Community Action Package in Iran's Comprehensive Mental and Social Health Services (the SERAJ Program)

Abstract

Objective: The social component of health plays a significant role in improving the mental health of the people of a district. A national program on providing comprehensive social and mental health services, entitled ‎‎“SERAJ”, was developed and piloted in three districts of Iran. The present study aims to determine its model for improving the indicators of the social component of mental health.

Method : This study is a system design for which a literature review, interviews with experts, and focused group discussions with stakeholders were used.

Results: Community action in promoting the mental health of the districts has three main components: strengthening intersectoral collaboration through the memorandum of understandings (MoU), increasing people's participation by establishing People’s Participation House (PPH) with the presence of the representative of current People’s network, and social protection of people suffering from mental disorders by establishing the Social Support Unit (SSU) for self-reliance activity. All three components are controlled by the governor and with supervision and technical consult of the health network of the district and stakeholder participation.

Conclusion: The model uses the inner capacities of the city instead of creating new structures. The prerequisites for the effective function of the main three components are educating departments, educating members of the PPH, and hiring a social worker at the SSU. The effective measures taken by the departments to reduce the risk factors for mental disorders are dependent on the technical and financial support of relevant organizations at the provincial and national levels.

It is estimated that more than 50% of the causes of developing mental disorders are due to social and environmental factors (1-3). According to the World Health Organization (WHO) report in 2004 (4), numerous social and environmental factors leading to mental disorders are avoidable (5). Violence (6), the education system deficits in life skills training (7), inappropriate child development (8, 9), divorce (10-12), inappropriate marriage (13), unplanned population growth (14), untreated mental disorders (15), inadequate family interaction (16), unemployment (17), parental addiction (18), war (19), disasters (20), and inappropriate school (21) are of main factors.

After more than three decades of rural health network system design in Iran, infantile mortality rate, under-five mortality rate, and maternal mortality ratio have reduced significantly throughout the country (22, 23). The cooperation of various departments, such as the Department of Road and Urban Development, the Power Department, the Water and Sewerage Department, the Department of Education, the Post Office and other organizations to provide basic living facilities for the villagers, were the leading factors for improvement of the aforementioned indicators (24).

Although these interventions have been improving physical rather than mental health indicators, scientific evidence suggests that interdepartmental collaboration has also been effective in reducing the mental disorders' risk factors (24).

There is still room for improvement in mental health services in Iran (25). For instance, mental health services have not been developed in cities, while 74% of the Iranian population live in urban areas (26). Although a mental health expert was recently added to the primary health care team due to the Health Transformation Plan, referral centers for specialized care for mental disorders and social protection have not been defined (27), nor is there a protocol to reduce the risk factors for mental disorders through intersectional action and people's participation (27). The social stigma of mental disorders in Iranian society is declining, but no systematic model aimed for its reduction has been proposed yet (28). According to the latest national census (29), Iran has a population of around 80 million people who are distributed to 31 provinces and 463 districts. According to the model of the primary health care system in Iran, each district has a health network whose director is appointed by the head of the medical university of each province. In this study, we aim to determine a responsive pattern of community action for a city generalized to the rest of the country after its pilot implementation.

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. The present study aims to determine its model for improving the indicators of the social component of mental health. Three main types of data collection were used for conducting this study:

1)   Review of the literature,

2)   An in-depth interview with experts and stakeholders,

3)   Focused group discussions.

