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A. Ghanizadeh,¹ N. Arkan,² M.R. Mohammadi,³ M.A. Ghanizadeh-Zarchi⁴ and J. Ahmadi⁵

ABSTRACT This study in 2005 compared the need for mental health services, actual use of services and barriers to use by 3 groups in Shiraz city in the Islamic Republic of Iran: a sample of the general population, parents of children with mental illness and primary-school teachers. Among the general population, 76.0% reported that they had wanted help in the previous 6 months and, of these, 50.0% actually sought it. The rates for parents of children with mental problems were 81.3% and 55.4% and for teachers were 60.0% and 35.0% respectively. The most common barriers to service use were logistic, especially the cost of and inconvenient access to services. Barriers related to perceptions of mental health services were also important, such as lack of trust and perceptions of friends/family.

Fréquence d’utilisation des services de santé mentale dans une population iranienne et obstacles à cette utilisation

RÉSUMÉ Cette étude réalisée en 2005 a comparé les besoins en services de santé mentale, l’utilisation effective de ces services et les obstacles à leur utilisation dans trois groupes à Chiraz (République islamique d’Iran) : un échantillon de la population générale, des parents d’enfants atteints de maladie mentale et des enseignants d’école primaire. Dans la population générale, 76,0 % des personnes ont déclaré avoir souhaité obtenir de l’aide au cours des six mois précédents et, parmi ces personnes, 50,0 % ont fait les démarches en ce sens. Les taux chez les parents d’enfants atteints de maladie mentale étaient respectivement de 81,3 % et 55,4 % et chez les enseignants, de 60,0 % et 35,0 %. Les obstacles les plus courants à l’utilisation des services de santé mentale étaient structurels ; il s’agissait en particulier du coût et de la difficulté d’accès. Les obstacles liés aux idées que les personnes se faisaient des services de santé mentale étaient également importants, par exemple le manque de confiance et l’opinion des amis ou de la famille.

¹Division of Child and Adolescent Psychiatry; ²Medical School; ⁵Department of Psychiatry, Research Centre for Psychiatry and Behavioural Sciences, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to A. Ghanizadeh: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
³Department of Child and Adolescent Psychiatry, Psychiatry and Psychology Research Centre of Iran, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
⁴Shahid Sadooghi University of Medical Sciences, Yazd, Islamic Republic of Iran.
Received: 15/09/05; accepted: 19/12/05
EMHJ, 2008, 14(2): 438-446 

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Introduction

After cardiovascular disorders, mental ill- ness is the second leading cause of disabil- ity and premature mortality. The burden of mental disorders is more than 15% of the overall burden of disease from all causes and is even greater than the burden asso- ciated with all forms of cancer [1]. In the Islamic Republic of Iran there has been little research into mental health, despite estimates suggesting that around 7 million people suffer from one or more psychiatric disorder [2]. There is an urgent need for prevention and treatment of mental health illness and for better access to mental health care facilities.

There are many effective treatments and service delivery strategies for mental illnesses. Therefore individuals should be encouraged to seek treatment when they find themselves experiencing the signs and symptoms of mental distress. Reluctance to seek care is a result of very real barri- ers including the stigma of mental illness. Utilization of services is affected by many interacting factors, such as individual and help-seeking preferences, access, availabil- ity and referral practices [3].

In terms of individual characteristics, culturally influenced cognitive explanatory models for constructs such as problem rec- ognition may help in explaining differences in service use [4,5]. Seeking help is a target- oriented behaviour that entails psychologi- cal “costs”, such as feeling dependent and inferior. The final decision to seek or not to seek help is a function of a range of different factors [6]. A study of barriers to seeking mental health care in a rural impoverished population in the United States reported that the most common reason was the cost of care (40.0%), followed by lack of insurance (30.4%), inconvenient hours (18.1%) and unavailability of care (15%) [7].

Part of the problem is that we lack a standard definition of outpatient mental health services utilization and there is lit- tle consensus on what services constitute mental health treatment. This impacts on estimates of demand for mental health serv- ice and, because it is highly sensitive to how treatment is defined, we should be cautious in evaluating mental health utilization data. A general population study showed that 41.1% of the people studied in the United States of America had received some treat- ment in the previous 12 months, including 12.3% by a psychiatrist, 16.0% by a non- psychiatrist mental health specialist, 22.8% by a general medical provider and 6.8% by a complementary or alternative medical provider [8].

To our knowledge there has been no published research regarding the frequency of, and the barriers to, utilization of mental health services in the Islamic Republic of Iran. This study in Shiraz city compared the utilization of mental health services by 3 groups of people: a sample of the general population, parents of children with mental illness and primary-school teachers. It also assessed the association between the groups and barriers to utilization of mental health care.

