A scoping review of health models for the community mental health needs of the United Arab Emirates: Nurturing the social determinants of mental health through social prescribing in the Middle East

Applied search strategy

The scoping review within this study incorporated the 2 identified questions to explore the aim of this study: What evidence is there of appropriate health models that can be adopted to use social prescribing to treat mental illness and address SDMH within the community care setting. The search determined that there had been regional interest in social prescribing within the United Kingdom (UK), Europe and the United States (US) and that this had created a wide-ranging source of research and literature on social prescribing (Morse et al., 2022). What was less evident was a review of health models to implement this strategy in community mental health care settings within the Middle East. This necessitated a need for the authors to undertake a broader and wider focus with a flexible hierarchy of evidence to identity relevant literature. The scoping review extrapolated the evidence from published literature and identified the profile and key themes aligned to the needs assigned to a proposed health model. The health models were analysed and identified in conjunction with the relevance of and success of their implementation on community settings, alongside information gained from an evidence base for their application to the ethos of social prescribing as an empowering and alternative as a non-pharmaceutical focused treatment scheme that could be implemented within UAE society and culture.

Key databases searched were: CINAHL, MEDLINE, Cochrane Library, ASSIA, Web of Science and Scopus. The database search was also supplemented by hand searches of relevant publications/policy documents located within the University of Sharjah libraries. All considered literature was considered key to underpinning and providing an evidence base for this review article. No time restriction was set initially, as the authors wanted to seek relevant literature that may be seminal and illuminated the historical significance of the evidence base presented. However, for specific studies relating to health models and social prescribing, a secondary literature search was undertaken from the time periods 1940’s to 2024 to capture the most current research. A wide range of studies were sought that focused on policy objectives and initiatives influenced by international and national health agenda, through to independent and statutory studies exploring relevant health models, social prescribing and SDMH. A wide variety of search terms were used independently or in different combinations which were directly pertinent to the research questions or were slightly tangential to the research questions, this was to ensure that any emergent sources that may be linked to seminal literature might be found, and their relevance explored to identify innovative new healthcare strategies and or approaches.

Ethics

The study has conducted a scoping review of existing relevant studies and will not recruit any participants directly; thus, ethical approval was not required.

Self-Management and Self-efficacy within the Inclusion of Health Models for Community Care

In following six-step approach the authors identified 22 possible models. There was limited published information within the MENA region but extrapolation from international studies allowed the authors to consult stakeholders and policy makers (step-six of the adopted scoping review strategy of Arksey and O’Malley, 2005). This consultation identified the importance of self-management given the comparable limitations of mental health provision within the region and early stage of development of community mental health services. Within the review of literature and consultation, the authors identified the concept behind self-management as mentioned previously to be self-efficacy (Liu et al., 2023). It is accepted that individuals experiencing mental ill-health may have different symptoms that directly affect their cognitive ability to engage in society. Therefore, managing the symptoms of mental health is extremely important. In coping with such conditions, healthcare providers within the community must empower clients and let them be positively involved in addressing their SDMH through an individualized plan of care. Williams et al. (2007) highlights that self-management education programs are significant for empowering clients to acquire new skills in order to enhance the self-care of their conditions. In reviewing the literature of the evidence base of health models the authors ensured that self-management and self-efficacy were adopted conceptually as gatekeepers for the inclusion of any identified models. Four noteworthy types of models identified by the authors are the Health Belief Model, Motivational Interviewing Health Promotion Model and finally the Crescent of Care Nursing Model. These four models can be utilised with minimal involvement of the traditional bio-medical model practices arguably entrenched within the region’s healthcare practices. These suggested models of care align with a social prescribing framework and could be applied to health policy directives within the region.

Identified Health Models for the Application of Social Prescribing to meet the Social Determinants of Mental Health Care needs of the UAE

Health belief model

The Health Belief Model (HBL) was developed by Hockbaum, Leventhal Kegeles and Rosenstock in the 1960’s. The model was identified within the scoping review as it has relevance as it creates a focus for the client to be able to make choices on their own health care needs (Rosenstock, 1966). This active decision-making approach was based on the seminal psychological theories first identified and explored by Lewin (1944), who proposed that individuals assign value to the potential outcome, this therefore influences the selection of health behaviours based on their belief of the results of the desired outcome.

Later studies by Wallston (1992) and Schenkman et al. (2008) demonstrated the benefits of this framework for health promotion for those with heath needs. Their research has relevance for this study in that their findings indicate that the HBM, as a socio-cognitive approach that could support the mental health needs of individuals. In applying this model to social prescribing, the authors propose that individuals might be likely engage in the selected psychosocial interventions prescribed if they have the mindfulness that the given health-related treatment has a positive impact on their activities of daily living, when they believe the intervention will be effective, and when they perceive few limitations to participating and taking empowering action. The authors believe that the HBM could provide a structure to developing and evaluating social prescribing in the UAE when applied to community mental health schemes as there is an enhanced emphasis on improving mental health awareness as applied to the causalities of the social determinants of mental health and associated well-being of people in the UAE.