Phase 1: Review of the Literature

The following keywords were used first for scoping review of the literature to collect data on experiences in implementing community action health care services in Iran and the world: “Mental Health Service, Mental Healthcare, Mental Health Hygiene, Social care, Healthcare, Primary healthcare, Primary Care, Social Care Services, Social Care System, Social Service, Community Service, Community Participation, Community Involvement, Consumer Participation, Consumer Involvement, Public Participation, Community Action. The motor engines we searched our keywords in were “Google Scholar, PubMed, and Embase” for English publications and “rc.majlis.ir (Iranian Parliament Research Center), Irandoc.com, Magiran.com, SID.ir, Iranmedex.com” for publications in Persian. Subsequently, indices of mental health at the results chain including impact, outcome, output, process, and input, were drawn. After reviewing the documents, a checklist was devised to identify mental and social health services that had to be prioritized. Then, mental and social health care providers were listed to perform organizational analysis. Finally, a framework was designed and a questionnaire was developed to collect stakeholders’ opinions.

Phase 2: Semistructured Interview with Experts and Stakeholders

Stakeholders were selected according to their power and influence, using stakeholder analysis. The intentional sampling method was used to recruit 10 experienced experts at different levels; three of them working at medical universities, three at the Ministry of Health and Medical Educations (MOHME), three at different associations, and 1 from people. Their role was general director of mental health and social affairs of the MOHME, project manager of a national plan for implementation of comprehensive mental and social health services (SERAJ), designer of the community action program, mental health provincial managers, manager of the district's health network, governor and the social security officer, members of the Governorate Council and People’s Participation House (PPH). Semistructured interviews were conducted using a set of open-ended questions. The interview questions were sent to the interviewees by email and then a face-to-face interview was arranged. All interviews were recorded on a digital audio recorder with the permission of the interviewees. The interviewer was a trained researcher and familiar with the in-depth interview method. The main themes were determined following reviewing the interview’s questions and the interviewee’s responses. The five main themes were the following questions:

4)   What is the goal of a community action program in your opinion?

5)   What will be the basis of such services?

6)   How will be the process of providing such services?

7)   How and from where will the resources (human resources, eg, information and education; physical resources, eg, necessary equipment and financial resources) of the aforementioned services be provided?

8)   How should this project be managed?

The thematic analysis method was used for analyzing the data collected through the interview. Interviewees were coded from 1 to n, their opinions in response to each question were collected by the interviewer, and the information collected through the interview was categorized into the most appropriate theme. The number of opinions placed in each theme was counted afterward. Having removed the controversies, responses were used for drafting.

Phase 3: Focus Group Discussions

In the next phase, the research team collected the data from the previous two phases and prepared a draft on how to determine a community action program to promote mental and social health services in districts. This draft consisted of four chapters, for which each chapter was reviewed and edited by experts in a focus group discussion (FGD) session. A facilitator raised the questions in each session, 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) Overall, do you agree with the provided draft?

2) Which part should be removed?

3) Which part should be added?

4) Which part should be revised?

Attendee’s responses to the above questions were collected and encoded. In the case of controversial responses, attendees voted to finalize the response.

Finally, a table consisting of a brief overview of four actions of the project for implementation 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

Based on the information gathered in this study, the goal of the community action program is to reduce the risk factors for mental disorders in the districts, to increase social protection of people with mental disorders, to reduce social stigma, and to increase mental health literacy in different groups of society. To achieve these goals, three strategies, including strengthening intersectoral collaboration, public participation, community, and individual self-reliance services, are needed. Accordingly, the main process of the community action program consists of five stages and seven activities (Table1).

Stage I. Advocacy for the Governorate

A meeting will be held at the request of the head of the health network of the district with the governor and his deputies. In this meeting, the prevalence of mental disorders at the level of the country, province, city, and their economic effects will be expressed. Then, the strategies for preventing and reducing mental disorders will be presented in the form of a model for mental health services of the district and the community action program will be described. The purpose of this support is to obtain a start-up permit. One of these permits is holding a special workshop for the heads of the departments on their role in reducing the risk factors for mental disorders. Other results of the meeting should include obtaining the governor's approval on the mental health promotion road map in the governorate council to form the Community Action ‎Secretariat‎ (CAS) and also to form a PPH in the district. To succeed in advocacy, written documentation must be provided to the governor, including the illustrative community action model, the duties of the CAS‎, the constitution ‎of the PPH, and the Gantt chart. Moreover, the comments of the governorate team should be considered and carefully recorded during the session.

