Positive Mental Health from the perspective of Iranian society: A qualitative study

Introduction

According to the World Health Organization (WHO), mental health is more than just the absence of mental illness and it is also considered a state of well-being where individuals realize their skills, cope with normal life stresses, can work fruitfully and productively, and are able to make a contribution to their community (see WHO statement on mental health promotion). Based on the results obtained in a study by Keyes et al., complete mental health is a function of two interrelated independent entities, with positive mental health (PMH) as one axis, and the absence of mental disorder as the other^1–3. The complete mental health approach covers previous approaches such as the pathogenic approach, which defines mental health as the absence of mental disorders, and the salutogenic approach, that focuses on the positive aspects of human abilities and functioning in emotions and behaviors¹.

Many studies on mental disorders and related diseases have been conducted so far throughout the world. A systematic review study by Steel et al., reported that worldwide one in five adults had experienced a mental disorder during the previous 12 months and 29.2% during their lifetime (lifetime prevalence) in 2014⁴. These disorders occur at younger ages, and are chronic, and thus have many adverse effects on various aspects of life, including educational performance, employment, income, personal relationships and social participation⁵. Thus, there is a need for further, more effective investment into prevention, treatment, and rehabilitation of these disorders.

Despite the advances made in medical and psychiatric therapies, the prevalence and burden of mental diseases has not decreased⁶. Therefore, community-based interventions should be conducted to prevent the incidence of new cases, and thus promote mental health at a community level⁷. Using the slogan "mental health for all", many countries have implemented extensive policies to promote mental health with an emphasis on its positive aspects⁸. In fact, the concept of PMH includes personal capabilities in psychological, emotional, and social dimensions and promoting PMH leads to a reduction in psychological disorders, a decrease in the probability of all-cause mortality, prevention of suicidal behaviors, and impairment in academic performance^9–12. Many studies suggest that PMH, as a key factor, will lead to positive cognition, positive behavior, and increased cognitive capabilities^12,13.

According to the literature, PMH or mental well-being has two traditional approaches: Hedonic or positive feeling/affects that relies on feeling good (subjective wellbeing, life satisfaction and happiness), and Eudemonic, or positive functioning, with emphasis on optimal social and psychological functioning (engagement, fulfillment, sense of meaning and social wellbeing)^3,14. PMH is formed by the combination of these two approaches, and is conceptualized by the presence of emotional, psychological, and social well-being¹⁵. Since this concept is affected by demographic, biological, cultural, socioeconomic and psychological factors etc.^16,17, it occurs very differently in different countries. For instance, the high level of PMH (flourishing) is 11.6% in South Korea, but 76.9% in Canada¹⁸. A study conducted by Nosratabadi on Iranian students showed that 16% of students were classified as flourishing¹⁹, and a study by Joshanloo et al. reported the level of PMH among Iranian students was lower than those in the Netherlands and South Africa²⁰. Understanding and determining the concept of PMH based on cultural-social differences is essential for promoting PMH and preventing psychological disorders. Furthermore, no study has yet addressed this subject in Iranian culture. Therefore, it was decided to conduct a qualitative study to carefully explore the concept of PMH and its domains in the Iranian society.

Methods

Ethics and consent

All participants completed informed consent forms. They were assured that their identities and other related information and responses would remain confidential throughout the survey and after.

Participation was on a voluntary basis, meaning they could leave the FGD at any time during the session. Permission to record the discussions was obtained from participants for appropriate and precise analysis. The study protocol was approved by the ethical committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1396.204).

Results

In the present study, eight FGDs were conducted with individuals living in Tehran (4 FGDs with men and women separately). A total of 51 adults (29 women and 22 men) took part in these FGDs. The mean age of participants was 46.1. About one fifth of participants were unemployed and 47% had at least one university education. In this study, all individuals who had university education were considered as educated and those with high school certificate and lower degrees were deemed uneducated persons. Demographic variables of FGD participants are shown in Table 1.

In our qualitative investigation, two main themes were extracted; namely, general concept of positive mental health and domains of positive mental health, and four subthemes namely a) emotional/psychological domain, b) spiritual domain, c) life skills domain, and d) social domain (see Table 2).

Discussion

The main objective of this present study was to explore PMH definition and its domains in accordance with the Iranian culture. Although this element of mental health seems to be the same in different regions, it is obvious that the concept of PMH is interpreted differently in diverse cultures with respect to its expression and significance²⁵.

The obtained results showed that Iranian participants considered the absence of mental disorder as a prerequisite for mental health and no one considered absence of mental disorder and PMH as two distinguished notions. According to Keyes et al., mental health has two separate but correlating axis – one referring to presence or absence of mental disorders, and the other expressing a high level of PMH to a low level of PMH - and existence of one does not contradict the presence of the other. It means despite having mental disorder, an individual can have some level of PMH or vice versa^1,10,13. The results of the study implemented by Gilmour in a Canadian community supported Keyes` two continua model¹⁸. This theory was not announced by any of the Iranian individuals participating in FGDs. Whereas Laidlaw and his challenges explored in their qualitative study that Scottish people paid attention to PMH and mental health separately²⁶.

