Introduction {#sec1-1}
============

The World Health Organization (WHO) believes that mental health is not merely the absence of mental disorders, as is the current assumption; rather, this organization emphasizes the positive aspects of mental health and acknowledges that mental health is a state of well-being that enables an individual to identify his/her abilities and be able to come to terms with the common stresses of life so that he/she can be productive and work efficiently and help his/her community.\[[@ref1][@ref2]\] The review of literature reveals that mental health is a function of two independent but interrelated domains, including positive mental health (PMH) and the presence or absence of mental disorders.\[[@ref3]\] Mental health and mental disorders are therefore not two ends of the same spectrum and the absence of mental disorder is not the only necessary condition of mental health.\[[@ref4][@ref5]\] Nevertheless, given the novelty of the subject of PMH and the inception of this science, a common definition is still being debated among the scientific community.\[[@ref6]\] There are two traditional approaches to illustrate the concept of PMH: the Hedonic approach, consisting of the positive feeling/affects or emotional functioning (subjective well-being, life satisfaction, and happiness) and the Eudemonic approach, consisting of a positive performance in personal and social life.\[[@ref3][@ref7]\]

Various studies conducted throughout the world on PMH had revealed that the concept of mental health is much wider than the mere absence of mental disorders.\[[@ref1][@ref7][@ref8][@ref9]\] Patients with mental disorders have shown different levels of PMH,\[[@ref10][@ref11][@ref12]\] and this finding suggests that PMH and mental disorder are affected by different factors.\[[@ref13]\] A low level of PMH (languishing) has been proposed as a risk factor for the development of depression\[[@ref7][@ref10][@ref12]\] and raises the likelihood of physical disorders,\[[@ref14]\] especially cardiovascular diseases,\[[@ref15]\] as well as all-cause mortality;\[[@ref16]\] its improvement, on the other hand, contributes significantly to the protection and promotion of mental health in the community.\[[@ref5]\]

Epidemiological studies assessing the level of PMH suggest that different societies experience different levels of PMH.\[[@ref8][@ref17][@ref18]\] The prevalence of high level of PMH (flourishing) has been reported as 11.6% in South Korea, 76.9% in Canada, and 20% in Iran.\[[@ref8][@ref19]\] A study conducted by Huppert and So on the data collected from 23 European countries showed a difference of four times between different countries in the prevalence of flourishing.\[[@ref20]\] These differences suggest the important role of the social determinants of PMH in different countries.

By establishing a Commission on Social Determinants of Health (CSDH) in 2005, the WHO identified two key groups of social health determinants, including structural and intermediary determinants.\[[@ref21]\] Structural determinants that generate social stratification in the society include the socioeconomic and political context and socioeconomic position (social class, education, occupation, income, gender, and ethnicity), which affect health outcomes through intermediary determinants (material circumstances, behaviors and biological factors, psychological factors, and health system) that have a vital role in the creation of health inequities between and within countries.\[[@ref21]\]

Dreger *et al.* have shown that languishing is associated with structural social determinants such as old age, not having a sexual partner, low education and unemployment, and also with intermediary social determinants such as social exclusion, poor social support, and material deprivation.\[[@ref22]\] Stewart-Brown *et al.* showed that the relationship of education and income with different levels of PMH is not linear, just like their relationship with mental disorders.\[[@ref13]\] Previous studies have also shown differences in how determinants such as education, marital status, socioeconomic status, gender, and ethnicity affect PMH and their association.\[[@ref7][@ref17][@ref23][@ref24][@ref25]\]

Given the key role of PMH in the promotion of public mental health and the effect of social determinants on PMH levels in the community, the existing gap in information, and the lack of a relevant study in the Iranian society, the present study was designed to identify the structural and intermediary social determinants of PMH in the Iranian society based on the WHO conceptual framework of CSDH.

Methods {#sec1-2}
=======

The present study was conducted in Tehran, the capital of Iran. This is a hypothesis-driven study. Given the nature and objectives of the study, qualitative directional content analysis was selected as the method of research. Data were collected through focus group discussions (FGDs) with the general population and semi-structured interviews with mental health professionals.

