Social Support, Quality of Life and Recovery from Mental Illness of Patients Re-Attending
Butabika National Referral Mental Hospital.
Andrew Bamulumbye
A Research Dissertation Submitted to School of Psychology in Partial Fulfilment for the Award
of a Master of Science Degree in Clinical Psychology of Makerere University
2018
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Dedication
This book is dedicated to my beloved wife, Rachael Bamulumbye. You are a blessing to me and very special that I may have no reward to offer to you. May God divinely reward you and meet your hearts desires.
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Acknowledgement
Thanks to my dear wife Rachael Bamulumbye for the emotional support accorded me during this time at school, God bless you. Special thanks to my family members more so my eldest brother C. Kagoda, those words you spoke, always still push me to higher levels in my academic carrier. I extend sincere thanks to the Sheep gate Christian Church brethren, my friends, Mr.
Morgan Otita and Joseph Olowo for the encouragement and all sorts of support accorded to me in this venture.
Thanks to Mr Simon Kizito, Dr John Odda (PhD) and Ms.Rhona Baigana for standing, encouraging and guiding me in this program .Please be blessed.
My special thanks go to my supervisors, Dr Dorothy Kizza (PhD) and Dr.Rosco Kasujja (PhD).
Surely you walked with me an extra mile and I lack the words to express my heartfelt appreciation.
May the Almighty God divinely reward you a hundred fold.
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Abbreviation
ADU Alcohol and Drug Unit
KCCA Kampala Capital City Authority
LMIC Low and Middle Income Countries
MHR Mental health recovery
MoH Ministry of Health, Uganda
PWMI People with Mental illness
QoL Quality of life
WHO World Health Organization
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Abstract
Mental health is pivotal in the general well-being of a healthy society. It is thus pertinent to study this area of society so as generate information to manage and sustain a healthy society. This study was done to generate information such as that among people with mental illness in some areas of their lives, Social support, Quality of life and Recovery from mental illness. The objective of this quantitative, cross-sectional, correlational and partly descriptive study was to investigate the available Social support systems, Quality of life and how these variables affect Recovery among people with Mental illness (PWMI) readmitted in Butabika National referral mental Hospital. The data was analysed using SPSS, version 16.0, Chicago IL. Regressions were done to determine the effects of variables, social support, and quality of life on recovery of PWMI. Descriptive statistics were used to infer the respondents’ status in various areas of the study variable. The results revealed social support as a predictor of quality of life both of which found as predictors of recovery among PWMI. Social support had higher predictability level of Recovery than Quality of life among the respondents. The family system was the most available social support system for the respondents in the study and so much in agreement with the convoy theory of social support. Quality of life predominantly revealed a degree of independence and many within the study population had a source of income a factor that promotes independence not only in the general population but the study population inclusive. The study findings revealed that the respondents did not have poor social support and Quality of life. Therefore recovery failure seem tagged to other factors that need further investigations Qualitative or case studies focusing on the community that lives with patients after discharge, empowering, training the community service providers, family members on their role in the management of PWMI, The government, policy makers and other stakeholders’ (NGOs) role to increase advocacy for mental health programs are highly recommended. In conclusion, the major reasons for recovery failure among PWMI remain a puzzle unanswered. Social support and quality of life are not the cores for failure to recover as revealed in this study. There must be other reasons that are responsible for failure of recovery of study population that need more investigations so that this phenomenon is resolved.
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Working definitions Mental illness:
This is any condition that affects a person’s mood, behaviour or thoughts, and in way causes distress or impairs the normal functioning of the individuals (Purse, 2013).
Social support:
This is emotional support, advice and other benefits one gets from interactions with ones co-survivors, who may include family members, friends, spiritual advisors, co-workers and supervisors, health care providers and others that the individual lives with(Komen, 2011).).
Participant’s social support was measured using Berlin social support tool, Schwarzer and
Schuiz, 2000
Quality of life (QoL):
This is the measurement of physical health, psychological state, level of independence, social relationships, personal beliefs and relationship with the environment and social economic status (money Basu, 2004). ) such as measured by Wisconsin QoL Questionnaire, 2000.
Recovery from mental illness:
This is the process of building a meaningful life according to the patient. It encompasses clinical, personal and insight recovery from mental illness. Clinically it involves getting rid of symptoms restoring social functioning and getting back to normal such as measured using the mental health recovery measure questionnaire-adult version (Shepherd, Boardman &Slade, 2008, Young,
Ensing, and Bullock1999)
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Table of contents
Dedication ...... ii
Declaration ...... Error! Bookmark not defined.
Approval ...... Error! Bookmark not defined.
Acknowledgement ...... v
Abbreviation ...... vi
Abstract ...... vii
Working definitions ...... viii
Table of contents ...... ix
Chapter one ...... 1
Introduction ...... 1
Background ...... 1
Statement of the Problem ...... 3
Purpose of the Study ...... 4
Objectives ...... 4
Research Questions ...... 4
Significance of the study ...... 5
Scope of the Study ...... 5
Conceptual Framework ...... 7
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Chapter two ...... 9
Literature Review ...... 9
Introduction ...... 9
social support ...... 9
Social Support And Recovery From Mental Illness ...... 11
Quality of Life ...... 14
Quality of life and recovery from mental illness ...... 19
Chapter three ...... 22
Methodology ...... 22
Research design ...... 22
Study population ...... 23
Inclusion criteria ...... 23
Exclusion criteria ...... 24
Sample selection and size ...... 25
Study instruments ...... 26
Data collection procedure ...... 28
Data management and analysis ...... 28
Ethical consideration ...... 29
Chapter four ...... 30
Results and interpretations ...... 30
Introduction ...... 30
Social support availability...... 37
Source of income /social economic status of respondents ...... 40
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Chapter five ...... 48
Discussion, limitations, conclusion and recommendations ...... 48
Introduction ...... 48
Limitations of the study ...... 58
Conclusion ...... 59
Recommendations ...... 60
References_
Appendices appendix 1: work plan appendix 2: budget appendix 3: research tool appendix 4: study tool
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Chapter One
Introduction
Background
According to World Health Organization (WHO), mental health problems constitute 14% of the global burden of disease and it is estimated that by 2020 mental illness will be the third leading cause of disability in the general population worldwide (Prince et al, 2007).