At this stage, the CAS and the Social Support Unit (SSU) will be launched. A full-time local social worker is selected and appointed to the ‎ CAS and SSU for self-reliance activity (box 1). A room that meets the privacy requirements should be provided; recording and phone follow-ups on the progress of MoU and individual referrals should be performed. The functions of Community Action ‎Secretariat are in the field of universal health; in this regard, a social worker is responsible for the empowerment of the health volunteers and members of the PPH, monitoring the intersectoral MoU, function-based ranking and rewarding, compiling the annual progress report, and presenting it to the Governorate Council.

Functions of the SSU are interviewing with individuals referred from health centers and community mental health centers. Thereafter, a social support program for the individual will be compiled, implemented, and followed. Providing these services, all departments' facilities, as well as public and private sector capacities will be used as the social worker is familiar with the city's capacities.

Stage II. Announcement of MoU

To achieve this, educational and explanatory workshops will be held for the heads of the departments to increase their knowledge, attitudes, and skills in the field of community action to prevent mental disorders. The educational needs shown in Table 2 will be presented and evaluated with appropriate methods at the workshops. By the end of the workshops, a timetable for community action of the district will be agreed upon, and each department will introduce an interested and capable health volunteer to monitor the desired assignments. These health volunteers should be announced mutually by the head of the network and the head of the department.

At this stage, the governorate invites representatives of active people’s networks in the district to establish Public Participation House, and in cooperation with the head of the health network, they will be informed of mental disorders' status of the district, possible options, and public's role. Finally, the head of the Public Participation House will be elected by the members present and voting. As shown in Table 3, the People’s Participation Council has three major tasks: forwarding people's voices to various governorate networks, forwarding messages for mental health promotion, and stigma reduction activities in this regard, as well as participation in projects that decrease mental health risk factors.

Having formed the team of health volunteers of the departments and the People’s Participation Council, the next stage which is empowerment will begin, so an educational workshop entitled "Principles and Techniques of Community Action in Mental Health" will be held for eight hours for this team. The contents of this workshop are listed in Table 2. Following this workshop, the same people are invited to the one-day writeshop. By facilitating the manager of the health network, the district's capacities are identified and documented in three sections: governmental, private, and public; these capacities should be determined in the following areas:

• Offices in the district and their facilities (related to all three judiciaries, legislative and executive branches);

• Active people’s network in the district and their facilities;

• Active private sector in the district and their facilities;

At the end of the meeting, the role and contribution of each unit should be determined based on the major risk factors for mental disorders; an example of the deliverables of this meeting is presented in Table 4 in the form of MoU. This text will be notified by the governor for implementation after being evaluated in the Governorate Council. An MoU in the form of posters should be installed in public places, departments, and offices of related networks. Resource financing for the implementation of the MoU is an important challenge. In general, the resources for the administrative services provided by SSU and the CAS are financed by the Department of Health or the Governorate in the form of an annual contract with the social worker and consumables of the Council. The costs of intergovernmental actions are mainly financed from the resources of both contractee administrations; in cases where there is a justified document, the governor can ask the provincial and national levels for financial resources. People’s networks themselves are responsible for the necessary resources for the Public Participation House.

Stage III. Monitoring the Memorandum

This stage begins by finalizing the timetable for the deliverables of each member of the memorandum. This MoU takes place between the health volunteer of each department as well as the head of the PPH and the CAS. In this memorandum, the calendar of supplementary educational programs for the health volunteers of the departments as well as PPH will be mentioned, and these workshops can take place in the last month of each season. The deliverable is sent to the CAS in a written document format according to the timetable. The deliverables are monitored monthly by the CAS and fault or drawback from the program will be conveyed to the health volunteers in a written document via a phone call or in-person. The progress of each department is reported to the governorate council quarterly as red, yellow, or green, which they state for reaching the progress agreed upon under 40%, 40% to 60%, and over 60% respectively.