In fact, Iranian participants generally considered PMH as getting positive energy, living happily, satisfaction and having peace and flexibility, with four main dimensions of emotional/psychological, spiritual, social, and life skills. Despite the difference in the perception of PMH in different cultures¹⁴, our findings appear to comply with the PMH concepts in the literature, especially the WHO description⁵.

Results of the study revealed four interrelated domains as emotional/psychological, spiritual, social, and life skills in Iranian culture. The findings support Vaingankar`s qualitative research in Singapore, another Asian country with a diverse cultural context, that described PMH domains as personal growth and characteristics, coping strategies, spiritual beliefs and relationships²⁵. Previous studies implemented by Keyes and his colleagues described PMH as salutogenic approaches of subjective wellbeing: with positive feeling defined as emotional wellbeing and positive functioning reflected as psychological wellbeing and social wellbeing^1,3.

The role and importance of satisfaction reasonably creating and maintaining PMH were mentioned in the emotional/psychological dimension. According to the present study results, in the emotional domain, attributes such as satisfaction, love, empathy, understanding feelings and emotions, living happily, and positive thinking were suggested by participants. Review of the literature is also indicative of the importance of satisfaction in the maintenance and promotion of PMH in different cultural countries (see WHO Summary Report on PMH)²⁵. Studies conducted by Monlina and Lyubomirsky indicated the importance of happiness, happy living and other positive emotions in increasing mental/physical well-being^27,28. According to a study conducted in Singapore, positive thinking is able to affect promotion of PMH through interaction with people's personality attributes²⁵.

In the spiritual domain, virtues such as faith in God and trust in a supernatural force, and also belief in the hereafter, were highlighted by the Iranian participants as with other Asian religious regions^25,29,30. It seems that spirituality is a notable way of obtaining wellbeing and there is a widespread belief that people with spiritual beliefs and faith have better mental wellbeing^31,32. Although religiosity is considered as a main variable in defining PMH, Ganga and his challenge showed that people with different religions experience diverse level of PMH³⁰. It is important to realize more about interpersonal variations. Previous studies have shown that the most common mechanisms through which religion promotes well-being include social support networks, coping resources and positive emotions^33,34. The spiritual dimension also increases creativity, patience, hope and vitality through communication and coping strategies³⁵.

In the social domain, proper social relations, respect for the rights of others, acceptance of social norms, and lawfulness were cited by Iranian participants. The literature contains evidence on the significant role of proper communication with others and high level of mental well-being³⁶. Close relationships provide support when needed as well as mutual cooperation²⁵. Social support networks have a considerable relationship with mood, performance and the quality of life (see WHO statement on mental health promotion). New theories of well-being also point to the social aspects which correlate with the present study results³⁷.

Regarding life skills, which were explored as one of the main dimensions of PMH; stress management, accountability, anger control, problem solving, financial management, and time management were proposed in the present study. Stress coping skills appear to be one of the most important skills for finding peace and promoting well-being. In fact, stress coping mechanisms are not only important as factors affecting PMH, but also as PMH outcomes³⁸. Studies showed there is a strong relationship between financial management and satisfaction, and mental wellbeing³⁹. Also, existing evidence demonstrates a positive relationship between problem solving skills and social competencies⁴⁰. Generally, life skills empower people to cope with stresses and emotions, think critically, and are capable of making proper decisions.

The present study has certain limitations. There is lack of generalizability and representativeness since the study was conducted using a qualitative method, and only its process and methodology can be generalized. The findings need more research attempts to be applicable to the broader Iranian adult population due to the multi ethnicity context of the country.

In this study, we interpreted the concept of PMH and its aspects according to Iranian adults’ experiences. The results highlighted the significance and influences of emotional, psychological traits, spiritual and religious beliefs, social aspects and life skills on PMH. Although PMH is considered a well-defined concept, sited as top priority and measured annually in various national mental health surveys in most developed countries, it is a new subject in our nations and needs more investigations and research so it can be introduced as a culturally and linguistically multidimensional concept. Furthermore, a proper understating of how mental health professionals conceptualize the concept of PMH is essential in policy making and implementing proper community-based interventions in order to promote and protect mental health.

Data availability

Using Persian language as the national language of Iran during the process of data gathering, all raw data including quotes are available in Persian. Translation and availability of complete raw data will be done upon the request and the permission of Ethical Committee of University of Social Welfare and Rehabilitation Sciences in order to maintain the participants’ confidentiality. Anyone wishing to access the data should first contact the corresponding author who will facilitate contact with the ethical review board (http://www.uswr.ac.ir Persian site, http://en.uswr.ac.ir/ English site. Contact email international_affairs@uswr.ac.ir)