Unfortunately, mental health is given low priority especially in Low and Middle-Income
Countries (LMIC) such as Uganda (Prince et al, 2007; Robinson, Rodger, & Butterworth, 2008;
Skeen, Lund, Kleintjes, Flisher, &The MHAPP Research Programme Consortium, 2010). The implication of such trend of events among many is low recovery rates among people with mental illness (PWMI) as opposed to those living in the high income countries with a lot of resources
(White, 2013). Recovery from mental illness is a process of building a meaningful life as defined by the sufferer. It encompasses clinical, personal and insight recovery (Shepherd, Boardman &
Slade, 2008). Clinically, it involves getting rid of symptoms, restoring social functioning and getting back to normal (Shepherd et al, 2008). The key factors among many that facilitate recovery include but not limited to social support (Basu, 2004; Kazarian& Evans, 2001), and quality of life (Zanker, 2008; Kazarian and Evans, 2001).It is noted that, a supportive social environment, good communication and relations with physicians promote recovery of PWMI since it is a factor that improves drug adherence among the sick such as those with mental illness. Furthermore, PWMI must adhere to treatment without which they can hardly improve so as to attain good quality of life (Basu, 2004; Bruggemann, Garlipp, Haltenhof &Seidler, 2007).
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Quality of life is a broad concept; it takes into account the individual’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationships to salient features of the environment (Basu, 2004). One of the key elements in the promotion of better quality of life is the social support from significant others, which is also a key factor in recovery from mental health problems (Hendryx, Green & Perrin, 2009). Social support refers to the emotional support, practical help, advice and other benefits one gets from interactions with ones co-survivors (Komen, 2011). The co-survivors include family members, friends, and spiritual advisors, co-workers and supervisors, health care providers and other people living with the sufferer (ibid).
PWMI struggle with the diseases’ symptoms and as a result, it becomes difficult for them to work and live an independent life or to achieve a satisfactory quality of life (Corrigan, Kerr &
Knudsen, 2005; Lee, Keating, de Castella, &Kulkarni, 2010; Rush, Angrmeyer& Corrigan,
2005). Furthermore, PWMI are often alienated by their family members and significant others particularly following episodes of mental illness (Ssebunnya, Kigozi, Lund, Kizza&Okello,
2009).
In Uganda, the burden of mental illness is high although the actual prevalence is not known (Byaruhanga, Cantor-Graae, Maling&Kabakyenga, 2008; Funk, &Ivbijaro, 2008;
Makumbi, 2012). Data available at Butabika National referral mental hospital indicate high patient readmission rates due to relapse, thus poor recovery among these patients (Birabwa et al,
2006;Butabika National Referral mental Hospital Records, 2009/2010 and 2014/2015; personal observation and communication with staff, 2011-2014). Although this study does not focus on adherence, the major reason cited as a hindrance to recovery was a poor social support system that failed to address adherence to treatment which would otherwise have improved the quality
2 of life among these patients (Birabwa et al, 2006).On the other hand, there is inadequate literature that addresses social support, quality of life and other reasons that lead to readmissions of PWMI and how these variables affect recovery among PWMI (Birabwa et al, 2006; Silva,
Bissani, &Palazzo, 2009). Therefore, there is need to study these areas of mental health care to establish existing gaps; in order to facilitate better care and thus hasten their recovery.
Statement of the Problem
In Uganda, the phenomenon of social support among PWMI appears not to have gained significant attention from the concerned stakeholders, hence poor quality of life in the former, this has on a greater scale negatively affected recovery in these people; thus, the burden of mental illness has remained high although the actual prevalence is not established (Byaruhanga,
Cantor-Graae, 2008; Funk, & Ivbijaro, 2008; Makumbi, 2012). High readmission rates have been noted in mental health facilities especially in Butabika National Referral Mental hospital
(Birabwa et al, 2006; personal observation and communication with staff). The major reason advanced among many is linked to social support that impacts on quality of life lived by PWMI.
Whereas the government of Uganda and other stakeholders have taken some strides such as policy formulation, revising the mental health laws, resource mobilization and bringing mental health services close to the people so as to mitigate mental illness in the community such that
PWMI can attain some degree of recovery (Kigozi et al, 2008), these efforts may not meet the intended goals if issues of social support and quality of life faced by PWMI are not addressed.
Thus, the need to establish the available social support systems, the nature of quality of life lived by these people and how these variables affect their recovery from mental illness.
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Purpose of the Study
To investigate social support systems, quality of the life and how these variables affect recovery among PWMI readmitted in Butabika National referral mental Hospital.
Objectives
1. To determine the available social support systems for PWMI readmitted in Butabika
National referral mental hospital.
2. To examine how the available social support systems affect the recovery of PWMI from
mental illness.
3. To determine the quality of life lived by the PWMI readmitted in Butabika National
referral mental hospital and how it affects their recovery from mental illness.
4. To establish the effect of both social support and quality of life on recovery of PWMI
readmitted in Butabika National referral Mental hospital.
Research Questions
1. What social support systems are available for PWMI readmitted at Butabika National
referral Mental Hospital and how do they affect their recovery?
2. What quality of life is lived by the PWMI readmitted in Butabika National referral
Mental Hospital and how does it affect their recovery?
3. How do both social support and quality of life affect recovery of PWMI readmitted in
Butabika National referral Mental Hospital?
4. What is the overall effect of Social Support, Quality of life on the Recovery of PWMI
readmitted in Butabika National referral Mental Hospital?
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Significance of the Study
The research findings of this study may provide new knowledge to the Ministry of Health
(MoH) on social support and quality of life as drivers of recovery in mental illness among
PWMI. Therefore, in an effort to promote recovery among PWMI, MoH may come up with new strategies to streamline advocacy and empower communities to comprehend their role in management of PWMI in Uganda.
The research findings may act as an eye opener to stake holders, to appreciate that to promote recovery of PWMI, is not only a role of health care providers, but rather a comprehensive approach which goes beyond the hospital settings to involve all those that interact with the patient outside the health care centre.
The findings of this study may provide more information to enhance further studies in this area as to answer more questions on study variables, social support quality of life and recovery of PWMI that this might not have answered.
Scope of the Study
This study targeted readmitted patients in Butabika National referral Mental Hospital.
The focus was specifically the patients’ support systems, the quality of life lived and how these affect their recovery. The social support systems that were examined included the family support system, friend support system and the significant other support system such as religious leaders, teachers and role models. The areas of quality of life that was studied included physical health, service satisfaction, psychological wellbeing and social economic status (money) of
PWMI.
Justification
This study enrolled patients re attending at Butabika National referral Mental Hospital.