While the levels of service utilization are a reflection of barriers to mental health care, it is important to assess both aspects. Barriers to mental health care focus on the perceptions of subjects about the factors that prevent access or create difficulties in accessing mental health services [9], while service utilization focuses on the actual receipt of services [10]. Thus, we used a general population sample to look mainly at barriers to help-seeking and a sample of parents of children with mental illness as a group who have actually received services. A group of teachers was included because we hypothesized that they were likely to be better educated on average and would be more aware of mental health problems and face fewer barriers to utilization.

Methods

The study was conducted in January and February 2005 in Shiraz city.

Sample

The 3 study groups included 100 people selected from the general population, 80 parents of children with psychiatric disor- ders and 100 primary-school teachers. The entire city was divided into a grid of sectors covering 4 educational areas. The teacher and general population participants were selected by stratified random sampling, 25 subjects for each group from each area sector. The parents were randomly selected from the parents of children referring to the Hafez Hospital outpatient child psychiatric clinic. The psychiatric diagnoses of the children were mostly disruptive behaviour disorders, anxiety disorders and mood dis- orders. Parents of children with mental re- tardation were excluded. None of the people selected refused to participate.

Data collection

A self-reported questionnaire was prepared by the authors based on a previous study about barriers to mental health care [10]. The questionnaire was translated into Farsi by the psychiatrist researchers, and the Farsi version was back-translated by another psy- chiatrist. It was reviewed and reconfirmed by the team and the final translation was fixed by consensus. To examine the feasi- bility of the questionnaire, it was adminis- tered to parents in a child and adolescent psychiatry clinic in a pilot study. After approval of its performance, it was used in the current study. The test–retest validity was 0.85.

The questionnaire asked about demo- graphic data (age, sex, educational level and marital status) and history of referral for any mental illness in the past 6 months to a general practitioner (GP), psychiatrist, friend, psychologist, relative, counselling centre or traditional fortune-teller (falgir in Farsi). They were also asked about bar- riers to referral to any of these. No formal classification system for mental disorders was used. The study was not limited to ask- ing about specific mental health problems and therefore mental health problems were defined as the respondents’ perceived need for mental health care.

The questions included: Have you ever sought help for a mental health problem or did you think you had symptoms of a mental disorder in the last 6 months? Have you ever had any mental health problem or thought you had symptoms of a mental disorder in the last 6 months for which you did not seek any help? What were the barriers to using the help sources? For the last question re- spondents were asked to respond to each of 15 possible barriers to use of services; there were 6 statements about logistic barriers, 2 about barriers related to perceptions of mental health problems and 7 about barriers related to mental health services. Each state- ment was scored 0 (no barrier) or 1 (barrier). The respondents were divided into those who had actually contacted a mental health service provider and those who wanted help but had not yet made contact.

The participants were given sufficient time to complete the questionnaire in pri- vate. The questionnaire was self-reported, but illiterate respondents were interviewed by the researcher. All participants were informed about the purpose of the study and reassured about anonymity and all gave consent for participation and publication of the results.

Analysis

The association of any reported barriers between the groups was analysed using chi- squared tests. Independent t-tests were used to compare the mean scores of the items in 3 categories: logistic barriers, barriers related to perceptions of mental health problems and barriers related to perceptions of mental health services. The correlation of age and years of education with the different catego- ries of barriers was analysed. A univariate general linear model was used to compare the mean score of the types of barriers be- tween the 3 groups and study the effect of educational level as a covariant factor.

Results

The study samples were 100 people from the general population, 80 parents of chil- dren and adolescents with mental illness and 100 primary school teachers. The pro- portions of males in the 3 samples were 44 (44.0%), 30 (38.0%) and 20 (20.0%)

respectively. The proportion of married subjects was 84.4% in the general popula- tion, 98.8% among relatives and 60.0% among teachers. The mean number of years of education was 12.1 years in the general population group, 13.4 years for the teachers and 10.8 years for relatives of children with mental illness.

Table 1 shows the proportion of each sample who said that they had wanted help or thought they had symptoms of a men- tal disorder in the last 6 months and the proportion who actually sought help for a mental disorder in that time. Of the general population, 76 (76.0%) reported that they had wanted help and, of these, 38 (50.0%) actually sought it. The corresponding per- centages for parents of children with mental problems were 81.3% and 55.4% and for teachers were 60.0% and 35.0%

The types of barriers to seeking help reported by the whole sample and by those who said they had wanted help with mental problems are shown on Table 2. Logistic barriers to service use were reported by 34.0% of the general population, 47.5% of parents and 18.0% of teachers and this was a significant difference between groups (chi- squared test, P < 0.001). Among the logistic barriers, the cost of the services was the most commonly reported barrier, followed by inconvenience of services, distance to services and not knowing where to go. Bar- riers related to perceptions of mental health services were also important, with 46.0% of the general population, 50.0% of parents and 34.0% of teachers reporting lack of confidence, negative experiences with professionals, fear of what family/friends would say, lack of trust, etc.