Motivational interviewing

First devised by Millar (1983) and then expanded by Millar and Rollnick (1995) motivational interviewing (MI) has been recognized as highly effective in the treatment of mental illness. MI was first devised for the treatment of addictions and alcohol misuse as a directive counselling approach. From its conception there have been encouraging results demonstrating its effectiveness in promoting change in health behaviour and client led lifestyle changes. A key concept of MI is that it seeks to delve into the individual’s ambivalence not to promote healthy change and seeks to alter these maladaptive responses (Levensky et al., 2007). When exploring this model for the use of social prescribing within community mental health settings, there is strong evidence for this client-centered approach but does rely on the client’s intrinsic motivation to change and so there would be a holistic effort from all multi-disciplinary teams to have a familiarity and confidence in applying MI within the community setting. This model follows four key counseling principles (Rollnick, Miller, Butler, 2023; Levensky et al., 2007) which the authors have reviewed and adapted to the focus of this study:

The adapted model of Rollnick, Miller, Butler (2023) and Levensky et al. (2007) by this study’s authors provides a proposed framework for the use of social prescribing in the community mental health setting that focuses on and seeks to impact the social determinants of mental health. The framework relies on the practitioner’s interpersonal style ability to engage in reflective listening, asking open-ended questions, affirming, and summarizing their engagement with their client. This approach could instill motivation to change in the client by creating alternative cognitive realities of their life post engagement with MI (Table 2).

Health Promotion Model

Historical conceptions on health promotion were predominantly focused on supporting the individual with healthcare needs to help themselves make lifestyle changes (Minkler, 1989). However, as discussed by Whitehead (2004) there has since been an evolving dominance of socio-political emphasis in health promotion which has overtaken a former emphasis on individualistic and behaviour focused care. The authors highlight the ability of the health promotion model to assist with the transformative process of developing community mental health services in the UAE as the model has an evidence base within the socio-political of health promotion activities. Therefore, the model has an evidence base to develop and reform social structures through developing participation with social prescribing with representative stakeholders from multiple agencies and disciplines. However, caution should be taken as the model has historically incurred criticism that with the focus on individual responsibility for health can contribute to victim blaming (Hancock, 1986). Early studies by Robertson and Minkler (1994) acknowledged that health promotion recognized the social, economic and political determinants of health with a later inclusion of social justice as noted by Carlisle (2000).

The authors determine that the health promotion model could create a workable framework by which the ecologically driven socio-political-economic determinants of health are addressed as they impact on community mental health. However, the authors acknowledge that this model does not have a specific focus on religion and spirituality. As emphasized by Lovering (2008) there is a need to create an emphasis on the importance on Muslim faith as it applies to health in countries in the Middle East. Therefore, the authors expanded the parameters of the scoping review and identified the following model for inclusion in this study.

Cresent of Care Nursing Model

The Crescent of Care nursing model is derived from an ethnographic study of the health beliefs and care meanings of Arab Muslim nurses caring for Arab Muslim patients in the Middle East region by Lovering (2008). The model is a culturally sensitive and holistic approach to the spiritual, cultural, psychosocial, interpersonal, and clinical caring needs of Arab Muslims within the UAE and the wider MENA region. Lovering (2008) demonstrates the linkage of professional nursing values and combines them to creation of this model. The model creates a central organizing point with the client and their family as the focal point. Shared meanings on spirituality between the nurse, patient and family nurture meaningfulness and enhance care. The authors remonstrate that this model links into the SDMH as it is set within a context of psychosocial, cultural, interpersonal, clinical, and spiritual elements of care by respectfully acknowledging that an Arab conceptualization of health is derived from the religion of Islam. The wisdom of including this model within this scoping review is the presence and relevance of the concept of tawhid. Kounsar (2016) describes tawhid as a oneness with Allah and requires that a Muslim lives in a way that demonstrates a unity of the body and mind with Allah. Lovering (2008) writes that Tawhid implies therefore that there is no separation of the body from the spiritual dimension of health. Kounsar (2016) highlights central beliefs to Islam that Muslims also believe. This ethos can be applied to seeking to address the SDMH via social prescribing as illustrated within the following model (Figure 1) used by Al-Fayyadh et al. (2022) to illustrate Lovering’s Cresent of Care Nursing Model:

Figure 1. Spiritual Care Model Crescent Care Model.