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This hospital is National referral hospital with a high patient turn over coming from across the whole nation. Patients off all sorts of mental illness are found with in this facility. Therefore a study such as this was worth conducting from here and provides such a good percentage of the general picture of mental illness in Uganda.
In order to understand the interactions that exist among the study variables, social support, quality of life and recovery among PWMI a conceptual framework was developed which is presented on figure 1 below.
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Figure 1
Conceptual framework
Drug Adherence
Quality of Life Social support Family support Physical health state systems Recovery Friends Service satisfaction support systems Psychological wellbeing Other support systems Social economic status
Cultural beliefs
Social support systems are diverse to include among many, family, friends and other support systems. PWMI at least in their life time belong and have had such systems around them
7 and if they are supportive, such as a supportive family system, can provide an environment which not only promotes recovery but can lead to good quality of life of these patients.
Each family has a friend system and significant others such as the clergy (Religious leaders), teachers and all those individuals that matter in people’s lives. If these social support systems are in place and can embrace the problem of mental illness, they can positively influence recovery of PWMI. On the contrary, if PWMI lack the various aspects of social support, it is very likely that they will face many problems such as isolation, discrimination, lack of independence, and the like; all that will culminate into low levels of recovery among these patients. At another level, there is a significant link between social support system and quality of life in that if humans have good social support system, they will tend to live a normal and have good quality life. Social support enhances adherence to therapy and these factors combined increase recovery from mental illness and in turn lead to good quality of life.
PWMI usually live a life full of challenges in such a way that they find it hard to meet the standards of living needed to attain a good quality of life, given the nature of their illness.
However, if the various aspects of quality of life such as their physical state, health service satisfaction, psychological wellbeing, financial support and personal growth are holistically addressed, chances of drug adherence are high, which in turn promotes recovery from mental illness. On the contrary, if the government and other stakeholders do not address the various areas of quality of life of PWMI, their recovery levels will still be low, thus mental health disease burden may undoubtedly persist.
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Chapter Two
Literature Review
Introduction
Mental illness is any condition that affects a person’s mood, behaviour thoughts, and in way causes distress or impairs the individual’s normal functioning (Purse, 2013). Mental health problem involves various factors whose coordinated or uncoordinated interplay contribute to the ultimate purpose of achieving recovery or otherwise failure (Kleintjes, Lund & Flisher, 2010).
Some of these factors include, but not limited to, social support systems that surround the patient and also the quality of life they live.
Social Support
Social support is emotional support, advice and other benefits one gets from interactions with ones co-survivors, who may include family members, friends, spiritual advisors, co-workers and supervisors, health care providers and others that the individual lives with (Komen, 2011). A number of theories have been advanced to explain social support among individuals. These include the exchange theory and convoy theory. Exchange theory (Keel, 2013), draws on the behaviourist concept of operant conditioning as proposed by Skinner to argue that individual behaviours are reinforced through interactions with the environment. Reinforced behaviours are often repeated and those which are not reinforced tend to extinct (ibid). Social support is a factor in the environment that acts as reinforcement in this regard and impacts on PWMI either to attain good quality of life and/or otherwise attain recovery (Nueringer, 2004).
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Conversely, the convoy model of social support is a theory first advanced by Kahn and
Antonucci (1980) as a theory for understanding social support and social networks across the life span of people. The convoy theory posits that social support is a vital determinant of individual well-being. Furthermore, social support is believed to also enhance well-being indirectly by acting as a buffer between individuals’ well-being and life stressors (Kahn &Antonucci, 1980).
According to Kahn and Antonucci (1980), a convoy is the personal network of people surrounding an individual through which social support is given and received. Family, friends, and other individuals constitute the personal support networks who serve particular roles that may differ across the life course of individuals (ibid). This personal network of people is arranged in form of concentric layers that surround the individual to provide support in times of need (ibid). The outermost layer is made up of individuals who are the least close but serve as sources of support by fulfilling some roles, such as co-worker or neighbour. Social exchanges at this level are role dependent and thus are the least stable across time (ibid). The middle layer includes individuals who are rather closer, and the support received from these social exchanges is not so much role dependent. The relationships at this level are still somewhat unstable as other individuals may be substituted for current convoy members across different life situations. The innermost layer/circle comprises of individuals who are very close and viewed as significant social supports. Members of this level are primarily family and include spouses, children, and siblings (ibid). This is the most stable level, as membership at this level varies the least across time and circumstances.
According to Corrigan and Phelan (2004), social support reduces readmissions in hospitals. It acts as buffer and protective factor among people with sickness in general and those with mental illness in particular (Duckworth, 2008; Robinson et al., 2008).Thus the convoy
10 theory is important in explaining the influence of social support and health and wellbeing among humans (Philips, Ajrouch,& Nalletamby, 2010).
Social Support and Recovery from Mental Illness
Social support is a key component in rehabilitation programs of PWMI. Research and existing literature cite social support as a key tenet that promotes adherence to treatment and in achievement of recovery such as those with bipolar affective disorder (Duckworth, 2008;
Kazarian, & Evans, 2001; Rovers, 2011).Social support does not only promote adherence, but it is also very important in nurturing recovery of PWMI. (Alexander,2009). Positive relationships with friends and family as well as service providers who believe in people’s capacities and share in their hope are key factors of recovery(Alexander, 2009).Families are key in the management of mental illness and they determine the journey to take for recovery to occur among
PWMI(Champagne,2012).
In addition, the family and the patient’s community are very important if patients are to adhere to treatment regimens because such conditions promote health-seeking behaviours which enhance recovery (Vogel, Wade, Westar, Larson & Hackler, 2007; Sariah, 2012).Furthermore communities that provide psychosocial support services to PWMI reduce readmissions of the patients and in a way promoting their recovery (Silva et al, 2009).
On the contrary, poor family support and poor social integration are among the factors that promote psychopathology most especially among patients with schizophrenia (Gilmer et al,
2004).PWMI, most especially those with schizophrenia, need family, friends and professionals to keep their hope if they are to realize a sense of recovery(Martin,2009). Unfortunately these patients usually lose friends because of their sickness which in a way hamper their recovery
(Martin, 2009; Ssebunnya et al 2009).
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Life begins in families. It is the families where we get our first experiences of the world.
Families offer security, friendship, socialization and bonding (Gullotta& Adams, 2005).