Participants {#sec2-1}
------------

The participants were from two groups: (a) mental health professionals (psychologists and psychiatrists) with at least 10 years of clinical and research experience and (b) residents of Tehran aged 30--60 years who were willing and able to participate in the study. Purposive sampling was used to obtain varying experiences from different people. Participants were selected from a diverse background in terms of age, gender, education, marital status, and social class FGDs and a diverse background in terms of expertise and work experience for the individual interviews.

Data collection {#sec2-2}
---------------

Data were collected from May to September 2017 using semi-structured interview and FGD. Qualitative methods were chosen to promote an in-depth understanding of the study concepts, since they enable proper interaction with the participants and can be flexible.\[[@ref26]\] The number of interviews and FGDs was determined based on data saturation. It means that there was no new information by repeating the interviews or FGDs. FGDs were performed in different gender groups. Each interview lasted 60--90 min on an average and each FGD lasted 80--100 min and ended when no further new concepts could be extracted. FGDs were held in groups of 6--8. Prior to FGDs, all the participants were contacted over phone or in person and briefed on the general objectives of the study and, after submitting their verbal consent, they were invited to take part. Furthermore, before conducting the interviews with the professionals, necessary arrangements were made, such as introducing the study and its objectives, obtaining verbal consent, and deciding on a time and place for the interview.

All the FGDs and interviews were conducted by the first author who has expertise in qualitative studies. In each FGD/interview, first, the facilitator introduced team members and explained the study objectives, and then, the participants completed consent forms for participation in the study and were told that their participation was completely voluntary and that they could withdraw at any time they wished. Participants' permission for recording the interviews/FGD was also obtained. A guide questionnaire was used to direct the interviews/FGDs. This guide questionnaire was developed by the research team using a review of literature and group discussions with experts. Each interview/FGD began with the general question of "In your opinion, what are the attributes of a person with PMH? Please elaborate." Then, the dimensions of PMH were debated, and finally, the social determinants affecting the concept were also discussed. Appropriate probing questions or question words were used with questions such as "What do you mean?" and "Please explain more." The probing questions were used to ensure the proper understanding of the concepts discussed by the participants and to discover new concepts. Wherever necessary, the participants were asked to provide objective examples to allow for a deeper and richer understanding of the subject. The issues discussed were summarized at the end of each FGD/interview for the participants to confirm.

Data analysis {#sec2-3}
-------------

Given the nature of the subject and the research objectives and questions, data were analyzed using directional qualitative content analysis. In cases where there is a theory or research on a phenomenon that requires further explanation, content analysis is performed with the directed approach. In this approach, the availability of a theory or research thesis can help make a prediction about the study variables and the relationship between them and this prediction then leads to initial data encoding and the detection of a relationship between them.\[[@ref26]\] The data obtained from each interview/FGD were transcribed verbatim immediately after the end of each session. To ensure their accuracy and rigor, the transcribed data were compared against the audio-recorded files. Then, all the transcribed interviews/FGDs were imported into Dedoose 7.6.6 software (SocioCultural Research Consultants, CA) and were reviewed line by line. Meaning units and codes were extracted according to the study framework and the social determinants of PMH. The extracted codes were reviewed again to obtain the subthemes and themes.

Trustworthiness {#sec2-4}
---------------

To ensure credibility, the participants were selected with maximum variation (considering different categories of marital status, occupation, gender, and education), and the findings from each FGD/interview were shared at the end to get respondent validation. The prolonged engagement of the research team with the subject during the data collection, interaction with the participants, and frequent review of the data as well as the data saturation that occurred can be regarded as a confirmation of the validity of the data.

To ensure dependability, all FGDs/interviews were transcribed immediately after the end of the sessions and all their nonverbal contents were added to the transcriptions as well. Team consistency was assured by research team members throughout the process of data analysis.

To ensure transferability, the transcription and data analysis were performed by two experts from the research team. In addition, the details of all the stages of the study including data collection, analysis, and encoding were thoroughly recorded for use by other researchers.