At this stage, the social worker will set seasonal meetings with stakeholders on the topic of social support for individuals referred from SSU. This session specifically addresses the quality and quantity of departments, private sectors, and People’s network' responsiveness toward social referral of individuals; moreover, a root cause analysis will be held on possible faults or lack of social support. For example, if an individual is referred to the employer syndicate of the district but hasn't received any results within three months, then, its causes will be investigated, options will be suggested accordingly, and implemented.

Regarding the action monitoring of members of the PPH, the following scopes should be monitored by the PPH itself as well as CAS:

1.  Does each member of the People’s Participation Council correspond to the demands of its network members to the governorate?

2.  Does each member of the People’s Participation Council convey mental and social health messages to their network members as appropriate? How does the quality of teaching and conveying such messages have been?

3.  Has each member of the People’s Participation Council started at least one mental health promotion project with its resources? How is the quality and quantity of such progress?

4.  How are the quality and quantity of public messages installed in public places?

During all stages of monitoring, after determining the quantity and quality of progress, the CAS must document the effective causes of progression or lack of progress and suggest options.

Stage IV. Evaluation and Future Perspectives

The evaluation of the action community program and its three components, including intersectoral collaboration, public participation, and self-reliance services, are as follows:

• The extent to which the MoU has progressed in general and stratified by departments and People’s network (in percentages);

• The change in the annual rate of social determinants of mental health expected in the memorandum stratified by departments

• The extent of stigma reduction and mental health literacy of people;

• The level of responsiveness of the authorities to the demands of the PPH (the number of requests that have been appropriately replied);

• The number of projects (each action with a specific product) that members of PPH have partnered with their resources to promote mental health;

• The number of referrals from SSU which reached the expected result;

• Increased satisfaction of district officials (directors, health volunteers, and people's representatives) in community action;

Using the above indicators, the current status of mental health will be determined, the extent of progress towards the expected items in the MoU will be assessed, and in the case of the lack of progress or slow progression, corrective actions will be added to the next year's MoU. The CAS must evaluate the level of satisfaction, mental health literacy, and the social stigma of district officials. This report will be annually presented and all departments of the contractee will be ranked accordingly. Then, the top departments and people’s network will be awarded as appropriate.

Table 1.

The Main Process of the Model for Action Community for Improving Mental Health of the District

Stage	Deliverables of stages	Activities of each stage
I	Advocacy from the Governorate (Sensitization)	1.Presenting the mental health status (at the national, provincial, and district levels) and the socioeconomic effects of mental disorders to the governor and his/her deputies, and obtaining necessary licenses and permits, including approval of the roadmap for improving the mental health of the district in the Governorate Council, establishing the CAS and PPH 2.Commissioning of CAS and the Social support unit (SSU) by appointing a social worker and providing facilities
II	Announcement of MoU (Empowerment)	1. Holding educational and justificatory workshops for the heads of the departments on their contribution and their role in reducing the risk factors of mental disorders and how to fulfill advocacy from the related provincial and national organizations 2. Identification and issuance of health volunteers 3. Establishment of the PPH with the presence of the heads of People’s network 4. Specific Workshop for members of PPH and health volunteers (as in the third activity) 5. Writeshops for members of PPH and health volunteers to identify the major risk factors for mental health, determining the districts' capacities and intersectoral division of labor in the form of a memorandum 6. MoU approval at the Governorate Council, signing the partnership, governor's announcement, and its installation at a public place
III	Monitoring the MoU (Implementation)	1. To determine a timetable for the supplementary training program that is planned for the health volunteers and PPH 2. The final agreement with the health volunteers and PPH on the timetable set for each deliverable mentioned in the MoU. 3. to monitor the progress of the MoU and sending feedback to the departments and PPH 4. Seasonal Progress Report of the MoU to the Governorate Council 5. Providing self-reliance services to individuals referred to self-reliant staff and seasonal monitoring of referrals with the presence of supportive authorities.
IV	Evaluation and future action (Continuity)	1. to collect information on indicators for evaluation. 2. to analyze information and draft a report 3. to report to the Governate Council and making decisions for the coming year's MoU 4. Reward and appreciation from the offices, PPH, and all the people involved in improving the mental health of the district 5. Submit a provincial-level report to strengthen vertical intersectoral collaboration and to request technical and financial support

Table 2.