In families where PWMI have high levels of social support that is satisfying have little psychological distress and in one way enhancing recovery (Cano et al., 2003). Social support most especially perceived social support reduces both psychological symptoms and related disorders of PWMI and in a way promoting their recovery (ibid). Social support does not only enhance adherence to treatment regimens as earlier stated but also promotes recovery from mental illness and it acts as a protective factor of PWM (Alexander, 2009;Compton, 2010,
Hendryx, Green & Perrin, 2010; Muir-Cochrane, Barkway &Nizette, 2010). Actually, peer social support in some studies, shown reduction in admissions among PWMI (Corrigan & Phelan 2004;
Rogers, Anthony &Lyass, 2004; Tartakovsky, 2011). In addition, social support is a salient component in service utilization among the sick most especially PWMI; hence, promoting recovery (Kim, Sherman & Taylor, 2008).
Social support especially family network is very important in management of PWMI especially those that are suicidal because the family network is a good source of information of the home environment that could be precipitating and perpetuating the illness of the patient.Therefore, to attain recovery among PWMI, social support must not be undermined but rather be emphasized Samra, Monk, White, & Goldner, 2007).
The size of social network also promotes recovery from mental illness and is a good predictor of good mental health (Fugita & Kanaoka, 2003; Nicholls, 2006). In addition, social support improves mental health subjects, moderates mental health problem, effectively reduces psychological distress, helps in treatment endeavours and improves subjects’ wellbeing especially among PWMI (Eshun&Gurung, 2009; ,Fugita&Kanaoka, 2003;Kim et al,2008;
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McCorkle,Rogers,Dunn,Lyass& Wan, 2008). From one other dimension, individuals that have a community closure, community connectivity which are aspects of social support suffer less from psychological distress as opposed to those who are distant from the community ties and are more likely to suffer from mental illness (Kirmayer & Paul, 2007). Furthermore spirituality which is another dimension of social support is noted to influence recovery among the sick especially
PWMI (Cornah, 2006). It is however, sad to note that social relationships of PWMI deteriorate very rapidly because of the sickness such as the case in Uganda (Ssebunnya et al, 2009).
The public view of PWMI as dangerous, aggressive and violent also increases social distance of these patients .The public tend to exaggerate the association between violence and mental illness which of course escalates the problem of mental illness (Stuart, 2003).This kind of treatment of these patients increases social distance for PWMI and hampers their recovery (ibid).
Their family members and friends often tend to dissociate themselves from these patients
(Ssebunnya et al, 2009), yet social inclusion is very important in not only adherence to treatment but pertinent and promotes recovery among PWMI (Arbuthnot et al, 2009;Merton &Bateman,
2007;Keleher, &Armstrong, 2005). On the contrary social exclusion is cited as a precipitator and a perpetuator of mental health problems(Calgary,2012) Hence, such social support related behaviour ends up aggravating the health problem of these patients (Carrol, 2008; Merton &
Bateman, 2007; Ssebunnya et al., 2009; Zartaloudi & Madianos, 2010). Among patients with drug and alcohol, related mental health problems, social support plays a big role in recovery and affects treatment positively if available (Magura, Rosenblum& Fong, 2011; Miller, 1999;
Warrena, Steina& Grellab, 2007). Since social support is very salient in the lives of PWMI, it is likely that this factor is one of those at the centre stage leading to readmissions among these patients, in any case social support systems including friends and family members act as a
13 protective factor among PWMI which may not only reduce readmissions but may promote their recovery (Duckworth, 2008; Robinson et al., 2008).
Quality of Life
Quality of life (QoL) is a broad concept (Basu, 2004). Embedded in it include some of the following; physical health, psychological state, level of independence, social relationships, personal beliefs and relationship with the environment and their social economic status (money;
Basu, 2004). Among PWMI, QoL is very pertinent if they are to attain recovery (ibid). QoL is however, hard to be attained by PWMI because of the symptoms of their disease (Corrigan et al,
2005). They are hardly employed and end up leaving below the poverty line and cannot easily be independent (Corrigan et. al, 2005; Ssebunnya et. al, 2009).
Some of the theories used to explain quality of life include: Integrative theory of global quality of life, which views quality of life in two perspectives, subjective and objective quality of life. The subjective quality of life perspective includes wellbeing, satisfaction with life, happiness, and meaning in life. On the other hand, the objective quality of life perspective takes into account the biological information system, realizing life potential, objective factors (such as cultural norms) and fulfilment of one’s needs (Ventegodt, Merrick & Andersen, 2003). The interplay between these two perspectives establishes an existential quality of life (ibid). Another theory that addresses QoL is based on Abraham Maslow’s theory of hierarchy of needs, which is the human developmental perspective. This theory states that developed societies involve members who are preoccupied in satisfying higher order needs and less developed societies have members preoccupied with satisfying lower needs (biological & safety) in Abraham Maslow’s hierarchy of needs. In this study, the researcher will use Maslow’s theory of needs of hierarchy.
PWMI will be studied with the view that they strive to have good QoL in search for self-
14 actualization or their sickness is towards self-actualization such as may be the case among alcohol and drug abusers who start to use drugs to feel good(Bancroft, Cunningham-Burley,
Backett –Milburn &Masters, 2004).
Recovery from Mental Illness
Recovery from mental illness refers to the “personal experience of the individual as he or she moves out of illness into health and wholeness” (Hendryx, Green, & Perrin, 2009).
It is a dynamic process characterized by movement toward conditions of hope, purpose, and wellness (ibid). Participation in meaningful social life is a major goal for many persons in recovery processes (Mezzina et al, 2006). Recovery from mental health problem requires interplay of various factors such as social support and quality of life (Hartwell-Walker, 2011).If such factors are poorly coordinated may result in mental illness to escalate in the community. On the contrary if these areas of life are well balanced, chances are that PWMI will recover such as revealed by various research findings such as discussed above in this literature view ( Kleintjes et al, 2010). .
Social Support and Quality of Life of People with Mental Illness
The convoy theory of social support stated above is also applicable in understanding the interplay between social support and quality of life of PWMI. The availability of a good social network around the patients can create good standard of living and hence good quality of life as already highlighted in previous paragraph. In addition, the integrative theory of global quality of life which addresses, wellbeing, satisfaction with life, happiness and meaning of life is also applicable in understanding the relationship between social support and quality of life of individual to include PWMI (Ventegodt et al, 2003).
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Social support plays a key role in day-to-day living and in attainment of quality of life. In any case, social support especially having friends is QoL (Martin, 2009).The perception of having their rights and interaction with family/friends are factors that significantly influence the self-perceived satisfactory QoL of people with severe mental illness (Wu, 2013).Good QoL is associated with good social support among the sick especially PWMI and in addition, more developed social network promotes better QoL(Eklund &Hansson, 2010; Martin, 2009).