Ethical considerations {#sec2-5}
----------------------

The ethical considerations taken in this study included obtaining informed consent from the participants and ensuring the participants of the voluntary nature of participation in the study and their right to withdraw at any time as well as the confidentiality of their personal information and issues discussed. The study protocol was approved by the Ethical Committee of the University of Social Welfare and Rehabilitation Sciences under the code IR. USWR. REC.1396.204.

Results {#sec1-3}
=======

Ten individual interviews were held with the mental health professionals. Seven psychiatrics and three psychologists with a mean age of 52.7 years participated in interviews. Furthermore, their mean work experience was 21.6 years. Eight FGDs were implemented with the general population. Overall, 51 people (57% women) with a mean age of 46.1 years participated in FGDs. Tables [1](#T1){ref-type="table"} and [2](#T2){ref-type="table"} present participants' demographic details.

###### 

Characteristics of participants in focus group discussions

  Variable                         Categories                       Female (*n*=29)   Male (*n*=22)
  -------------------------------- -------------------------------- ----------------- ---------------
  Age (year)                       Minimum                          30                30
  Maximum                          58                               59                
  Mean                             45.3                             46.9              
  Education (*n*)                  Diploma and lower (uneducated)   18                6
  Higher than diploma (educated)   11                               16                
  Working status (*n*)             Employed                         14                18
  Homemaker                        9                                0                 
  Unemployed                       6                                4                 
  Marital status (*n*)             Married                          20                14
  Single                           5                                6                 
  Divorce                          4                                2                 
  Number of children (*n*)         No child                         5                 8
  One child                        4                                4                 
  Two children                     14                               8                 
  Three and more children          6                                2                 

###### 

Characteristics of participants in semi-structured individual interviews

  Sex (*n*)   Mean of age   Expertise   Work experience   
  ----------- ------------- ----------- ----------------- ------
  Women (5)   53.8          4           1                 24.8
  Men (5)     51.6          3           2                 18.4

Determining the social determinants of PMH in Iranian society, 190 codes were extracted. The revision and summarization of the codes based on their similarities led to the emergence of 22 subthemes and 2 main themes. Based on the WHO conceptual framework of the CSDH, two main themes were extracted as follows: (1) structural determinants of PMH and (2) intermediary determinants of PMH.

Structural determinants of positive mental health {#sec2-6}
-------------------------------------------------

### Socioeconomic and political context {#sec3-1}

One of the most important issues raised in this part was political, economic, and social stability in the society, and all the participants emphasized the significant role of this subtheme. Political disarray, political instability, the threat of foreigners, sanctions, socioeconomic instability, etc., can affect people\'s PMH by affecting the pillars of the society and setting bad economic and social processes and rules in place such as unemployment, lack of societal security, and inappropriate social welfare system. The education system and its governing body have a major role in public mental health in various ways, such as by creating unhealthy competition and encouraging qualification-orientation. Alongside these sociopolitical issues, cultural issues can also affect PMH, and cultural disarrays and poor cultural values are particularly important in this matter.

"*Culture is very influential. For example, the culture of succeeding as much as possible is an imposed culture that creates unhealthy competition and a conflict between different classes and eventually affects people\'s mental health*" (Psychiatrist).

In general, social justice should be embedded in the dominant political, social, and cultural structure of the society in all its components and its presence contributes significantly to the promotion of PMH.

Socioeconomic position {#sec2-7}
----------------------

### Income {#sec3-2}

Majority of the experts believed that income has a relationship with PMH, but this relationship is not linear at all the levels of PMH, that is, PMH does not necessarily increase with income; rather, above a certain level of income, PMH does not only increase, but may even decrease due to the many concerns that accompany more money.

"*It\'s not as if the higher is your income, the better will be your PMH. This relationship surely holds below or above a certain level of income, but is not linear all the way*" (Psychiatrists).

The participating public also regarded income as a double-edged sword whose shortage and excess are both troublesome and reduce PMH. The majority of the participants believed that the increased expectations, especially among the youth, regarding the acquisition of income and wealth regardless of its implications are the main cause of psychological and mental problems in the society.

"*Money does not always bring happiness, and being wealthy does not necessarily mean a high PMH. But being poor definitely messes your PMH anyways*" (Uneducated woman).

