Fatemeh Karimi
1 
, Nadereh Memaryan
2* , Shahrbanoo Ghahari
1 , Mozhgan Lotfi
1 1 Department of Mental Health, School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran
2 Spiritual Health Research Center, Mental Health Department, School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran
Abstract
Background. One of the main activities that plays a significant role in the prevalence of mental illnesses is the issue of referral. According to the evidence, the lack of proper implementation of the referral system is one of the obvious weaknesses of the Primary Health Care (PHC) system. Therefore, this study aimed to investigate the challenges of referring mental health clients in the PHC system in Iran. We also examined the weaknesses in this process from the perspective of mental health experts.
Methods. The present study is a qualitative study with conventional content analysis approach. Data were collected through semi-structured interviews with 15 PHC psychologists selected through purposive sampling. After transcribing the interviews, the data were analyzed based on the Graneheim and Landman model.
Results. We identified two main themes and 12 categories. The theme of intra-centered referential challenges included categories such as weaknesses in health care providers screening and low referrals, clients' lack of trust in health care providers, clients' lack of cooperation, physicians' poor cooperation, and barriers to clients' desire to visit a psychologist. Meanwhile, outer-centered referential challenges included a shortage of referral centers, lack of transparency in referrals, lack of direct referrals, poor follow-up, barriers regarding referral to a higher level, and barriers to clients’ referral to the institute.
Conclusion. The findings of the present study showed that poor intra-sectoral and inter-sectoral communication is one of the main challenges that has disrupted the referral process in the field of mental health in the PHC system. Many challenges such as the lack of designated referral centers, poor follow-up due to lack of referral feedback, and clients' financial inability to refer to a higher level can be improved by strengthening cross-sectoral communications such as two-way communication with support organizations and psychiatric and psychotherapy centers.
Extended Abstract
Background
The Primary Health Care (PHC) system is the first level of contact of the individual, family, and community with the health system, through which essential health care is made available to families and individuals. Given the access of people to this system, and the suitability of this platform for the implementation of mental health programs, the integration of mental health services in this system has been one of the most important achievements of the last 50 years. However, the issue of referral plays a vital role in providing mental health services in this system because the reception of clients and their guidance in receiving the required services is done in a referral process. Since the lack of proper implementation of the referral system is one of the obvious weaknesses of the PHC system, this study aimed to investigate the challenges of referring mental health clients from the perspective of mental health experts in the PHC system in Tehran, Iran.
Methods
The present study is a qualitative study with a conventional content analysis approach. Using a purposeful sampling method, interviews with 15 participants were conducted and data saturation was obtained. Data were collected through semi-structured interviews with psychologists in the PHC system. Interviews and data collection were gradually completed over seven months and the interviews lasted for 33-108 minutes (average: 65 minutes). During the interviews, code of ethics such as confidentiality and obtaining informed consent were observed, and the interviews were conducted in a calm environment with prior coordination with the participants. After transcribing the interviews, the data were analyzed based on the Graneheim and Landman model. The inclusion criteria were job experience ( at least 2 years) and being employed as a mental health expert in the Comprehensive Urban Health Services Center. The exclusion criteria were lack of job experience or having worked as a mental health expert at the relevant centers but having a different job status at present.
Results
We identified two main themes and 12 categories. The first theme was related to intra-centered referential challenges in relation to the challenges and weaknesses in the process of referral of clients in health centers, i.e., referral from health care providers and physicians to mental health experts. This theme had five categories: weaknesses in health care screening and low referral, patients' lack of trust in health care providers, clients' lack of cooperation, poor cooperation of physicians, and barriers to clients' desire to visit a psychologist (Table 2). The second theme was related to outer-centered referential challenges, which considered weaknesses and gaps in the referral process to higher and out-of-center referrals for more specialized services. This theme had six categories: lack of centers for referral, lack of transparency in referral, lack of direct referral, poor follow-up, barriers for clients to go to a higher level, and barriers to referral of clients to Tehran Institute of Psychiatry (Table 3).
Conclusion
The findings of the present study showed that poor intra-sectoral and inter-sectoral communication is one of the main issues that has disrupted the referral process in the field of mental health in the primary health care system. Many challenges such as the lack of designated referral centers, poor follow-up due to lack of referral feedback, and clients' financial inability to refer to a higher level can be improved by strengthening cross-sectoral communication such as two-way communication with support organizations and psychiatric and psychotherapy centers. Accordingly, the following reforms are recommended: increasing the correct and continuous training of health care providers regarding the significance of mental health and proper screening by the headquarters and health deputy, providing qualitative and continuous monitoring of caregivers screening in mental health and referral instead of quantitative monitoring, and shortening the referral process and rising the level of referrals at low cost for clients.