this was a community based participatory research(cbpr ) conducted for needs assessment and setting priorities for women s mental health in district 22 in western part of tehran . this method was selected because the cbpr begins with a research topic of importance to community with the aim of combining knowledge and action for a social change to improve the community s health and eliminate health disparities . it is a participatory , cooperative and capacity building process that achieves a balance between research and action . the district 22 of tehran has an approximate population of 100 thousand , of which , 49% are women ; this district has nine zones and has also special characteristics such as easy access to the community , having active humanitarian organizations and hyper active volunteers that led us to select this district as the venue of our study . in this area , more than 41% of the population has impaired mental health ( 18 ) . for needs assessment , we used enhr approach ( 8) that has four phases : stakeholder s analysis , preparatory phase , needs assessment and priority setting . in the third phase , gathering the secondary data was implemented as a quantitative study , and focus group discussion sessions and in - depth interviews were carried out as the qualitative part . this part has three steps consisting of identifying stakeholders and prioritizing them based on some criteria such as influence , power , interest and finally considering key stakeholders . to implement these steps , the following actions were taken : at first , we coordinated with regional stakeholders and key persons and explained them the aim of the study . volunteers were chosen according to some criteria such as being married , having at least high school diploma and motivation to participate in activities , and finally ten candidates were selected . the volunteers had to do the necessary arrangements in order to carry out the different steps of the study which were as follows : to encourage the community to participate in the needs assessment process to carry out the focus group discussion sessions with married women and conducting in- depth interviews with key persons . knowing different disciplines in the area and forming the intersectional and multidisciplinary working groups . providing a check list of stakeholders . this check list consisted of all stakeholders names which were prioritized based on some criteria . doing preparatory work which consisted of awareness raising and capacity building , reaching agreement with the stakeholders and planning for needs assessment and priority setting . one of the most important parts of this process is capacity building of the individuals . gathering secondary data such as demographic characteristics , executive programs and extracting the results of the 28-item version of the general health questionnaire ( ghq ) from urban health equity assessment and response tool ( urban heart ) . in tehran , an improved model incorporates the six domains of infrastructure , social and humanity development , economics , governance , health and nutrition . in 1999 , this questionnaire was translated to the official language of iran ( farsi ) , and its validity and reliability were approved in an independent study by noorbala ( 19 ) . the best cutoff point was 6 ; and those participants who scored 6 and above were designated as possible cases of mental disorder . the sensitivity , specificity and overall misclassification rate for the ghq 28 cut - off score of 6 were 84.7% , 93.8% and 8.2% , respectively ( 19 ) . a qualitative study was done to extract the mental health needs and their social determinants in women . four focus group discussions ( fgd ) with married women and five in- depth interviews with key stakeholders were conducted to reach data saturation . the guide questionnaires consisted of three general questions related to mental health needs , mental health priorities and appropriate interventions followed by some probes such as when , who , how , where and so on . each interview lasted for almost one hour , and informed consent was obtained from all the participants . the analysis of health situation consisted of health status and health system in the study area . different techniques such as brainstorming and nominal group ( 20 ) with stakeholders were used to assign the scoring system . using the bottom up approach or enhr model ( 6 ) , the mental health priorities were extracted by stakeholders participation ; and then based on the public health analytical framework of who , five levels of social determinants , priorities and interventional programs were determined . ( figure 1 ) data analysis in the qualitative study was done based on conventional content analysis . in this method of analysis , coding categories are derived directly from the text data ( 21 ) . in order to increase the reliably of the data , all codes and classes were cross - checked by the research team . to address conformability , we shared the summarized interview findings with the key persons at the end of the interview ( respondent validation ) to get find the participants recognition of the finding ( 22 ) . to assess dependability , peer checking was done by an experienced colleague to re - analyze some of the data was performed . team consistency checks between colleagues were also performed throughout the coding process ( 23 ) . in this study , they were assured that the data would be managed in line with regulations in the law of confidentiality and anonymity . this part has three steps consisting of identifying stakeholders and prioritizing them based on some criteria such as influence , power , interest and finally considering key stakeholders . to implement these steps , the following actions were taken : at first , we coordinated with regional stakeholders and key persons and explained them the aim of the study . volunteers were chosen according to some criteria such as being married , having at least high school diploma and motivation to participate in activities , and finally