Slade, (2009) noted that connections with others and actively engaging in life are important sources of well-being more so of PWMI. Research in this area further reveals that
PWMI have low levels of quality of life because of social support issues (Slainte, 2007).One reason among many could be due to social economic status which is a daily requirement for survival yet PWMI can hardly work because of the disease and the accompanied symptoms, thus poor economic status resulting into poor QoL (Corrigan et al, 2005; Rush et al 2005). Social support systems such as the bankers and microfinance institutions are required to access money so as to improve one’s social economic status. Unfortunately, it is hard for the mentally ill to access credit services and other such services (Basu, 2004; Ssebunnya et al, 2009). Whereas there are many programs geared at availing financial support to the public such as is the case in
Uganda, PWMI are not cared for to this effect (Ssebunnya et al, 2009). This kind of treatment keeps these patients below the poverty line (ibid). This phenomenon precipitates their illness and hampers their possibilities of recovery (Basu 2004; Kleintjes et al., 2010, Ssebunnya et al.,
2008). This implies that PWMI will always remain in a vicious cycle of poverty and hardly acquire good quality of life.
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Social support systems, especially friend support system and peer support groups, strongly influence the quality of life among resident patients (Sharir, Tansescu, Turbow&
Maman, 2007). Hansson and Björkman and Hansson (2006) noted that strengthening social networks of PWMI improves their subjective QoL. At another level, religion plays a big role in improving the QoL of PWMI because it provides coping measures among these patients (Al
Showkan, 2012).Spirituality functions to provide social support and social networks. The architecture and sculpture around areas of worship and the building environment such as temples and churches plays a positive role among PWMI, that is, spirituality promotes and maintains good mental health and in a way improves QoL of PWMI (Cornah, 2006).
In addition marital status which is a component of social support is a significantly predictive of QoL and having a romantic or sexual partner is critical component of QoL of clients with mental illness (AlShowkan, 2012; Basu 2004; Martin, 2009;Sharir, et al,
2007).Some other elements of social support that are very crucial in improving the QoL of
PWMI include love, support and acceptance by one’s spouse, immediate and extended family
(Martin, 2009). Perceived social support from both significant others and friends positively correlates with various aspects of QoL to include, life satisfaction, increased freedom and independence (Ali et al., 2010). On the contrary, social support does not influence positively on self, home maintenance and financial services among the mentally ill (Ali et al., 2010; Davey,
2008).
Following hospitalization, PWMI are usually discharged when they regain some degree of recovery and are expected to get better quality of life afterwards. However, this may not be the case unless these patients join supportive community schemes (Davis, 2007). Furthermore, in a
17 supportive environment, PWMI get high levels of satisfaction, freedom and independence all of which are components of quality of life (ibid).
Social support is also exponentially important in maintenance of good physical and mental health (Ozbay et al, 2007). In a study among patients with bipolar affective disorder and schizophrenia, there was a positive correlation between social support and patients with bipolar affective disorder as compared to those with schizophrenia (Chand, Matto&Sharan, 2004).
However, Courtney and Browne, (2005), in their study among people with Schizophrenia stated that supportive social relationships leads to fewer symptoms, reduces admissions to hospital and improves QoL of these patients. Increased social support not only promotes the well-being of the mentally ill, but also reduces psychiatric symptoms and thus enhances recovery from mental illness (McCorkle, et al, 2008). In addition, development of social networks initiated by the patients themselves emphasizes promotion of recovery from mental illness in that it promotes sharing individual’s experiences and this is adequately therapeutic (Corrigan, Sean & Phelan,
2004). In study by Young (2004), Young found out that hospitalization was not a good predictor of QoL instead residential approach revealed better QoL of PWMI. This in away means that good QoL of patients may be better attained outside hospital where there is more social support.
Therefore the need to strengthen the community approach in management of mental illness as opposed to hospitalization such as is the case in Uganda.
Among chronically ill patients due to mental illness, if given social support, they tend to improve and get good quality of life (Bronowski & Zaluska, 2008). In the same regard, moderate levels networking are associated with reduction in psychiatric symptoms, thus recovery (Goldberg,
Leman & Rollins, 2003). On the contrary, poor social support precipitates mental illness, yet good social support is a shield for PWMI and improves their quality of life (Ozbay et al., 2007;
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Corrigan et al., 2005).In addition, Compton (2010) noted that social economic factors are protective factors among PWMI. Therefore if such factors are taken care of in rehabilitation processes of PWMI, they would probably have good QoL
Quality of Life and Recovery from Mental Illness
Learning theories most especially, theory of reciprocal determinism, which entails the triad interactions of the environment, person factors and behaviour is best to explain quality of life, and recovery of PWMI. The benefits the patients achieve by adhering to treatment including drug effects influence their behaviours (Gilmer et al, 2004). When a patient appreciates the benefits of adherence, it is very likely that they will comply with the treatment regimen
(ibid).This implies that the individual will recover, which in turn may improve the quality of life lived by PWMI (Schrank & Slade, 2007).
Socioeconomic status of people which is a component of quality of life has a correlation with disease burden (Kazarian& Evans, 2001). Morbidity follows a gradient across socioeconomic classes (ibid). In addition, people with lower social status have overall poor health. This means that recovery from mental illness correlates to socioeconomic status of patients (ibid). On the contrary, however, some research reveals no relationship between socioeconomic status and recovery from mental illness (Hendryx et al, 2009).
Employment plays an important role in recovery processes, however, the type of employment and the workplace thought to be flexible and supportive to the patient are the factors that meets this school of thought (Coutts, 2007). Employments is a protector and plays a role in adherence to treatment resulting into recovery among the sick especially PWMI (Sariah,
2012).Employment among PWMI provides sense of meaning, belonging, self-worth and increased connection to other people and communities (Coutts, 2007) and all these aspects of life
19 are components of QoL and all if taken care of ,will promote recovery of PWMI(ibid).On the other hand unemployment is cited as factor that leads to poor QoL among PWMI(Al
Showkan,2012).Unfortunately, most PWMI are unemployed and in one study by Artazcoz,
Benach, Borrell and Cortes (2004) men’s employment is cited to be affected by their mental health status. This phenomenon keeps them in a low socioeconomic status. This means that most of these patients are poor and this resonates with low quality of life (Coutts, 2007; Funk, Drew,
&Knapp, 2012). In addition, quality of life is highly affected due to lack of money, therefore, this makes it difficult for PWMI to access health facilities and to acquire the basic needs to have good quality of life (Basu, 2004;Funk et al,2012;Sharir et al, 2007). If PWMI are to have good quality of life, they have to access treatment as often as necessitates so that they attain recovery from mental illness. Unfortunately, this is not usually possible because of persistent poverty among these patients- a factor that deters them from accessing treatment (Eshun &Gurung 2009,
Ssebunnya et al, 2009).