### Education {#sec3-3}

The participating experts acknowledged the key role of education in the promotion of PMH, provided that it is accompanied by life skills' training and believed that university education alone cannot promote PMH; rather, it gives people an identity that may help promote their mental health.

"*Education can promote PMH in people with a normal personality and an intrinsic capability*" (Psychologist).

The majority of the participants in FGDs believed that educated people have better PMH due to having gained a better self-awareness and knowledge of other things; however, the actuality of the matter in the society does not always support this assumption. Some of the participants believed that since education raises people\'s expectations of life, in the absence of favorable conditions, it may even cause disheartenment and decrease PMH.

"*When you find that your education is of no use in the society and can get you no good jobs, it makes you even more depressed and messes up with your mental health*" (Educated man).

### Occupation {#sec3-4}

All the experts believed that, regardless of income and financial independence, working people are better at management and planning, enjoy better social interactions, and have more effective personal capabilities for overcoming stress and hardship. Having a job provides identity and security in the modern world and plays a major role in improving PMH.

In all FGDs, the participants stated that having a job and being employed is very important and has very positive effects on mental health. Attributes such as hopefulness, motivation and purposefulness plus earning a good income, and having a good financial status ensure PMH in employed people. Stress, disheartenment, absence of peace of mind, and mental disorders are the consequences of unemployment, especially in the youth.

"*Unemployment is not good for anyone. Life gets very hard without a job and income. The pressure will be overwhelming, and controlling yourself mentally gradually becomes very hard, and one may even turn to illegal acts*" (Uneducated man).

The majority of the female participants believed that although many women work alongside men nowadays and hold different jobs due to the poor financial conditions, women can still be much more effective as mother and wife and these roles entail a higher PMH both for the women and their family members.

### Gender {#sec3-5}

All the participating experts discussed the role of gender as a determinant of PMH and argued that PMH is different among men and women in the Iranian society and believed this difference to be due to the different roles of men and women in the society, which is defined by the culture and values dominating the society.

"*There\'s a difference between men and women in our society. This gender gap says that it\'s alright for men to be out at midnight, but stigmatizes a woman who is out late*" (Psychiatrist).

The views expressed by the participating public varied widely. Although the male participants find no differences between men and women in terms of PMH, the female participants openly pointed out the difference and believed that men have better PMH compared to women due to their lower expectations, better problem-solving skills, greater patience and calmness, and lower stress. Moreover, due to the increasing number of working women and their high stress levels, the gap in PMH between men and women is increasing.

### Ethnicity {#sec3-6}

The experts and female participants argued that since beliefs, values, and culture, which themselves are affected by social factors, have a significant effect on PMH, people from different ethnicities and races can experience different levels of PMH. The experts also believed that the experience of deprivation and limitations, on the one hand, and receiving more social support due to living in a minority ethnicity, on the other hand, affect people\'s PMH.

"*In Iran, the Kurd ethnicity is famous for high self-confidence and bravery, and their mental health is not easily affected by different factors*" (Educated woman).

Intermediary determinants of positive mental health {#sec2-8}
---------------------------------------------------

### Working conditions {#sec3-7}

The interviews with the experts revealed that people\'s working conditions, such as job security, occupational stress, job satisfaction, and workplace conditions, highly affect their PMH. They believed that the improper use of personal potentials in the workplace, loss of motivation, absence of meritocracy, and discrimination at work are factors that slowly and subtly reduce PMH in an individual who is constantly exposed to these factors without having the necessary stress management or coping skills.

"*It is not important if you like your job or are capable of performing it or not. Nowadays what is important is having a job and income. The lack of interest and motivation, the lack of purpose or even the inability to bear stress affect your PMH*" (Psychologist).

Working conditions were one of the most important social factors that affected working people\'s PMH according to the majority of the participating public. The most important feature of a good job in the view of the public was job security and stability. Someone who has a job and a fixed income (insurance and pension plan) can plan for his/her future, life, and family with peace and confidence. Factors such as job satisfaction, job stress, work environment, discrimination at work, and the job\'s social status were also discussed as factors affecting PMH.