ten candidates were selected . the volunteers had to do the necessary arrangements in order to carry out the different steps of the study which were as follows : to encourage the community to participate in the needs assessment process to carry out the focus group discussion sessions with married women and conducting in- depth interviews with key persons . knowing different disciplines in the area and forming the intersectional and multidisciplinary working groups . providing a check list of stakeholders . this check list consisted of all stakeholders names which were prioritized based on some criteria . doing preparatory work which consisted of awareness raising and capacity building , reaching agreement with the stakeholders and planning for needs assessment and priority setting . one of the most important parts of this process is capacity building of the individuals . gathering secondary data such as demographic characteristics , executive programs and extracting the results of the 28-item version of the general health questionnaire ( ghq ) from urban health equity assessment and response tool ( urban heart ) . in tehran , an improved model incorporates the six domains of infrastructure , social and humanity development , economics , governance , health and nutrition . in 1999 , this questionnaire was translated to the official language of iran ( farsi ) , and its validity and reliability were approved in an independent study by noorbala ( 19 ) . the best cutoff point was 6 ; and those participants who scored 6 and above were designated as possible cases of mental disorder . the sensitivity , specificity and overall misclassification rate for the ghq 28 cut - off score of 6 were 84.7% , 93.8% and 8.2% , respectively ( 19 ) . a qualitative study was done to extract the mental health needs and their social determinants in women . four focus group discussions ( fgd ) with married women and five in- depth interviews with key stakeholders were conducted to reach data saturation . the guide questionnaires consisted of three general questions related to mental health needs , mental health priorities and appropriate interventions followed by some probes such as when , who , how , where and so on . each interview lasted for almost one hour , and informed consent was obtained from all the participants . the analysis of health situation consisted of health status and health system in the study area . different techniques such as brainstorming and nominal group ( 20 ) with stakeholders were used to assign the scoring system . gathering secondary data such as demographic characteristics , executive programs and extracting the results of the 28-item version of the general health questionnaire ( ghq ) from urban health equity assessment and response tool ( urban heart ) . in tehran , an improved model incorporates the six domains of infrastructure , social and humanity development , economics , governance , health and nutrition . in 1999 , this questionnaire was translated to the official language of iran ( farsi ) , and its validity and reliability were approved in an independent study by noorbala ( 19 ) . the best cutoff point was 6 ; and those participants who scored 6 and above were designated as possible cases of mental disorder . the sensitivity , specificity and overall misclassification rate for the ghq 28 cut - off score of 6 were 84.7% , 93.8% and 8.2% , respectively ( 19 ) . a qualitative study was done to extract the mental health needs and their social determinants in women . four focus group discussions ( fgd ) with married women and five in- depth interviews with key stakeholders were conducted to reach data saturation . the guide questionnaires consisted of three general questions related to mental health needs , mental health priorities and appropriate interventions followed by some probes such as when , who , how , where and so on . each interview lasted for almost one hour , and informed consent was obtained from all the participants . after each session the analysis of health situation consisted of health status and health system in the study area . different techniques such as brainstorming and nominal group ( 20 ) with stakeholders were used to assign the scoring system . using the bottom up approach or enhr model ( 6 ) , the mental health priorities were extracted by stakeholders participation ; and then based on the public health analytical framework of who , five levels of social determinants , priorities and interventional programs were determined . data analysis in the qualitative study was done based on conventional content analysis . in this method of analysis , coding categories are derived directly from the text data ( 21 ) . in order to increase the reliably of the data , all codes and classes were cross - checked by the research team . to address conformability , we shared the summarized interview findings with the key persons at the end of the interview ( respondent validation ) to get find the participants recognition of the finding ( 22 ) . to assess dependability , peer checking was done by an experienced colleague to re - analyze some of the data was performed . team consistency checks between colleagues were also performed throughout the coding process ( 23 ) . they were assured that the data would be managed in line with regulations in the law of confidentiality and anonymity . based on the enhr model , four steps were implemented . in this part , we presented the result of the three steps . the preparatory work consisted of some actions which were explained in the method s section . based on the stakeholder s analysis , the five categories are as follows : 