PWMI who are always in the hands of professionals and health service providers receive satisfaction from the services and also are provided with room for good quality of life to enhance recovery from mental illness. This is evidenced by the fact that presence of mental health providers increases social inclusion (Slade, 2010), yet social inclusion is a factor of improved
QoL and recovery among PWMI (Huxley &Thornicroft, 2003). Literature in this area also reveals that professional control is not a good predictor of quality of life among PWMI but quality of life is a strong predictor of psychological wellbeing and it is very important before engaging these patients to psychotropic medications (Blenkiron & Hammil, 2003,Chaplin, 2007) yet in some context, strong clinician-patient relationships, relational continuity, caring and
20 collaborative approach in management of PWMI fosters recovery and leads to better quality of life among these patients (Green et al., 2008;Roh, Chang & Kim, 2012).
In summary, according to this literature review, it is evident that the study variables, social support systems if available promotes quality of life both of which lead to recovery among the sick and even those with mental illness. On the contrary if these factors if not available, that is, poor social support systems around the PWMI and the sick in general lead to decline in QoL and recovery. Furthermore QoL as reflected in the above literature review, is a key factor in promotion of recovery among the sick and those with mental illness not exceptional and reverse thereof detrimental to the sick and those with mental illness.
Hypotheses
1. Social support systems are predictors of recovery among
PWMI readmitted in Butabika National referral mental hospital
2. Social support systems are predictors of Quality of life among
PWMI readmitted in Butabika National referral mental hospital
3. Quality of life is a predictor of Recovery among PWMI readmitted
in Butabika National referral mental hospital
4. Social support systems, Quality of life are predictors of Recovery among PWMI readmitted in Butabika National referral Mental hospital.
5. People with Mental Illness have poor social support systems and quality o the sick and those with mental illness.
21
Chapter Three
Methodology
Research Design
This research was a cross sectional correlational in nature at the same time it was descriptive because two of the objectives intended to determine the social support available and quality of life of PWMI attending Butabika National Mental Referral Hospital during the study period. It was correlational because it sought to establish the effect of social support, quality of life, on patients’ recovery from mental illness.
Study Site
The study site was Butabika National Mental referral hospital. This hospital is within
Kampala Capital City Authority (KCCA) in Nakawa division about 13 kilometres from Kampala city centre. Butabika National Mental referral hospital offers services to both PWMI and outpatient in general to the neighbouring communities. For in-patients, the hospital has a female wing, male wing , children wing, a forensic unit, alcohol and drug unit (ADU), trauma centre ,a private wing and two wards for the physically sick (male and female) patients. It has a bed capacity of 550 patients but the actual admission usually goes up to750 patients (both male and females) excluding the in patients who are children. Butabika hospital is a national referral hospital for mental illness. Therefore, the patients who access psychiatric treatment come from all over the country. For the purpose of this study, participants were drawn only from the two male and two female wards (Admission and convalescent wards) and ADU where readmissions are normally found.
22
Study Population
The study population was all PWMI attending mental health facility and all drawn from the national referral hospital for mental health in Uganda. The patients admitted in this hospital are from across the whole country and thus gives a representative picture of mental health in
Uganda. The target population was PWMI admitted in Butabika National Referral Mental
Hospital. The study sample was drawn from adult patients of age 18years and above such as stated in the inclusion criteria below and readmitted in this Hospital.
Inclusion criteria
This study enrolled participants such as described thus, those aged 18years and above.
The major reason in this case was to minimise modalities of seeking consent in older children which would take a longer time to obtain if it involved children as per the law of Uganda concerning children. On the other hand mental illness is not categorical among children but rather their conditions are categorised as childhood disorders and therefore if any hardly would meet the criteria of true mental illness
Participants that participated in this study were those treated for mental illness and readmitted in the hospital. This was because these were the ones that would meet the concept of failed recovery and thus readmitted. The participants were those with clear mental state, with insight and are able to communicate coherently. It was such clients who could comprehend and answer the various aspects of question that were in the study tool.
Participants were those that understood either English or Luganda. This was so because the study tool was only in these two languages. In addition these two languages are widely spoken and understood by most Ugandan who was the participants of this study.
The participants were only those that consented to participate in the study. This was to meet
23 the obligation of ethics which is the case for any form of research which entails participants to consent before they participate.
Exclusion criteria
The participant that did not meet inclusion criteria in this study included those of age below 18 years. These clusters include children according to the existing law of Uganda. These could not be part of the study because of being children, their mental related problems are hardly categorised as having mental illness but rather childhood disorders. Furthermore to obtain consent from these was quite hard since it would involve a third party, the parents or so which given the constrain of time I had no choice but to leave them out.
The newly admitted and admitted for the first time in this hospital were excluded from the study in that such could not meet some areas intended for the study for example, such could not provide information on how often they have been admitted and the like part of the question that gave answers to determine levels of recovery
All participants who did not understand either English language or Luganda were left out during the study. This was because the researcher could only articulate himself well in these two languages.
Clients with no insight were excluded from this study on ground that such could not appreciate as to why they are in hospital and in other words could not even understand that they had any mental health problem. These would also not be able to answer the content in the study tool.
It is an ethical code of all research protocols for any participant to consent before engagement in research. It is from this point of view that any participant who refused to be part
24 of this study by declining consent was not enrolled in this project. In any case any participant had all the rights to withdraw from the study at any time during the study.
The study involved answering several questions in the study tool. Therefore clients who by whatever cause would not communicate coherently did not take part in this study.
Clients with forensic issues such those who killed and involved themselves in atrocities that are of capital nature did not take part in this study. One major reason for their exclusion lays around bureaucracies in administration of the Hospital, thus to accesses them in order to be part of the study such as was not possible given the limitation of duration for the study.
Chronically institutionalized were not enrolled in this study because they are ever in hospital and the concept of recovery which was the dependent varriabl could not be met by such patients thus not worthy studying.
