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Descriptive Reports of Integration of Mental Health into the Primary Health Care (PHC) System in One of the Areas of Iran

Mahboubeh Dadfar, Fazel Bahrami*

Department of counseling, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Abstract: Integration of mental health into the Primary Health Care (PHC) system has been carried out many ago years in Iran. There are three services levels in the program including: Health house (The first level), rural health center (The second level), and city health center (The third level). Aim of the study was descriptive reports of the program in one of the regions of Iran. This was a descriptive cross sectional study in one of regions in Iran which has carried out this integration on it. Data gathered by monthly reports from one of regions of Hashtgerd, Savojbalagh, Alborz province, Iran. In Khurvin health house of Hashtgerd, Savojbalagh, Alborz province, Iran, integration of mental health performances into the PHC system including training, case finding, identifying, referral and follow-up of mentally patients were done by behvarzes. Most of patients under coverage this health house, were visited and followed by a general physician (GP) and they were cared by behvarzes. In Shahid Kohsar Golbaz rural health care center in there, which is one of the mental health service providing levels, diagnosis and treatment were done by a GP who was a director of the center. Patients who were visited at this center had been referred by Khurvin health house. Mild mental patients referred directly more than severe mental, epilepsy and mental retardation patients to this rural health care center. Psychiatric emergency cases were under covered by the same GP. Activities in this area were in a framework of a program and were including such activists: Mental health services, mental health training, mental health promotion, and mental health research. Level of case finding was excellent (for epilepsy) and poor (for mental retardation). On the bases of an report from the city health center in Hashtgerd, Savojbalagh, disorders were 1 case for severe mental disorder and mental retardation, 10 cases for mild mental disorder, 1-5 cases for other disorders per 100 under coverage population, and 1-3 cases for epilepsy per 1000 under coverage population. The most and the least common of disorders were mild mental disorder (56.9%) and mental retardation (6.9%). The most important achievement of the project of integration of mental health into the PHC is reduction of load of hospital professional services. This integration is successful in this area and can be continue with some changes and reforms that will be discussed in the paper.

Keywords: integration, mental health, primary Health Care (PHC), Savojbalagh, Hashtgerd, Alborz province, Iran

Citation: Mahboubeh Dadfar, Fazel Bahrami, Descriptive Reports of Integration of Mental Health into the Primary Health Care (PHC) System in One of the Areas of Iran. American Journal of Educational Research, 3 (11). 1429-1432. January 2015. doi:10.12691/education-3-11-12

1. Introduction

In recent years, an increasing emphasis has done on decentralization policy in providing of mental health services and its integration in primary health care (PHC) systems in many countries [1]. Since the formal adoption of "mental health" as a component of the primary health care system in the Iran in 1989 and offering its services in the network, many researchers have investigated its different aspects [2-32] and led to promising results and is demonstrated significance of this method in the development of mental health services.

After Shahreza and Shar-e-kord examples, the third example of integration of mental health in PHChas carried out in Hashtgerd, Savojbalagh, Alborz province, Iran and its executive operations is lasted April 1993 to February 1994. Results of Hashtgerd study showed that prevented from transfer over the 271 psychiatric patients that 154 cases who were referred by behvarzes and rural health care centers and other patients who were from Hashtgerd and its around to province center. Rate of finding of patients was 4/45 per 1000 under coverage population. Patients in per 1000 under coverage population were including severe mental disorder (0/58 cases), mild mental disorder (1/38 cases), epilepsy (0/58 cases), mental retardation (1/16 cases), and other disorders (0/75 cases). 271 patients were identified including 35 patients with severe mental disorder, 85 patients with mild mental disorder, 36 patients with epilepsy, 70 patients with mental disorder, and 45 patients with other disorders [4,6].