 team researchersdecision makers on provincial and district levelshealth service providers at the district levelcharitable actionsthe most important category is community . decision makers on provincial and district levels health service providers at the district level the most important category is community . the status of mental health was extracted by ghq via urban heart developed by the who office ( 5 ) ( table 1 ) . in the qualitative study , four fgd and the characteristics of the participants in the fgd are as follows : the participants in the individual interviews consisted of the representatives from the municipality , health centers , two of volunteers and one member from of the ngo related to women s health in the district . based on data saturation , and according to the analytical framework of who in mental health condition , five categories and twenty sub categories related to social determinants of mental disorders are extracted as follows : - socioeconomic and position : this category was presented by key persons . there are four sub- categories in this level consist of : including instability on policy and planning , social gradient , lack of insurance for unattended family families and income inequality . member of ngo said :  instability on of policy can cause mental health problems , because you can not have any plans for your life . today you are wealthy , but tomorrow you will may be poor . - differential exposure : based on the views of the majority of participants view , there are some exposures leading to impaired mental health such as unemployment , income insecurity and increased living costs that can lead cause to a decrease in social welfare . married women in fgd said :  when you are poor and can not pay the rent , you will be depressed  . globalization , internet access and changing changes in the cultural norms , despite some benefits , can make cause complex problems especially particularly for the youth . in addition , in the opinions of the majority of the participants tobacco use and addiction could in opinion s majority of participants destroy the capacities of the community . - differential vulnerability : in this regard , two important needs were expressed by most of the women , : at first lack of mental health literacy and then lack of knowledge and skills related to dealing with stress . most of married women in the fgd : said ,  we do nt know how to manage the techniques of our stress management and or how to dealing deal with daily stress pressure  . - differential health outcome : in this category , three important sub- categories were presented as follows : - lack of free counseling centers in the study area - stigma and delay in help seeking - lack of access to mental health services representative from a health center said:to promote mental health , having access to mental health services and free counseling centers in the district are needed to mental health promotion  . the above mentioned categories are related to the prevention of mental disorders , but the following themes are related to harm reduction . - differential consequences : the most important need in this part is lacking of facilities for mental health rehabilitation is an important issue needing attention , and . failure to response to satisfy this need may be create social exclusion and reduce the ability to work . during the nominal group and brain storming sessions with participation of the key persons and research team , based on the participants view , for each subcategory , scores 0 - 3 was considered . after a score was given to each of the social determinants of mental disorders in each level , the first important priority was determined ( table 4 ) . based on the stakeholder s analysis , the five categories are as follows : 
 team researchersdecision makers on provincial and district levelshealth service providers at the district levelcharitable actionsthe most important category is community . decision makers on provincial and district levels health service providers at the district level the most important category is community . the status of mental health was extracted by ghq via urban heart developed by the who office ( 5 ) ( table 1 ) . in the qualitative study , four fgd and the characteristics of the participants in the fgd are as follows : the participants in the individual interviews consisted of the representatives from the municipality , health centers , two of volunteers and one member from of the ngo related to women s health in the district . based on data saturation , and according to the analytical framework of who in mental health condition , five categories and twenty sub categories related to social determinants of mental disorders are extracted as follows : - socioeconomic and position : this category was presented by key persons . there are four sub- categories in this level consist of : including instability on policy and planning , social gradient , lack of insurance for unattended family families and income inequality . instability on of policy can cause mental health problems , because you can not have any plans for your life . today you are wealthy , but tomorrow you will may be poor . - differential exposure : based on the views of the majority of participants view , there are some exposures leading to impaired mental health such as unemployment , income insecurity and increased living costs that can lead cause to a decrease in social welfare . married women in fgd said :  when you are poor and can not pay the rent , you will be depressed  . representative a representative from municipality : commented ,  income insecurity as much as unemployment can create mental disorders  . globalization , internet access and changing changes in the cultural norms , despite some benefits , can make cause complex problems especially particularly for the youth . in addition , in the opinions of the majority of the participants tobacco use and addiction could in opinion s majority of participants destroy the capacities of the community . - differential vulnerability : in this regard , two important needs were expressed by most of the women , : at first lack of mental health literacy and then lack of knowledge and skills related to dealing with stress . most of married women in the fgd : said ,  we do nt know how to manage the techniques of our stress management and or how to dealing deal with daily stress pressure  . - differential health outcome : in this category , three important sub- categories were presented as follows : - lack of free counseling centers in the study area - stigma and delay in help seeking - lack of access to mental health services representative from a health center said:to promote mental health , having access to mental health services and free counseling centers in the district are needed to mental health promotion  . the above mentioned categories are related to the prevention of mental disorders , but the following themes are related to harm reduction . - differential consequences : the most important need in this part is lacking of facilities for mental health rehabilitation is an important issue needing attention , and . failure to response to satisfy this need may be create social exclusion and reduce the ability to work . during the nominal group and brain storming sessions with participation of the key persons and research team , some criteria ( table 3 ) for setting the priorities were extracted . these criteria consisted of three main categories and seven sub - categories . based on the participants view , for each subcategory , a score was given to each of the social determinants of mental disorders in each level , the first important priority was determined ( table 4 ) . in this study , three main approaches have been used simultaneously ( cbpr , enhr and analytical framework of who ) to design the interventions of public health condition . in the cbpr approach , community participation can improve the positive health behaviors , human resource mobilization , community empowerment and finally mental health promotion ( 24 ) . enhr model is a bottom up approach that set the priorities based on stakeholders opinion ( 6 ) , and then determines the stage of the intervention based on the analytical framework of who . in our study , stakeholders analysis was essential to start the project . in this analysis , the role and function of each stakeholder is important , and not the personal identity ( 25 ) . in our society , with rapid changes in the political positions , the sustainability of the stakeholders was not enough and this was one of the limitations of our project . interventions that address the socioeconomic context are at the national level . providing insurance coverage for unattended families is one of the policies in this level . according to the result of this project , secure employment is important in differential exposure level , but at the vulnerability level , training the positive coping mechanism has been considered . in 2009 , the result of the study of the regional office for the eastern mediterranean of who showed that in this region , the interventions related to the above levels , consist of reducing risk behaviors such as tobacco use , unsafe sex , improving access to basic health care and reducing social problems such as school drop - outs and domestic violence(26 ) . it seems that the first priorities in our study are not completely compatible with this study . in iran , during the recent years , access to basic health care has been facilitated , but the development of free counseling centers and providing coping mechanisms trainings are necessary . considering the differential consequences , the majority of the interventions can not evaluate these consequences , because they are frequently distal to the intervention . furthermore , given the multiple , interacting nature of the social determinants , it may be difficult to identify which aspect of the intervention caused  the mental health outcome ( 26 ) . also , it is necessary to recognize that mental health as a determinant can help explain outcomes for individuals and communities ( 1 ) , and as an outcome it has multi - factorial etiologies consisting of genetic , biological , psychological and social determinants , with social determinants having particular salience ( 27 ) . for sustainability of all the interventions targeting social determinants , existing political will , strong community partnerships , availability of financial and human resources are broad requirements ( 28 ) . improving the coping skills to deal with stress is one of the most important interventions for mental health promotion in women . improving the coping skills to deal with stress is one of the most important interventions for mental health promotion in women .
objectivemental health is an essential component for positive adaptation that enables people to cope with adversity to achieve their full potential and humanity . in this study , using a community based approach , the social determinants of mental health in iranian women were extracted ; and in addition , priority setting for interventional programs according to analytical framework of who was implemented.methodthis study was a community based participatory research ( cbpr ) in district 22 of tehran ( iran ) . 
 the target group was married females with age range of 18 - 65 years . 
 in this study , mental health priorities were extracted by qualitative methods according to essential national health research model ( enhr ) and the analytical framework of who . 
 data analysis was done based on content analysis by the open code 3.6 software.resultsin the quantitative phase , according to secondary data , 1144 individuals ( 560 females and 584 males ) were selected , of whom 41 percent had impaired mental health based on general health questionnaire ( ghq ) ( p<0.05 ) . according to the qualitative phase , the first mental health priority in socioeconomic level was lack of insurance for unattended families , it was unemployment in differential exposure level and it was lack of knowledge and skills related to dealing with stress in the differential vulnerability level ; in differential outcome and consequence levels , the priorities were lack of free counseling centers in the study area and lack of facilities for mental health rehabilitation.conclusionproviding training courses to improve the skills to deal with stress is considered one of the most important interventions for mental health promotion in women .