This model is based on Al-Fayyadh et al. (2022) interpretations of Lovering’s Crescent Care Model which supports clients to understand and appreciate the link between short and long-term goals. This paper suggests that this approach is driven by religious and cultural sensitivity that may enhance motivation for the client and so support them adhering to the psychosocial interventions identified as part of social prescribing. The authors suggest that the inclusion of a focus on the ethos of tawhid may promote continued involvement in goal setting, active participation, and enhanced responsivity in that the clients take responsibility for their own health and empowered care through social prescribing. The interplay via shared belief can foster and promote effective and culturally and religiously nuances psychosocial intervention that the client wholeheartedly embraces through tawhid. As in all changes, there are inherent challenges to progress which will be discussed now.

Future Considerations: Stigma and Habitus

Identified challenges exist in developing workforces capable of mental health within communities setting and independent from the current institutional arrangements that do not meet all SDMH. Caution must be taken not to replicate errors and delays away from institutionalized care which can isolate clients away from families and their communities, making reiteration all the more difficult. The authors believe that there is a lack of mental health awareness due to engrained practices (habitus) are further compromised with the presence of stigma within health systems not utilizing health models that seek to enhance the quantity and quality of care. Such issues have existed in much of the world and should not be seen as solely regional concerns. The papers finding indicate that opportunities exist for shifts in treatment provision as suggested by the inclusion of social prescribing to aid services to meet the full range of SDMH. The inclusion of mental health strategies and laws herald improvements with a recognition of the likely benefits of integrating mental healthcare delivery with community care and the management of common mental health conditions indicating encouraging changes to current practices.

The World Health Organisation (2022) estimates that the majority of individuals with mental illness do not seek treatment, citing reasons as concerns a perceived damaging of their family’s reputation, standing within the community, opportunities for marriage, encountering discrimination, exclusion from society, and stigma. Consequently, these individuals experience diminished self-esteem (Stuart et al., 2019) and poor academic achievement (Bruffaerts et al., 2018).

Goffman (1963, p. 3) describes stigma as “an attribute that is deeply discrediting. It diminishes the social status of an individual by reducing them in the eyes of others from being whole and usual to tainted and discounted”. Stigmatization has the potential to diminish an individual’s self-esteem, cause friction within familial units, and have an impact on their prospects by negatively affecting their employability (Picco et al., 2019). Within a previous study by Mottershead and Ghisoni (2021) it was proposed that social prescribing is an empowering strategy to assist individuals to connect and thrive within their communities and supports improvements in their health. This has also been observed within the Middle East within a study by Mottershead and Alonaizi (2022) and Mottershead (2022) in exploring social prescribing use with addiction and substance misuse treatment strategies. Whilst further research is required, it may be theorized that there is an associated stigma towards mental illness that still creates challenges for treatment within a public and community setting. Again, noted by Mottershead and Alonaizi (2022) was that whilst, social prescribing schemes have demonstrated a reassuring evidence base and continue to gain popularity, there has been little evidence of its use within the Middle East. A question, must there be contemplated – why?

This article argues that stigma alone is not the causality but rather that healthcare systems have these become transfixed on hospital-based care for mental illness due decision making predominantly focusing on the foundation of medical services since the conception of the UAE in 1971. This is in no way a criticism, few countries have achieved the success of the UAE in healthcare, but a realization might acknowledge a concept that Weber, Husserl and later Bourdieu (1990) identified as ‘Habitus’. It has been seen in other areas of research as argued by Professor Loader at the University of Oxford (Loader, 2007) that society can directly impact the formation of services. It is feasible that a symbiotic relationship may be experienced to a general public’s sensitivities (stigma) towards mental illness and the ability of a health services to create new strategies and treatments. Habitus, entails competence and know-how, it demonstrates great skill and awareness of how to achieve success through a pre-determined set of strategies, policies and procedures almost effortlessly through reflexivity (Bourdieu, 1990).

As the reference to ‘dexterity’ suggests, entails competence and know-how. It captures the skilled activity of the expert player rather than the conditioned response of the lab rat. The footballer who moves instinctively into the right position on the pitch, arriving just as the ball does and at exactly the right angle to it to put it in the back of the net, all without having to think reflectively about doing so, exemplifies this, as Bourdieu’s (1990). However, as was seen during the Covid pandemic, preexisting systems either failed or had to be modified, innovation became the lifeblood of a healthcare ability to become resilient and to adapt. To this end, the article has explored the available published scientific literature on health models including the research designs used and assed their credibility for clinical practice to support social prescribing and to address SDMH. In addition, the diverse international spectrum of co-authors and engagement with stakeholders has allowed further dialogue on the adoption of the proposed community focused treatment strategy of social prescribing to provide a suggested examination of SDMH within the UAE and wider Middle East healthcare practices. The authors argue that further research should follow to allow a wider contemplation of the SDMH, and how social prescribing can support the evolvement of current practices that utilize treatments pre-dominantly focused on pharmaceutical interventions for mental illness.