Sample selection and size
The sample size was determined basing on the number of patients that relapsed in the financial year 2014/2015 at Butabika National referral Hospital for mental illness and the total number of in patients was, 4362.
Therefore, the sample size (n0) was determined using the formula,
n0 =
Z2P(1 − P)
d2
Where,
Z= confidence level (1.96)
P = estimated proportion of re-occurrence cases at Butabika national referral hospital in
the financial year 2014/2015
d=confidence interval (0.01776401) 25
Hence,
(1.96)² × 0.015(1 − 0.015)
(0.01776401)2
0.0568
0.00031556
n0 = 180
Therefore, from the calculation above, the sample size for the study was 180 patients who are re- attending Butabika National referral mental hospital for the mentally ill.
The number of male participants was obtained as follows, 2826 which is the number of male re- attendances (Butabika Hospital Records) for financial year 2014/2015 and overall total was
4262, and thus the male enrolment was:
2826 × 180 = 116 4262
Similarly, the female enrolment was based on general re-attendances of female patients,
2014/2015 in Butabika National referral hospital who was; 1536.Thus the female enrolment was as follows:
1536 × 180 = 64 4262
Study instruments
In order to examine the different aspects of the study, the investigator with permission employed the following standardized questionnaires:
1. Wisconsin, (W-QLI 2000) revised quality of life questionnaire was used to collect data
on socio- demographic characteristics and the various aspects of quality of life namely
satisfaction level, psychological well-Being, physical health and social economic status.
26
An example of the question on area of QoL and responses respectively are: How satisfied
or dissatisfied are you with the way you spend your time: Very dissatisfied, Moderately
dissatisfied, A little dissatisfied, A little satisfied, Moderately satisfied and Very satisfied
In the areas of satisfaction and psychological wellbeing there were 10 dimensions to explore with maximum score of 30. Scores below 10 was ranked low, 10 to 20 moderate and 21 to 30 high.
Psychometrically, this tool has been tested in other areas of the world and found valid and reliable such as the study by, Nordansting, Karlsson, Pettersson &Kumlien, 2012.
2. Berlin social support scale, (Schwarzer and Schulz, 2000) was used to collect information
about how various support systems available for participants.
An example of questions and responses in this area of the study tool is: “There are some people that truly like me: Strongly disagree, Disagree, Agree and strongly agree.
Psychometrically, this tool has been tested for which case, it was found reliable and valid such as documented by Schwarzer & Schulz,(2003). Participant’s levels of social support availability, 8 areas were assessed and the minimum and maximum scores were scored 8 and 32 respectively.
These scores were grouped as follows, 8- 16, 17-25 and 26 and above and then ranked as low moderate and high respectively. Similarly there was 15 areas to determine participant’s need for social support and with minimum score of 15 and maximum 60.These scores were grouped as follows,15-29,30-44and 45 -60 and ranked as low moderate and high respectively
3. Mental health recovery measure questionnaire-adult version (Young, Ensing, and Bullock
1999) was used to measure the recovery levels from mental illness. An example of the
questions and responses in area is: “am willing to work hard to recover: Strongly
disagree, Disagree, Neutral, and Agree and strongly agree. This part of the study tool had
27
29 areas of assessment with a minimum score of 29 and maximum score of 116.These
scores were grouped thus, 29-58, 59-88 and 89-118.These groupings were ranked as low,
moderate and high in terms of recovery respectively. Psychometrically, this Recovery
tool has been tested and found to have high validity,realibility such stated by ozbey,2012
Data collection Procedure
The researcher obtained a letter of introduction from the School of Psychology, Makerere
University. The researcher further sought permission from the administration of Butabika national referral hospital in order to carry out this study. Due to the limited duration of the study and the nature of the study population (mentally ill), the researcher identified the participants purposively with guidance from the ward In-charges and other staff of the hospital. In addition, the researcher obtained informed consent from the participants. They affirmed this by either signing a consent form or by use of a thumbprint. Thereafter the questionnaires/study tools were subjected to the participants so as to collect data.
Data management and Analysis
The researcher cleaned the completed questionnaires/study tools for accuracy and completeness and then data was entered in a Statistical Package for the Social Sciences (SPSS, v
16.0; Chicago, IL).
For objectives one and two, linear regression was done to determine whether there is a relationship between social support, quality of life affects and recovery from mental illness. For objective number three whose aim was to find out the effect of social support and quality of life on recovery of PWMI, multiple linear regressions was used to determine the overall effect of the two variables on recovery among PWMI. In addition descriptive statistics were used to explain the respondents’ status in various areas of social support such portrayed in chapter 4 of this book,
28 quality of life. The various scores were tabulated and scores grouped as, low moderate and high such as in areas of social support, quality of life and recovery. In all these analyses, low scores meant no effect, yet moderate and high scores implied the respondents were generally doing well in the dimensions measured such as reflected in chapter four of this paper.
Ethical consideration
This study was done with approval of school of psychology and administration of
Butabika National referral mental hospital. Before the study was conducted, Butabika National referral hospital research committee was consulted and gave approval for the study. The participants were highly protected, not manipulated, neither exploited nor harmed.
Confidentiality and respect for all stakeholders was the epitome of the study. The participants consented by signing a consent form before they enrolled into the study. Furthermore, the participants were free to opt out of the study if any wished to do otherwise. Autonomy, beneficence, non-maleficence, justice and equity were among the cores of ethical consideration that were practiced during this study.
29
Chapter Four
Results and Interpretations
Introduction
Mental health plays a pivotal role in the lives of individuals and the community in which they live. This research study was done to explore some pertinent areas of daily living and find out how these areas impacts on recovery of people with mental health problems. This chapter presents the findings of the study variables that included, social support systems , the Family support systems, Friends support systems such as significant others religious leaders available and health services providers, quality of the life that was limited to physical health, service satisfaction, psychological wellbeing lived by PWMI and how these variables(independent variables) affect the dependent variable recovery among PWMI readmitted in Butabika National referral mental Hospital. In the study various data was collected so as to address the specific objective of the study such as displayed otherwise.
Social demographic Characteristics of the Respondents.