Bolhari, et al (2012) evaluated mental health program integration into the PHC system of Iran and reported that there was significant difference between behvarzes in areas under coverage and out of coverage in knowledge and attitude, as well as between general population in areas under coverage and out of coverage in knowledge and attitude. Knowledge of general practitioners in the coverage areas was high, but 34.3% of them had difficulty in diagnosis and 48.6% had problem in treatment of psychotic patients. They concluded that integration of mental health programs into PHC is an effective and affordable method which with continuous monitoring and evaluation could be lead to valuable results [31]. Aim of the study was descriptive reports of the program in one of the regions of Iran.

2. Methods

This was a descriptive cross sectional study in one of regions in Iran which has carried out this integration on it. Data gathered by monthly reports by behvarzes from one of regions of Hashtgerd, Savojbalagh, Alborz province, Iran.

3. Results

In Khurvin health house of Hashtgerd, Savojbalagh, Alborz province, Iran, integration of mental health performances into the PHC system including training, finding, identifying, referral and follow-up of mentally patients were done by behvarzes. Most of patients under coverage this health house, were visited and followed by a general physician (GP) and they were cared by behvarzes. In Shahid Kohsar Golbaz rural health care center in there, which is one of the mental health service providing levels, diagnosis and treatment were done by a GP who was a director of the center. Patients who were visited at this center had been referred by Khurvin health house. Mild mental patients referred directly more than severe mental, epilepsy and mental retardation patients to this rural health care center. Psychiatric emergency cases were under covered by the same GP. Activities in this area were in a framework of a program and were including such activists: Mental health services, mental health training, mental health promotion, and mental health research.

Table 1 shows that level of finding of patients was from excellent (for epilepsy) to poor (for mental retardation).

Table 1. Cases and levels of findings of patients on the report center mental health network

On the bases of an report from the city health center inHashtgerd, Savojbalagh, disorders were 1 case for severe mental disorder and mental retardation, 10 cases for mild mental disorder, 1-5 cases for other disorders per 100 under coverage population, and 1-3 cases for epilepsy per 1000 under coverage population (Table 2).

Table 2. Type of mental Disorder and expected cases percent of city health center

4. Conclusion

Results showed that the most common of disorder was mild mental disorder (56.9%), and the least common was mental retardation (6.9%). Mental health training to behvarzes in a region causes change in their attitude and on the basis they can train mental health to people, find and refer mental disorders patients. So attention to their problems about mental health to people, diversity of under coverage population, cultural problems and adding of numbers of behvarzes. Successful the program related to function of behvarzes. With simultaneously providing of educational health care, especially mental health they can play a critical role in order to obtain to access all of people to the basic health services that it is main goal of PHC. Job satisfaction of behvarzes is a main component of community participation in PHC and it has a significant rolein providing of health care. Consideration to increasing of their job satisfaction different aspects such as physical, psychological, social, organizational, educational, management/supervisory and welfare is necessary and managers of health care system should identify their resource of satisfaction/non satisfaction. Also with respect to addiction in the region, more identification of addict persons bybehvarzes and making of motivation in them for treatment, and the use of strategies for coping with deny of addiction and avoidance from treatment are necessary. Since preparing of a good referral system is one of essential aspects of health care system, lack of higher supportive levels of health houses, potentially non effects referral sequence in rural health care centers and looses relationship between these centers and hospital.

According to research in the world, it is expected that the real number of mental retardation is about 10 per thousand. 85% are patients with mild mental retardation [33] and with regard to identification of mild mental retardation cases in the rural environment with cognitive tools is hardly feasible, so the number 1 in per 100 people for the disorder can be an acceptable number. Tendency to hide of mental disorders and different abilities of health staff in the identification of cases and relation with community can justify statistics of finding of cases in Shahid Kohsar Golbaz rural health care center and Khurvinrural health house.

