discussions.

Review of the literature: The following keywords were used: “Mental Health Service, Mental Healthcare, Mental Health Hygiene, Social care, Healthcare, Primary healthcare, Primary Care, Social Care Services, Social Care System, Social Service, Drug Abuse, Substance Abuse, Drug Addiction, Drug Dependence, Substance Dependence, Drug Habituation, Social problem, Social Harm, Labor Exploitation, Alcoholism, School Dropouts, Student Dropout, Crimes, Violence, marginal settlement”. Google Scholar, PubMed, and Embase were used for English publications and rc.majlis.ir (Iranian Parliament Research Center), Irandoc.com, Magiran.com, SID.ir, and Iranmedex.com were used for publications in Persian.

An in-depth interview with experts and stakeholders: Semistructured interviews were conducted using a set of open-ended questions. The main themes were determined following the review of the interviews’ questions and the interviewees’ responses. The thematic analysis method was used for analyzing the data collected through the interview.

Focused group discussions: A facilitator raised the questions in each session, and ideas and opinions were collected by assigning a member as the session manager. The discussions were recorded with the group's consent and were analyzed by the thematic analysis method. The following four questions were selected for each chapter as the main themes: (1) Do you generally agree with the provided draft? (2) Which part should be removed? (3) Which part should be added? (4) Which part should be revised? Finally, a table consisting of a brief overview of four actions of the project was indicated and then the requirements of implementation were defined. The collected data were reviewed by the steering committee and a consensus was reached on how to implement this study.

Results

Integrated mental and social health service model, which we thoroughly explained and described in other studies, has an impact on reducing social harm and addiction (Table 1). In our proposed model, referral to the health centers where comprehensive mental and social health services are provided will be a great opportunity to simultaneously screen social risk factors, drug abuse, and alcohol consumption, along with physical and mental disorders. Providing education on social health principles and techniques helps people become aware of socially desirable behaviors, which is the first step in preventing behavioral disorders. Screening for social harm and drug abuse or their risk factors lead to identifying affected or susceptible individuals who require counseling and will be referred to capable centers if desired.

Table 1

Suggested Interventions to Reduce ‎Social Injuries and Drug Abuse in the Model for the Comprehensive Mental and Social Health Services

Service packages	Interventions that should be done to reduce social harm and/or drug abuse
Basic Package	Educating the population under the coverage of the CMHC on the principles and techniques of promoting the social health of individuals.Calling on family members for risk factor screening (including factors affecting the incidence and prevalence of social injuries)Physician visit and evaluation of physical and mental illnesses associated with social harmShort counseling by a mental health expert and if necessary, referral to an SRU in the governorate for receiving social support and specialized treatment, including referral to addiction treatment centers.Keeping track of the services received from the SRU and its consequences.
Specialized Package	People with social harm and/or drug addiction who are at the same time resistant to the treatment of mental disorders will be referred to CMHCs.
Community Action Package	This package, which is the responsibility of the district’s governorate, offers three major services:1. SRU conducts exploratory interviews with the referred individual in the presence of a social worker. By examining the referred individual’s eligibility, an intervention program will be developed to provide employment support (eg, training skills, introducing to employers, etc.), and tangible support (such as insurance, portfolio, counseling, etc.). Thereafter the client is referred and followed.2. People at the PPH conduct interventions within relevant Public networks in order to increase social health literacy. For instance, parents and educators associations convey social health messages to all members, provide training sessions and/or transfer the members’ demands related to improving social harms to the governorate.3. Each of the government agencies in the district determines their responsibilities for reducing the risk factors that cause social harm, sign an MoU in the form of inter-sectoral collaboration, promote health literacy on addiction prevention, and support SRU.

SRU: Self-reliance Unit; CMHC: Community Mental Health Center; PPH: Public Participation House; MoU: Memorandum of Understanding

Discussion

Social issues, such as the presence of a prisoner, a drug addict, disability, or domestic violence inside the family, are more likely to be stigmatized than mental disorders (3). In this respect, researchers found that the public often stigmatizes mental and behavioral disorders to a greater degree than physical disorders (4). Also, research has shown stigma to be a barrier to treatment-seeking behaviors among individuals with addiction, creating a "treatment gap"(5). On the other hand, addressing the family's economic and social problems, such as unemployment or divorce, are more important for individuals than regular treatment for mental or physical disorders such as depression or diabetes. Therefore, the integration of physical, mental, and social health services creates conditions for counselors and therapists to be more effective.

For the reasons mentioned at the beginning of this article, social support units were scattered in districts of Iran; thus, establishing a headquarters for social workers at the governorate was necessary to identify individuals’ needs and refer them if necessary. Social support needs are divided into four types of emotional, tangible, informational, and companionship (6). Emotional support, also known as "esteem support" or "appraisal support" is the value-laden offering of empathy, concern, affection, love, trust, acceptance, intimacy, encouragement, or caring (7). Tangible support, also known as instrumental support, is the provision of financial assistance, material goods, or services and encompasses the concrete, direct ways people assist others (8). Informational support is the provision of advice, guidance, suggestions, or useful information to someone and has the potential to help others solve problems (9). Companionship support is the type of support that gives someone a sense of social belonging. This can be seen as the presence of companions to engage in shared social activities (10). As shown in Table 1, by combining all four types of social support needs, three types of support, including employment, education, and umbrella policy, are provided at the self-reliance unit (SRU).

In the community action package, two strategies of public participation and intersectoral collaboration must work together to improve all three aspects (the physical, mental, and social) of the people. Effective childhood development, adequate literacy, safe employment, social support, proper environment, and factors such as effective governance affect all three dimensions of health. Therefore, the establishment of the Public Participation House and strengthening intersectoral collaboration improves all three dimensions of health (11, 12).

Limitation

Following diagnosing injured or high-risk individuals at the primary level, they will be referred to CMHC. One of the limitations of this model is that there is no systematic plan for providing social care at the referred level. In other words, there is no guarantee that the referred individual from SRU will socially become self-reliant.

Several social care centers in Iran often deal with a particular problem, such as the Center for Anger Control (which is established at the municipality level), Center for Addiction Treatment, which operates independently from Centers for Social Support such as Support Clinics. Moreover, some processes are formed within the national governmental systems to detect a social problem and provide early intervention. For instance, the judiciary has defined a process that directs those applying for divorce to advisors within their system as the first step. Childcare centers are separated and their records are not maintained at CMHCs. In such a condition, it is difficult to study the coverage, quality, accessibility, and utilization of social services, which is another limitation for the evaluation of the proposed model. For these reasons, the effectiveness of the interventions listed in Table 1 depends on two more interventions. First, redesigning and defining the social care system at the later levels of the CMHC and SRU, and clarifying the duties and responsibilities of each unit concerning social harms. This requires the cooperation of the MOHME, the State Welfare Organization, and the Organization for Social Affairs. Second, improving the governance score at the macro level should become a policy priority. Setting macroeconomic policies on political stabilization, increasing social capital, improving economic conditions, reducing unemployment and poverty, increasing the value of the national currency, protecting the environment, and improving international relationships and business are all effective in reducing social harm and drug abuse.

Conclusion

Theoretically, if mental disorders are reduced, social harm and addiction will be reduced because it is one of the important risk factors for divorce, violence, crime, drug abuse, and alcohol consumption. SERAJ reduces mental disorders, therefore, it can reduce social problems and addiction. We suggest implementing our proposed model and piloting it in 6 other districts of Iran. After recognizing the challenges and solving its probable weaknesses, it should be expanded to the whole country.