In 2005, commission on the social determinants of health, as a global network brought together by the World Health Organization (WHO) to give support in tackling the social causes of health inequities. ¹ According to the conceptual framework of Social determinant of health, psychosocial factor, and behaviors are considered as intermediate social determinant of health because; they have powerful effects on health. Psychological circumstances can cause long-term stress, anxiety, insecurity, low self-esteem, social isolation and lack of control over work, and home life specially in women. ² Hence, it is needed to design and implement the interventional program to the mental-health promotion.

Many studies related to mental health promotion have been conducted in around the world. In 2006, Wright and Jorm verified the beliefs of young people and their parents about the effectiveness of interventions for mental disorders in Melbourne. The findings of this study suggested ways in which interventions can be labeled to make them more acceptable to these groups. ³

In 2007, Barry and Jenkins discussed that there are several key factors that influence the effectiveness of community collaborative partnerships in the mental-health promotion. ⁴

In 2009, in Iran, Ebadifard et al., conducted the Quasi-experimental study. The results of this project showed that the educational intervention through Belief, Attitude, Subjective Norm, and Enabling Factors (BASNEF) model was affected on attitude and healthy behaviors in girl adolescent. ⁵

Also, in Iran, in 2010, a community based participatory research was designed by Dr. Malek Afzali. In this study, at first, the elderly health needs assessment was carried out and then based on community participation, the interventional programs have been designed. The results showed that these programs were affective to promote healthy life-style in this age group. ⁶

Despite various studies regarding mental-health and community based participatory research, as far as we know very few studies have explored narratives of the mental-health process and ways to promote it by this approach. One way to improve this situation would be to explore this process and concern to participant′s recommendations with experience from individuals. For this reason, the aim of this study was to explore women′s experience of the mental-health problem and related action-interactions activities to design the appropriate interventions.

In this study, we use Grounded theory as a qualitative method that is useful to generate new understanding about the processes ⁷ that interact to form mental-health in women. In this method, the meaning is constructed and developed via social interactions. ⁸ , ⁹ Data collection started in December 2011 and ended in July 2012.

Participants and procedure

In-depth interviews were conducted with sixteen married women 18-65 years, who are residents in Western part of Tehran (Olympic area). ¹⁰ The reason of selection this age group was based on the epidemiology of mental-health problems in women that related to reproductive transition and also there is a significant difference among this age group with adolescence (less than 18 year old) and elderly (more than 65 year old). ¹¹ The number of participants was determined according to data saturation, ¹² it means that, there is no new idea and experiences about subject. ¹³ At first, based on purposeful sampling, with the aim of maximal variation of the participants′ experiences, the interviews were implemented. Variations were initially chosen regarding ages, education, number of children, status of employment. ⁹ However, the following participants were then chosen based on theoretical sampling to provide depth and different dimensions for rich categories.

Theoretical sampling was used in two ways: First, as the interviews proceeded and new questions arose in order to more exploration. Second, in some cases, there were participants that might affect the processes studied. Therefore, we framed the theoretical sample to include two single women and two married men ¹⁴ and finally the total number of participants in this study was twenty based on data saturation. In each interview, the moderator began the interview by explaining the purpose of the study. Permission to audiotape the interview session was sought orally prior to the interviews. The discussion started with how the mental health might be defined and described. Then respondent was asked to define a day with the mental health problem. During the interview the appropriate probes with words as where, when, how and why were carried out. Probes were used to confirm concepts mentioned and to explore new areas. Each interview lasted almost 1-1.5 h and it has been ended when no new issues seemed to arise. The place of the interview was chosen based on the interviewee.

Analysis of data

Collection and analysis of data was carried out manually, it means that each interview was coded as soon as it was implemented. ¹⁵ The base of grounded theory analyses is looking for psychosocial processes ¹⁶ that first the raw data were fractured to initial codes and then these codes rebuilt the categories. Finally, the categories were integrated into an explanatory theory. Constant comparison, repetitive questioning and memo-writing are three main analytical tools were used during this entire process of analysis. ¹⁵ The steps of analysis consist of open coding, axial coding, and selective coding. ⁸

In the open coding process, the interview transcripts were broken down and conceptualized. ¹⁷ Furthermore, during this step, there was a continuous comparison for similarities and differences in different parts of the data that formed categories and subcategories. In axial coding, the category was seated on the center of the process as axis and related subcategories were situated around it. For better understanding of social process, the dimensions of categories were explored. In final step, in order to find pattern, we paid attention to social action - interactions. ¹⁸ In this phase, core category was recognized and explained the narratives of women with mental-health problems and their process of dealing with them. The analysis ended when the categories seemed to relate with each other and can explain the mental-health process. ¹⁹

In this study, different aspects of trustworthiness have been observed. Transferability, dependability and peer checking were performed throughout the analysis process.

Ethical aspects

In this study, ethical issues were considered. Informed consent was obtained from all the participants. They were assured that the data would be managed in line with regulations in the law of secrecy and anonymity. The local Ethics Committee of Welfare and Social Science University approved the study design.

The demographic characteristics of participants are shown in Table 1.{Table 1}

In the analysis, a substantive theory was generated; explaining how female with daily stress handled their main concern which was identified as their effort to achieve comfort (Core variable). Six categories are integrated to initiate and subsequently to support and maintain core category that is presented according in following themes:

Daily stress as a trigger

According to participants view, daily stress has broad dimension from simple physiologic pain to major disability. The types of stress are classified to individual, familial and social stress:

a. Individual stress consists of physical disability and behavioral problem such as jealousy, lies and anger.

"…When the body and mind are healthy it means that the person has Mental health. Physical health effects on thinking…"

"…In my opinion, jealousy makes impaired mental health and I think, these people have busy mind and constantly comparison…"

b. Familial stress has different types such as Family dispute, leave home by parents, death of parents and lack of family support and so on.