Weakness of health management leads to mental health services, finding of cases and recoding of activities in a low level. Therefore, good health management and effective mental health staff is essential. Function of management of mental health program in PHC of Hashtgerd area should measure in four dimensions: planning, organization, executive performance, monitoring/control. In planning dimension, survey of employee views lead to making of motivation and more active participation in them the process of improving the quality of health services. In organization dimension, having an organization chart has important because it provides a system or design that shows quality of formal process of activities in the organization and it is a tool to describe the tasks of members in each organization. Members need to be aware of their current status in the organization and find more opportunities for understanding of organizational relations and cooperation in order to achieve the objectives. In executive performance, continuous training is found of organization understanding and support for comprehensive quality improvement and is a promotion of efficacy, one of necessary efforts to improve of quality. Intersectional cooperation should be strengthened. For appreciation of staff’s good performance should be exist an appropriate evaluating criterion. In the monitoring/evaluation should consider the following: 1) use of the timetable for activities of under monitoring, 2) use of a checklist for monitoring, 3) to familiarize of managers, especially executives to monitoring set targets and mechanisms, and 4) more attention and more support of managers with higher levels on the monitoring consequences. Monitoring on correct implementation of the guidelines and application of learned skills, especial if it be along with evaluative forms, will provide good training materials to periodic retraining. Management associated with control has a guarantee for accuracy, certitude, and full implementation of integration programs.

More involvement of GPs and health technicians this region has many important. To further contribute of staff, giving of higher job degree can be considered for example grant of retraining and other accolades. The most important problems reported by GPs were lack of cultural acceptance especial for Afghan settled in this region, having some problems about referral, follow-up of the patients, and lack of coordination between executive different sections that directors should consider to them seriously. Other problems reported about mental health by GPs were including: 1) follow-up of patients, 2) decisions making about diagnosis and treatment, 3) side effects of drugs, and 4) the appropriate amount of administered drugs.

This study revealed that patients who were referred from Khurvin health house to Shahid Kohsar Glbazrural health care center, visited by GP who works an average of 3-6 months in this center. This short time causes that he/she trains a low level and completely unaware of his/her responsibilities/tasks.

With respect to believe and referral to traditional therapists and using of different forms of traditional therapies such as taking of pray letter (named Doa), use of herbs, and other non-medical treatment forms by the people, mental health public education and training of GP for optimal using of psychiatric available services are necessary. Increasing of fulltime or weekly psychiatric clinics in the region is necessary and recommended.

There are some problems in this region including: Insufficient justification staff about goals and methods of the program, their insufficient information and experience, being non regular of monitoring/evaluation due to inappropriate coordination of transportation, violation of the referral system, quick change GP that prevents their sufficient information about the project and their insufficient mental health training, non coordination for participation of staff and GPs in educational courses, drug shortage, lack of psychological treatments, non coordination of the third level (professional care) and inpatient psychiatric centers affiliated to Iran University of Medical Sciences, problems with transportation of patients, lack of certain duties and inefficiency of the project coordinator, insufficient diagnostic facilities and lack of admitted to the emergency, payment problems (overtime & the mission) to staff, and one-month salary of psychiatric residents who work in there.

One of evaluating criteria about health services is its efficacy in three dimensions: Technical, scaled, and economic. For enhancing of efficacy, using of more effective strategies is suggested. Including of informative course with referral system for GPs, coordination to more having drug in health center pharmacies, more coordination of the third level (professional care) with hospitals affiliated to Iran University of Medical Sciences, bring in diagnostic facilities and preparing of short-term inpatient beds for The emergency cases of third level (professional care), preparing of staff duties, preparing of transportations, described educational activities, holding of city mental health committee to coordinate of intersectional for more coordination of the third level (professional care) with psychiatric centers affiliated to Iran University of Medical Sciences, Sending of social workers from psychiatric hospitals to the third level professional center, take advantage of people's participation in providing of health services to the community, health mediators, and local health volunteers for promotion of integration project are strategies that can be use to faster grow of integration project.

Maybe the most important achievement of integration project of mental health into the PHC is reduction of load of hospital professional services. This integration is successful in this area and can be continue with some changes and reforms.

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