"*The job itself is not as important as is job security. If I have to constantly worry about them taking away my job, I'll also go crazy with stress*" (Educated man).

### Living condition {#sec3-8}

Living condition was addressed in two general categories as follows.

Physical conditions

All the participants stated that traffic, air pollution, population density in metropolises, lack of proper access to urban service centers, industrial life, poor culture of technology use, and generally all the problems resulting from urbanization affect PMH. The public mostly considered a high PMH characteristic of rural life and its associated peacefulness. Living in rural areas is associated with a higher PMH not just in contrast to the environmental conditions dominating large cities, but also because the place of residence affects the residents' attitudes, and rural people therefore have lower expectations and live in greater peace with less stress.

"*Rural people don't spend hours in the traffic and are not under much pressure and breathe clean air and so always live in peace and have a good positive mental health*" (Psychiatrist).

Social conditions

Most of the participants stated social conditions such as the social class, the absence of violence and robberies, and generally public safety of the neighborhood contribute highly to PMH.

"*For instance, a man pestering a woman who\'s walking down the street. Security is very important, especially in public places such as parks. It is much better now, but there is still room for improvement*" (Women\'s group).

### Family factors {#sec3-9}

According to the participating experts, family affects PMH by the way of different factors, including family upbringing, interpersonal relationships, and emotional support. The experts believed that a supportive family has a significant role in promoting family members' PMH. The amount of support and its conditions are also important. Besides, family can be regarded as a reliable source of information and education in this regard.

The majority of the participating public also emphasized the role of family in PMH. Accountability, children\'s upbringing, mutual respect, a proper marital relationship and being together, a warm and happy family environment, and a family with good socioeconomic position were important factors.

"*It is very important that a person is brought up in a family. The effects of the lack of a family are very clear in people who haven't had one. Many of them are unable to come to terms with this deprivation*" (Men\'s group).

### Lifestyle {#sec3-10}

All the participants unanimously agreed that lifestyle affects PMH in different ways. One of the most important issues raised was the use of virtual networks and the Internet, which have greater effects on PMH than does the family. This issue has not only reduced people\'s physical activity, but also affects their interpersonal relationships. Virtual networks are very important sources of information for people but are not properly monitored. Creating stress by giving false news, offering wrong models that diminish the family\'s role in the children\'s upbringing, and negatively affecting interpersonal relationships are among the effects of virtual networks and the media on PMH. According to some of the participants, the effect of high-risk behaviors such as drinking, smoking, and drug use, especially artificial drugs, is detrimental to PMH. Others, however, considered the tendency toward high-risk behaviors, especially among adolescents, a result of low PMH in this generation. These behaviors not only affect how leisure time is spent, but also affect the quality of family relationships, the solidarity of the family, interpersonal relationships, and even personal accountability. In the view of the participating public, exercise and physical activity and spending leisure time wisely, such as through traveling and spending time with family and friends during the holidays, also have significant effects on PMH.

"*Your mind opens up to new possibilities and finds solutions when you travel, deal with yourself, become rejuvenated and build up your tolerance*" (Women\'s group).

### Psychosocial factors {#sec3-11}

According to the experts, social support has many levels and begins from emotional and spiritual support from family members and continues with the support emanating from social relations and is reinforced by the social support given by the government in the form of supportive insurances. Insurances have a key role that is more important than ever before for promoting PMH due to the smaller size of families and their diminishing role in supporting family members. Moreover, the participating public also emphasized the role of social support in PMH and believed that when people are filled with kindness, friendship, and morality, mental problems can get resolved and happiness and love can rule. A number of participating public, however, noted the important effect of social support for the elders and the role of policymakers in providing social support for all groups of the society.

"*It is important to get support on a community level, but there is very little of that now and family is the source who mostly provides support*" (Uneducated woman).

All the participants believed that the stresses of daily life and stressful living conditions are the key psychological factors that highly affect PMH. In the view of the experts, perceived stresses and proper mechanisms of coping are factors that affect PMH. The participating people also believed that knowing how to properly deal with problems in life affects PMH.

From the perspective of the majority of the general public, a happy and lively environment contributes to PMH by creating positive vibes. Nonetheless, the experts did not discuss such notions.