Educational Needs for Workshop on Community Action Principles and Techniques in ‎Promoting Mental Health

Educational Needs	Suggested Methods	Time(min) *
Description of the state of mental disorders and its social and economic outcomes at three national, provincial, and territorial levels.	Slideshow Presentation, Infographics Presentation, and Group Discussions	30
options implemented in countries which were successful in preventing mental disorders and stigma reduction	Slideshow Presentation, and Group Discussions	30
model for community action and its components in the district	Slideshow Presentation, and Question-and-answer Session	30
remarking expectations including the contribution and role of each department in reducing mental disorders	Slideshow Presentation	30
Principles and techniques of advocacy, intersectoral collaboration, public participation, and social marketing	Slideshow Presentation and problem-solving exercises, including drafting a document which plays a leading role in the advocacy, intersectoral planning, displaying public participation in a region, and planning social marketing for changing a public behavior	30 each

^*‎‎‏ ‏The times set out in the table are specific for workshops designed for heads of departments. For members of the Public Participation House ‎and health volunteers, each time is doubled.

Table 3.

Description of the People's Participation House in Promoting the Mental Health of the District

Mission	People’s Participation House (PPH) is a network model for organizing people's activities. This model increases access to groups of people, especially vulnerable groups. This council is formed by the presence of people's network leaders in the district with the hosting of the governorate and the district's healthcare system. The goal of the PPH is to empower brokers to participate in the formulation, implementation, and evaluation of health promotion projects in the district, and as a result, speed up improving the following indicators:1) increasing the mental and social health of people 2) reducing social stigma 3) reducing risk factors for mental disorders and social harms
Pillars	The PPH consists of two main pillars of the secretariat and council. The chairman of the PPH is elected from the members every two years and for the first year, he/she is appointed by the head of the health network and the governor's confirmation; moreover, he/she is a social worker out of the ‎ CAS‎ in the governorate. After one year of activity, the chairman of PPH is elected from among its members. The meeting place is in the governorate. The members of the PPH are representatives of the active people's networks at the district level. In the Islamic Republic of Iran, such networks, which their head is invited to form the council, are as follows: The City and Village Councils of the district, NGOs, health workers, health volunteers, religious groups, athletes, workers, Basij, benefactors, mayors, mourners, Friday Imams and established clerics and periodicals, artists (paintings, visual arts, music, film, and theater), employers, educators of Literacy Movement Organization, teachers, Parent Teacher Association, representative of the advocates for Imam Khomeini Relief Foundation, the national Retirement Center and Retired Military Personnel Club, and students.
Tasks and How it was Formed	The three specific deliveries of each PPH are 1) collecting demands of the network members (e.g. students' demands for the student network), 2) the transmission of social and mental health messages, and 3) the implementation of specific health promotion projects with the network's resources. Each network member is independently monitored concerning these three tasks, and their annual reports are compiled and ranked. At the beginning of every year, the head of the PPH, in consultation with the CAS, is required to present the Action Plan of each member of the Council. In the first step, a workshop for training members of the network is required (Table 1), and then their demands should be collected to be transferred to the authorities. The head of the PPH sums up all the demands for social and mental health promotion and corresponds with the governor. To complete the measures taken by PPH, mental health promotion messages should be provided to members of the People's Participation Council, and the CAS‎ is required to ensure that the messages are distributed fairly and effectively. It is necessary to measure mental health literacy and social stigma at the beginning of the work.

