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Children and Adolescents’ Mental Health in Iran’s Primary Care: Perspectives of General Practitioners, School Staff, and Help Seekers

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Abstract

Background

Iran has well-established networks for primary care staffed by general practitioners who provide services to patients across the lifespan. Iran recently established collaborative care networks to build general practitioners’ capacity to provide adult mental health services. In an NIH-funded study, we are designing and evaluating a training program for general practitioners (GPs) to extend this collaboration to include services for children and adolescents. In the formative phase of this project, we conducted a qualitative study to obtain information relevant to the design of the training program.

Methods

We conducted semi-structured individual interviews with 28 stakeholders, including 15 GPs working in a collaborative care network, 6 parents and 4 adolescents who had received child mental health care from a GP, and 3 policymakers. We also held a focus group discussion with 8 school teachers and counselors. All interviews were transcribed during the interviews’ sessions and then were thematically analyzed.

Results

GPs reported seeing a range of child emotional and behavioral problems but felt the need for additional training in diagnosis and management, especially in skills for interviewing and communicating with children. GPs also expressed the need to understand legal issues involved in treating children, including cases of possible child abuse. School staff agreed that GPs could help with children’s educational and emotional problems but also believed GPs would need extra training. Parents indicated a preference for GPs over psychiatrists (as did adolescents) as a source of mental health care and for psychological over pharmacological interventions. Adolescents expressed a preference not to speak about private issues in the presence of their parents and expressed concern that the GPs did not respect their preference. They also desired a more active role during visits.

Conclusions

Before expanding the scope of practice of Iranian GPs to provide management of common emotional and behavioral problems in children and adolescents, the concerns and specific needs of these practitioners need to be addressed. Parents and youth in the study expressed a preference for mental health care from a GP rather than a specialist. However, they also commented on the need for restructuring the current GP visits to facilitate youth participation. These findings provide directions for expanding the scope of practice of adult collaborative care networks to meet the mental health care needs of children and adolescents more expeditiously and effectively.

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Acknowledgments

We appreciate all the stakeholders participating in the study, as well as the colleagues who conducted the interviews (Leila Moazami Goodarzi, Shima Sadat Zohrabi, and Hoda Layegh).

Funding

This study was funded by the US National Institute of Mental Health (grant number 1R34MH106645-01A1).

Author information

Authors and Affiliations

  1. Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Hadi Zarafshan

  2. Division of Child and Adolescent Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Lawrence S. Wissow

  3. Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Zahra Shahrivar & Vandad Sharifi

  4. Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Ramin Mojtabai

  5. Department of Psychiatry, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Mojgan Khademi

  6. Shahid-Emami Community Mental Health Center, Tehran University of Medical Sciences, Tehran, Iran

    Morteza JafariNia

  7. Research Center for Addiction & Risky Behaviors (ReCARB) and Department of Psychiatry, Iran University of Medical Sciences, Tehran, Iran

    Ahmad Hajebi

  8. National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran

    Farid Abolhassani

Authors
  1. Hadi Zarafshan
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  2. Lawrence S. Wissow
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  3. Zahra Shahrivar
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  4. Ramin Mojtabai
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  5. Mojgan Khademi
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  6. Morteza JafariNia
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  7. Ahmad Hajebi
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  8. Farid Abolhassani
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  9. Vandad Sharifi
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Corresponding author

Correspondence to Vandad Sharifi.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

The study was approved by the Institutional Research Boards of the Tehran University of the Medical Sciences and the Johns Hopkins Medical Institutions. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

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Appendices

Appendices

(1) Parent interview questions

  1. 1.

    Do doctors give you enough time and ask enough or the right kinds of questions so that you can tell what is on your mind?

  2. 2.

    Do you think that the doctors want to help you with your feelings? Probes to be developed using common terms and concerns

  3. 3.

    Which people in the GP office do you feel comfortable talking with? Probes: doctor, receptionist, someone else?

(2) Youth interview questions

  1. 1.

    What kind of problem or concern did you have?

  2. 2.

    How did the doctor find out about your problem?

    1. a.

      Was this a new or old problem?

    2. b.

      Had you ever told anyone else or been treated for it in the past?

  3. 3.

    What did you think about the process of talking to that person about your problem?

  4. 4.

    What did you think of the treatment that the doctor proposed? (Advice, medication, etc.)

    1. a.

      Did you have any concerns about it? Did you ask for something different?

  5. 5.

    If the doctor proposed that you might need to see a MH specialist, what did you think?

  6. 6.

    Has the treatment helped?

(3) GPs interview questions

  1. a)

    Questions about the scope of mental health services needed

    1. 1)

      Who are the kinds of children and youth you usually interact with – who you are thinking about when we ask the questions that follow:

    2. 2)

      What “syndromes” do you suggest that we look for? What are ways in which patients or parents may suggest that they are having difficulties? Are there particular words, phrases?

  2. b)

    Questions about approaches to diagnosis

    1. 1)

      What is it about the way that you talk to children, youth, or parents that you think makes them willing to tell you about their problems?

    2. 2)

      How do you start to ask people for more information? How do you explain why you are asking, or do you have to?

    3. 3)

      What do you think are the crucial questions to ask – the most important to detect serious problems and also the most important to get at what may be troubling to the someone? Are there questions to avoid at first?

    4. 4)

      If people reply with long or vague answers, do you have techniques for helping them be more clear or take less time that seem to be well accepted as still polite and interested?

  3. c)

    Questions about the approach to treatment

    1. 1)

      When people come to you with some of the problems you mentioned in the first question, what do you do or say that seems most helpful?

    2. 2)

      When people tell you about these things, what is it that you think they expect you will do or say?

    3. 3)

      Who else do you think your patients might have told about these problems and where might they have sought help?

    4. 4)

      What do you think that patients believe causes this type of problem? What do you think they believe are the implications for them?

    5. 5)

      If someone needs a higher level of help (you suspect a more serious problem, you think a medication might help) is there a way to raise that thought?

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Zarafshan, H., Wissow, L.S., Shahrivar, Z. et al. Children and Adolescents’ Mental Health in Iran’s Primary Care: Perspectives of General Practitioners, School Staff, and Help Seekers. Glob Soc Welf 8, 1–10 (2021). https://doi.org/10.1007/s40609-019-00144-5

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