"*For instance, a happy environment is very important because it very much affects one\'s mental health*" (Women\'s group).

The subject of spirituality was also raised as one of the social factors affecting PMH. In the view of the experts, moral beliefs and values have a significant effect on PMH. The participating public also regarded religious beliefs important to PMH and considered the lack of religious beliefs as one of the reasons for mental disarray. In general, the diminishing humanistic and moral principles in the society, whether in the form of religious beliefs or otherwise, negatively affect PMH.

"*Beliefs are most important because they create mental preoccupation and can ruin your mental health*" (Psychiatrist).

All the participants unanimously agreed that marriage increases PMH regardless of its quality. Humankind is a social creature who depends on others, and marriage (not just having a sexual partner) satisfies this need and entails a peace of mind. A married person is purposeful, responsible, committed, reliable, and is a manager. Marriage and building a family, especially at the right time, is a highly important and sacred matter that has been greatly emphasized in religion and culture. The participants believed that PMH is also influenced by the quality of the marriage. A close and stable relationship, proper interactions and mutual understanding in marriage, and generally marital satisfaction affect PMH.

### Health system {#sec3-12}

Access to mental health services and its quality were also issues discussed just by most of the experts, who stated that equitable access to mental health services such as consulting centers can protect and promote PMH in the society both in economic and sociocultural terms.

Discussion {#sec1-4}
==========

The present study was conducted to investigate the social determinants of PMH in the view of two Iranian groups, including mental health professionals and the general public. These social determinants were divided based on the WHO conceptual framework provided by the CSDH. As for the political, social, and cultural contexts, which are part of the structural social determinants of PMH, one of the most important determinants proposed by both the experts and the general public was the lack of political, economic, and social stability in the society. Different studies conducted in the UK on the determinants of PMH have revealed the effect of factors such as poverty, social discrimination,\[[@ref27][@ref28]\] and unemployment on PMH.\[[@ref29]\]

As for socioeconomic position, the present findings suggest that, although a higher income can have a relationship with PMH, this relationship is not linear at all socioeconomic levels because, as pointed out by the participants, the increased concerns due to a high income not only do not increase PMH, but they may also reduce it. Studies conducted in different countries suggest a relationship between PMH and income.\[[@ref17][@ref30]\]

In relation to education, the participants believed that although education can increase PMH, it is not university education alone that promotes PMH; rather, good knowledge and understanding about the world are what increase PMH. This matter has been also mentioned in literature. For instance, while Zhu and Chen believed that higher education has no effects on PMH,\[[@ref31]\] others believed PMH has a direct relationship with academic education.\[[@ref22][@ref25]\]

As for gender, different views were expressed. The participating women believed that men have higher PMH due to their greater problem-solving skills and ability to use adaptation mechanisms. Meanwhile, the participating men believed that there were no differences between men and women in PMH. Studies also suggest a disparity in findings regarding this relationship. A study conducted by Gestsdottir *et al.* showed that Irish girls have lower PMH at younger ages, but at older ages, their PMH becomes higher than boys.\[[@ref32]\]

Ethnicity was another mentioned determinant issued by most experts and women participating in FGDs. Despite various values and beliefs that have a direct impact on individuals' affections and behaviors in different manners, social deprivation and restriction perceived in ethnicities/minorities can affect the level of PMH and cause levels of inequity in this regard. Although the study of Smith *et al.* revealed the lower level of PMH in minorities,\[[@ref25]\] Stewart-Brown et al\'s. study showed that minority groups in the UK have a higher level of PMH status and social support.\[[@ref13]\]

Among the intermediary determinants, employment and workplace conditions, job satisfaction and security, and accompanied social security (health insurance and retirement) were especially important. One of the reasons for this finding is that the age of the participants was 30--60 years in this study, which falls into the working age population. All the participants believed that job security (having insurance), reduced job stress, improved workplace conditions, increased job motivation, and lack of discrimination at work were key factors contributing to PMH. All reviewed studies carried out in different countries also support these relationships.\[[@ref33][@ref34][@ref35][@ref36][@ref37][@ref38]\]