Table 4.

Sample Division of Labor of the Hypothetical City Administrations in Preventing the Incidence and ‎Prevalence of Mental Disorders and Social Issues in the District

	Effective Parameters and Measures on Mental Health	Responsible Unit
Childhood development	Kindergarten quality and quantity promotion	Welfare organization for the district
	Children's playgrounds in the district	Urban and Rural Municipality
	Ensure that all children of the district enroll in school	Education and Registration
Literacy	Identifying illiterate people and introducing them to the Literacy Movement ‎Organization ‎	CMHC
	Identifying school-leavers at school and helping them return to school	Identification: CMHC Returning: Education
	Strengthening Educational Counseling Centers and training administrators and teachers on non-discrimination and other health-oriented skills at school	Education
Income	Compilation of the district's investment book	Governorate
	Provincial and national advocacy for investment	Governorate
	Identifying unemployed people and offering job opportunities, identifying homeless people and acting appropriately, identifying households who are below the poverty line and taking self-reliance measures	Referral by Centers for Health Services and actions taken by relevant organizations, including the Employer Syndicate and the Center for Technical and Professional Education and Employment Centers
Safe and effective work	Creation of employee support centers in workplaces	Department of Labor and Welfare with Co-operation of the Health Network Management, Employer Syndicate, and Workers' Association
	Employee training for health-centered workplace practices and a healthy lifestyle for workers	Department of Labor and Welfare with Co-operation of the Health Network Management, Employer Syndicate, and Workers' Association
​Food safety	Providing fruit and vegetables locally and distributing food basket to the required households	Governorate and Municipality
	Promote healthy eating	Health Network of the District
​ Recreations	Formation of community recreational programs (traditional recreation of the district) and increasing physical mobility of people	Governorate and Municipality
​ Public transportation	evaluating and improving the District's public transport fleet	Municipality and Roads and Urban Development Administration
	Determining incident points and fixing problems	Municipality and Roads and Urban Development Administration
​Social services	Social care for sensory, motor and mentally disabled individuals, and redefinition of social services	The district's welfare organization and health center
Social safety	Strengthening programs for reducing substance abuse and alcohol consumption	District Police Commander
	Forming the Council for the Prevention of Crimes	Law Enforcement, Justice and Welfare of the District
Crisis management	Compilation of district risk map, prioritization, and action for risk reduction	Governance Crisis Management
Spirituality	Promoting morality in practice and appreciating citizens with ethical performance	Islamic Propaganda Office, Friday Imam Office, Urban and Rural Municipality
Governance	Establishing a center for sustainable development of the district (economy, community, and environment)	Governorate
	Integrating the training course on mental disorders' stigma reduction for employees and managers of all institutions	Governorate
	finding vertical support from provincial and national level organizations	Governorate
	education on principles and techniques of local governance for all the demarches, mourners and city and village councils	Governorate
People’s participation	Establishing PPH (People's Networks for Participation)	city and village councils
	Formation of Local Council (Geographical Approach to Partnership)	city and village councils
	Promoting the Mental Disorders Prevention Program through the PPH and the local Council	city and village councils
Health services	1) Preparing all health centers of the district, 2) establishing CMHC and provision of primary and secondary mental health programs and referring individuals in need of social counseling and support, 3) Establishing an educational and promotional information sheet for households in cooperation with Community Action Secretariat	District Network Management

Box 1.