Table 3 shows the mean scores of the barriers to use of mental health services by those who said they had wanted help with mental problems. The mean score of the logistic barriers was highest for parents of children with mental illness (0.68) and lowest for the teacher’s group (0.24) (P < 0.001). Meanwhile, the scores for other types of barriers were not significantly dif- ferent between groups. Comparison be- tween the 3 groups showed that the parents of children with mental problems reported more barriers than did the other groups.

When analysed by sex there were no statistically significant differences between the different categories of barriers (data not shown). There were also no statistically sig- nificant differences when analysed by age, but there was a correlation between years of education and the total score of logistic bar- riers and the total score of barriers related to mental health services (Table 4).

Table 5 shows that that when asked “did you get help when you had your mental problem”, parents of children with mental problems had received professional help from medical professionals more than the other groups: 18.8% had sought help from a general practioner (GP), 35.0% from a psychiatrist and 7.5% from a psychologist. The general population sample was more likely to use informal sources: 21.0% had sought help from friends for a perceived mental health problem. Teachers had sought help less than the other groups: only 26.0% of teachers sought help from at least 1 of the sources compared with 61.3% of parents and 45.0% of the general population. Very few of any group had consulted a traditional fortune-teller or falgir.

Discussion

The results of our study suggest that teach- ers referred less than the other groups to one of the sources of help for mental problems. Parents of children with mental illness re- ferred more to the GP, psychiatrist and/or psychologist. The findings suggest the pos- sibility of higher awareness of mental health problems among parents of children with mental health problems, and low confidence in services or greater barriers to referrals to psychiatrist among teachers and the general population. High utilization rates would be expected in this high-risk sample. Also, it should be noted that most of the parents in the sample were mothers, most probably due to the sampling method (they attend services with their children), and it has been shown that women use mental health serv- ices more than men [11] because they have a greater readiness to identify themselves as having a problem [12].

In all 3 groups the GP was one of the most used sources of help. It shows that GPs should be aware of the specific symp- tomatic and psychological needs of clients, the psychosocial context in which mental health problems are experienced and the im- plications for help-seekers. Also, it shows the necessity of keeping medical students’ education up-to-date in accordance with community mental health needs. Overall, the general population preferred family and friends to professional help agencies, which is consistent with the findings from previous studies [13]. Preference for friends over professionals for help-seeking raises questions about the quality and type of help received, because, although friends are a source of support, they are not trained in providing help for any kind of mental health problem. Therefore, using friends as the only source of support may place people with severe mental health problems at risk. Another interesting finding was the low rate of referral to fortune-tellers or falgir, suggesting that our participants were not superstitious and that health professionals play a greater role in helping people with mental health problems.

A greater use of friends by the general population sample may be due to their per- ceptions that health professionals cannot provide for their needs. However, parents of children with mental health illness who already utilized these services referred to them more than did the other groups. It shows that experience with professionals gives people greater confidence in using their services.

A previous study found that the main barrier to seeking help was the perception of family and friends about mental health problems [14]. In the current study this was not reported as a major reason. The most common barriers to service use were logistic. Parents of children with mental illness more than the other groups reported 1 or more such barriers as a reason for not referring to a psychiatrist, GP or a psycholo- gist. The logistic barriers included factors such as getting help was too expensive and inconvenience of services. It is possible that these parents had already referred to a psychiatrist for their children and they may have experienced these barriers. The mean score of logistic barriers was highest among parents of children with mental illness and lowest among the teachers’ group. These barriers were mentioned by the parents of children with mental illness who had already used the services. Meanwhile, the scores for other types of barriers were not significantly different between groups.

Some limitations of the current study are the potentially skewed age and educational level of the sample, and that factors such as family income and urban/rural location were not covered [15]. This cross-sectional study used data that relied on subjects’ self-reports, which may be affected by cognitive and culturally influenced biases. More research is recommended to study the complex processes that lead people to men- tal health service utilization and the specific reasons for lack of use of services in a larger sample in both rural and urban areas. The study also did not survey mental disorders as such, but addressed self-reported mental health problems.

Conclusion

This study provides an insight for mental health policy-makers and programme de- velopers in the Islamic Republic of Iran and strongly suggests that promoting the mental health of people would be a sound invest- ment to prevent mental health problems and to reduce the economic burden associated with them.

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