The quality of the living condition and neighborhood was another social determinant of PMH. Some of the participants considered living away from industrial life and urban problems (traffic, air pollution, crowd, etc.) affect PMH due to the lower stresses of daily life in villages and the increased peace of mind. A study conducted by McKay and Andretta in Scotland and Ireland showed a relationship between place of residence and mental well-being.\[[@ref39]\] Similarly, a study by Firdaus conducted in older adults showed a correlation between PMH and buildings with less residents, better residential conditions, and home satisfaction.\[[@ref40]\] There is sufficient evidence to suggest the association of various components of physical and psychosocial neighborhood environment.\[[@ref41][@ref42][@ref43][@ref44]\]

Lifestyle is also considered a determinant of PMH. Many participants noted the negative effect of virtual networks and the Internet on PMH and regarded its role as much more pronounced than the role of families, especially in the youth. High-risk behaviors such as drinking, smoking, and drug use, exercise, physical activities, and the amount of leisure time spent and its quality are other factors mentioned in this category. Although literature (studies mostly conducted in developed countries) confirmed the study findings and emphasized on the relationship of consuming tobacco, alcohol, and drug and low mental well-being, especially in the youth,\[[@ref45][@ref46][@ref47]\] and lack of physical activities,\[[@ref48][@ref49]\] there are more noticeable lifestyle components such as eating behaviors,\[[@ref50]\] weight,\[[@ref51]\] and healthy behaviors.\[[@ref50]\]

Family, as the first virtuous structure of the society, was considered by all participants as one of the most effective determinants. Participants noted various issues affecting PMH including marital relationship, family upbringing, interpersonal relationships, and solidarity in the family. A study conducted by Thomson *et al.* on 12 to 19-year-old Canadian adolescents revealed the role of family in PMH.\[[@ref52]\] A study conducted in Thailand showed a relationship between engagement in family activities and mental well-being in teenagers.\[[@ref53]\] A study by Nima *et al.* on Indian households also showed the major effect of parental care and the father\'s role in the family on the family members' PMH.\[[@ref24]\] The present findings confirm the role of the family and solid family relations in PMH.

Social support was one of the major factors affecting PMH according to most of the participating people and experts. Social support received from family and working environments was found to potentially increase PMH. A happy environment with heartfelt beliefs and bonds affects PMH as well as respect for humanistic and moral principles and generally all that is referred to as spirituality positively. A study conducted by Arnetz *et al.* showed a high positive correlation between spiritual values and PMH.\[[@ref54]\]

In addition, access to health services, which was raised by majority of the experts, indicates the importance of mental health-care services (PMH as well as metal illnesses) in the health system and accessible and inexpensive primary health services help protect and promote PMH and mental health in the community.

[Figure 1](#F1){ref-type="fig"} presents a summary of the social determinants of PMH in the Iranian population based on the WHO conceptual model.

![Framework of social determinants of positive mental health](IJPVM-10-170-g001){#F1}

This study has certain strengths and limitations. Due to its qualitative approach, the present study managed to examine participants' views and experiences in depth. Given that the participants consisted of both experts and the general public, this study has a good inclusiveness. Nevertheless, since the results of qualitative studies cannot be generalized, the present findings cannot be extended to other societies and should be complemented with a quantitative study. The present study has some limitations such as the age of the target group, which is only limited to middle aged; lack of distinction between different ethnicities such as Turks and Kurds; using the qualitative research method; and nongeneralizability of results to other societies.

Conclusion {#sec1-5}
==========

As the main practical point of this research, the majority of participants emphasize that having a job provides identity and security in the world and being employed with healthy working condition is very important to PMH promotion. Considering these findings, we proposed a holistic and multidisciplinary approach in different levels to proper policymaking and planning effective interventions to job creation and working condition development for people. In such condition, all stakeholders including governmental and nongovernmental sectors through the interactive process can help protect and promote PMH and public mental health.

Financial support and sponsorship {#sec2-9}
---------------------------------

Nil.

Conflicts of interest {#sec2-10}
---------------------

There are no conflicts of interest.

This article is based on a PhD by research student thesis which has led by the University of Social Welfare and Rehabilitation Sciences.