Job Description of the Social Worker in the Community Action ‎Secretariat (CAS)

A) Managing affairs of the CAS which include: 1. Compiling Memorandum of Understanding (MoU) for intersectoral collaboration focusing on the management of the health network of the district and stakeholder engagement. 2. Monitoring the progress of the operations required for implementing the memorandum by appropriate means, especially presenting it to the Governorate Council 3. Drafting and submitting monthly and annual progress reports to the governor and following their revision and editions. 4. Needs assessment and providing training on the empowerment of implementing partners of the MoU (heads of departments, health volunteers, members of the People’s Participation Council) 5. Supervising the formation of the PPH, contributing to the development of the People's Participation Council Action Plan, attending the meetings of PPH as secretary of the meetings during the first year, and then as a consultant. B) Management of the affairs of the SSU: 1. Coordination with health centers for a social referral to these staff. 2. Perform exploratory interviews with people who were referred to this staff from various health centers. 3. Apply and insert the self-referral program of the individual or household referred to and provide feedback to the primary centers. 4. Following the self-reliance program by monitoring the actions done every month. 5. Conduct monitoring sessions with all supporters to assess the extent to which social support is operational.

Discussion

The findings of this study suggest that community action should be based on three strategies: intersectoral collaboration, public participation, and providing self-reliance services (30). These strategies are local, in a hypothetical city, and according to the existing structure. It is expected that by the implementation of this model in the form of an action community program, the satisfaction of officials in terms of cooperation and participation in the health of the district will increase, so that the risk factors for mental disorders gradually decreases, the social support of individuals suffering from mental disorders increases, and at last, its social stigma diminishes. Comparing international experiences of intersectoral collaboration with our proposed model, the following components have been developed to ensure the success of intersectoral collaboration (31):

• Stakeholder identification, sensitization, and advocacy;

• Predetermined aim and division of labor to achieve the goal in the form of an MoU

• Use vertical support (provincial level) as well as horizontal cooperation between departments

• Demand for mental health promotion in people

• Creating a stable and trained team

• Monitoring, evaluation, and incentive awards

Moreover, comparing the model designed in our study with the ladder of public participation (32), we have involved both levels which are informing people and collecting their claims, and creating opportunities for people's direct cooperation.

The establishment of a staffing office for providing self-reliance services in the governorate overlaps with several organizations in their duties; among them are the Welfare Office of the district, the Municipality, the Imam Khomeini Relief Committee, and other charities. According to the surveys conducted, the social protection services provided by such organizations are not aimed to reach self-reliance in referred individuals; therefore, effectiveness is not going to happen (33).

Although CAS is designed for improving intersectoral collaboration in the mental health context, it can become the Council for Sustainable Development of the district. In other words, for all sustainable development indicators, including economic, social, bioenvironmental, and governance areas, two strategies should be used: intersectoral collaboration and public participation, whose operational tools are designed in the community action program (34). Another feature of the model is that instead of building new structures, it uses the district's inner capacities, so it has a less financial burden.

Limitation

There are several limitations to designing and implementing our model. The health network of the district has been operating in Iran for three decades, but neither has there been a systemic intersectoral collaboration nor public participation. Therefore, implementation of this model needs infrastructure reforms, which itself induces resistance after implementation (35). Another limitation is the lack of sufficient cooperation of administrations and departments of districts; in their mind, health is defined as a lack of disease and a healthy person is the one who is not sick. Therefore they consider the health network of the district to be responsible for improving mental health, and health in general, which will resist their maximum participation as their social responsibility (36). For various reasons, in developing countries, there is a lack of trust in the public's capacities and the power of people’s network; therefore, establishing PPH and their activities seems to be difficult (37).

Conclusion

To evaluate our proposed model, we recommend piloting this model by implementing it in one or more cities and later reform it if needed. The effective performance of this model requires the training of the departments and the members of PPH esp. on financing projects contained in the MoU, looking at other countries with the same experiences, and using the lessons learned from similar Iranian models. The effectiveness of measures taken by departments to reduce the risk factors for mental disorders is highly dependent on the extent of the technical and financial support from relevant organizations at the provincial and national levels. In our case, designers and implementers should fulfill advocacy by holding national meetings and requesting support from the ministries and the relevant national organizations.

Conflict of Interest

None.