"…With my father′s death, all of life′s responsibilities fell on my shoulders. Brothers did not work, I would feel responsible..."

c. Social stress: These problems have broad dimension such as economic, environmental and cultural problems. Poverty, Unemployment, job insecurity are in economic type, addiction, divorce and so on in social, traffic and air pollution in environmental and ethnic differences and some traditions in cultural problems have been presented.

"…We lived alone; we had a lot of economic problems...". "…Social problems are very important such as daily routines, traffic, and air pollution causes you to be worried about something…"

Strengthening human essence

In our study, all of positive and good human characteristic is named human essence. According to heavenly teaching, all of the people have been created based on clear essence that should be strengthened in different ways as follow:

· Strengthening the religious aspects:

The majority of participants mentioned that religion has good effect on mental-health. Some of them believed that prayer, Quran reading and participation in a religious meeting are helpful mechanisms in dealing with daily stress.

". ..In bad situation, the religion is very helpful, because it makes you feel not alone…"

"…Mentally healthy person who does not get angry easily and fast, it has control over his or her behavior, do not feel narcissism…"

0· Improvement of rational and positive thinking:

This means that the person in dealing with daily stress sees the glass half full and has logical thinking for problem solving.

"…We should learn that look at the problem without glasses…"

Improvement social relationship: One of the most important ways for strengthening human essence is having good social relationship and flexibility.

"….In my opinion, flexibility is a skill that helps us to keep calm …."

· Knowledge development:

Academic education and spending training courses are useful in health literacy promotion. Reading different books and magazines and participation in different courses can lead to develop mental-health knowledge.

Developing life skills

Based on participants view, study book is not enough for stress management, learning different life skills such as a coping mechanism, problem solving, and anger control are necessary for proper dealing daily stress. Moreover, improved performance such as future planning and priority setting are other steps for mental-health promotion. Monotony avoidance will be carried out by entertainment providing, recreation, traveling, listening to music, doing proper exercise, and finally female employment.

"…I know that the control aggression is good, but I don′t know how?"

Marriage is a key point for women

For Iranian women, marriage is a key point. Because it is the first right experience to be with the opposite sex. According to Islamic teaching, all of people need to marry and have a family. Good choose of spouse and marital adjustment is very important for women′s mental-health. Need to emotional support, economic dependency, and rely on male power are as reasons for special pay attention to marriage.

Help seeking

Help seeking consist of three parts:

A. Take the consultation:

Based on the participant′s view, the consultation resources consist of experts, family member, friends, and some teachers. The best source of counseling, based on most participants′ opinion was experts. However, there are some barriers such as cost and social stigma.

"Each person tends to visit secretly by psychologist, because when people know, they think a person has a mental problem."

Some participants prefer to consult with family members specially parents and spouse.

"I′d rather talk to my family because I believe that they know better what is best for me and they have more experience."

In the lower age group, people like to talk with their peers due to mutual understanding and in women with academic education, university teachers are an important source for consulting.

B. Resource Finding:

This item divided to:

a.

Information resource such as books, magazines, websites, and seminar and

b.

Emotional resource consist of familial support, spouse support and peers support as follow:

Familial support

Based on participants view, familial support has various types in different life steps such as childhood, adolescence, youth and adulthood periods. In childhood phase, they have devoted their lives to educating the children. Emotional support of mother and secure protection of father cause to train human essence. Furthermore, pay attention of parents to children′s problems are very important to make personality in future.

"I feel, I have a permanent protection that defense from me"

"Emotional support is very important. I had the support of my mother and I relied on her before marriage"

Another support of family members is their role to choose appropriate spouse. According to the majority of participants view, this role is very important in women mental-health.

"When I want to marry, my father said to me, not to endure excess. The door of this house opens always for you."

Furthermore, after marriage, the family support continues and the new couple need to material and spiritual support of parents.

"In my opinion, material and spiritual supports of our families are very important in our life. Consulting with them is very effective in correct decisions."

Spouse support

Based on the majority of participants view, appropriate and good marriage is very effective in women′s mental-health. Suitable choose and having healthy spouse from mentally aspect is necessary for perfection. Mutual trust can cause emotional relationship between the couple and this provides more kindness in family. In contrast, unhealthy mate ruin logical relations in the family. Some participants believed that economic dependency on husband is important. But a few of them also paid attention to women independency. Really, women′s emotion plus men′s power equal to happiness and satisfaction in life.

"…when he understand and help me, I enjoy life..."

"….unhealthy husband destroys heart and soil …."

Peers support

Some of participants specially youth believed that friends support is more important than family due to mutual understanding. Seeking this resource is completely voluntarily.

"When you are sad, you need ear not mouth. In this situation, friends are ears..."

Using non-medical therapy

Using herbal medicine such as borage in some cases is useful. Some participant said that these drugs have no side-effects. Furthermore, some exercise movement can help strengthening the skill of stress management.

Satisfaction as the end point

All of The participants with seeking tranquility in the mental-health process try to achieve satisfaction. In participants view, satisfied persons are mentally healthy persons. Spiritual dimension of satisfaction is more important than others.

"…In my opinion, mentally healthy person, who is a person that has a piece of mind and satisfied from her life..."

The core category generated, seeking comfort, explains how women to deal with daily stress and with which mechanisms reach to feel calm. Our participants managed to transform emotional and cognitive experience of living with stress to understand the mental-health process.

The categories that emerged provided the study paradigm of women mental-health Figure 1. Figure 1

The grounded theory of women mental health

Better understanding the mental-health process might be useful to design the interventional program among women with mental-health problems.