In the study the social demographics of the respondents was very important and part of data collected which included, gender, marital status, religious affiliation and their education levels. This data intended to gather information to determine the available social support of the study population which is in line with objective one of this study. The results obtained in this area are as displayed on Table 1 below;
30
Table 1 Respondent’s, Gender, Marital status, Religious affiliation and level of education
Characteristics Frequency Percent Gender Male 116 64.4 Female 64 35.6 Total 180 100 Marital Status Single 73 40.5 Separated 39 21.7 Married 37 20.6 Committed relationship 22 12.2 Spouse Deceased 04 2.2 Divorced 05 2.8 Total 180 100 Religious Affiliation Catholic 61 33.9 Anglican/Protestant 60 33.3 Born again 34 18.9 Moslem 22 12.2 Others 03 1.7 Total 180 100 Level of education None 16 8.9 Primary 64 35.6 O’ Level 75 41.7 UACE 12 6.7 Tertiary Education 13 7.2 Total 180 100
31
Results as shown on table 1 above, the total number of respondents were 180 both of which were female and male. The majority, 116 (64.4%) were males, and the females comprised of only, 64(35.6%). Regarding marital relationships, most, 73 (40.5%) and 4(2.2%) deceased. On the other hand, the respondents had religious affiliations save a few, that is most of the respondents were Catholic, 61 (33.9%) and only 3, (1.7%), others. Majority of the respondent had O, level education, 75 (41.7%), and 12 (6.7%) only attained advanced certificate of education.
Psychiatric Condition, Duration and Frequency of Admission of respondents
The psychiatric conditions diagnosed of every respondent, Frequency of readmission in relation to psychiatric condition in Months were pertinent in this study. This is because such
Information was important in generating answers for objective one of this study. That is it provided data of how social support plays a role in reduction of readmission (recovery measure) or otherwise the contrary. The results obtained are shown in table 2 below;
32
Table 2
Respondents Psychiatric Diagnosis; Frequency and Duration from Previous Admission
Frequency of Admission Duration from Previous Admission
(Months)
Psychiatric diagnosis Total Once Twice Thrice Four 0-6 7-12 13-18 19-24
N 180 &above
Bipolar affective 75 00 19 18 38 30 15 15 15 disorder
Psychosis 40 00 14 12 14 21 07 03 05
Schizophrenia 22 00 07 05 10 07 07 07 02
Drug abuse 12 00 03 03 06 11 01 00 03
Alcohol abuse 10 00 08 02 00 00 02 01 08
Substance problems 11 00 06 03 02 04 01 01 04
Organic psychosis 10 00 03 04 03 04 04 01 02
Total 180 00 60 47 73 77 37 28 38
The results shown on the table 2 above show that the majority of the respondent were
those with Bipolar affective disorder (BAD), 75 (41.6%), yet the least were, alcohol abuse and
organic psychosis, both, 10 (5.6%).Seventy two (40.0%) of the study population had been
readmitted four and more times and 48(26.7%) re-admitted three times in the hospital because of
their illness.
In relation to time lags from previous admission vis-à-vis current admission, those with Bipolar
affective disorders had the highest numbers, 30(16.7%) in regard to the shortness of time of stay
33 out (0-6month) after discharge and drug abuse with a significant value of 11(6.1%).In the same respect, at the time lag of 7-12months, respondents with Bipolar affective disorder had the highest number at,15(8.3%) and a significant value of 7(3.89%) for those with schizophrenia and psychosis. Furthermore at duration, 13-18 months, Bipolar affective disorder had the highest number of readmission at 15(8.3%), and significant value of schizophrenia at 7(3.89%).Finally at duration,19-24 months, the respondents with Bipolar affective disorder had the highest numbers,14(7.7%).It is such suggestive that the short the time and frequency of readmissions are indicators of poor recovery and this regard clients with bipolar affective disorder show poor recovery processes
Respondent’s Residential status prior to admission and where they wished to live.
The respondents were asked who they had lived within the past four weeks and who they wished to live with. The data obtained in this respect also was to reveal the available social support of the respondents which also answers objective one this study. The results from their responses to this effect are as displayed on table 3 below;
34
Table 3
Respondent’s residence during the period prior to admission and where they wished to live.
Prior Admission Frequency Percent
Alone 15 8.3
With parents 68 37.8
With Children 13 7.2
Friends 25 13.9
Significant others 19 10.6
Others 40 22.2
Preferred residence
Alone 20 11.1
With Parents 4 24.4
With Friends 20 11.1
With Spouse 64 35.6
With Children 08 4.4
With Others 24 13.3
Table 3 above shows that most respondents had lived with parents 68 (37.8%), and 13
(7.2%), with children in the last four weeks prior to their admission. On the other hand the respondents that wished to live with spouses were 64 (35.6%), and 08 (4.4%) preferred to live with children.
35
Participant’s Previous and Preferred Places of Residence
Furthermore as to establish more about the social support available for the respondents so as to explore more on objective one of the study, places where the respondents lived prior to admission and where they wished to live was answered. The results obtained are as displayed on
Table 4 below;
Table 4: Participant’s Previous and Preferred Places of Residence
Previous place of Residence Frequency Percent Home 89 49.4 School 01 0.56 Hospital 75 41.7 Homeless 01 0.56 Jail 02 1.11 Others 12 6.7 Preferred Place Home 150 83.3 School 11 6.1 Hospital 05 2.8 Homeless 00 00 Jail 00 00 Others 14 7.8
Eighty nine (49.4%) of the participants had been home yet only 02 (1.1%) homeless.
On the other hand the majority of the respondents, 150(83.3%) wished to live at home yet none wished to be homeless.
36
Social support availability One area of importance in this study was to determine social support availability of the respondents in different facets of their daily living. The results obtained to that effect are as displayed on table 5 below;
Table: 5
Participants levels of social support availability
Low Moderate High
Available social support 13(7.2%) 64 (35.6%) 93 (51.7%)
As showed on table 5 above the respondents responses to questions in relation to available social support, majority, and 93(51.7%) had very high scores and 13(7.2%) with a very score on available social support.
In order to establish the details of the type of social support and the individuals who often gave it to the respondent, various questions were answered by the participants with aim to establish actually received from the various members from the community including family members, religious leader (Clergy), political leaders cultural leaders other social leaders/significant others and health practitioners and the results obtained are as displayed on table 6 below;
37
Table: 6 Respondent’s actual received social support
Support System Family Religious Political Cultural Social Health system Leaders leaders leaders leader/SF worker Y N Y N Y N Y N Y N Y N Showed love 122 06 16 03 08 00 02 00 11 00 12 00 Comforted 110 03 16 03 06 01 02 00 19 00 19 01 Available when 111 16 16 01 06 03 02 01 08 02 14 00 needed Left me alone 82 40 03 07 01 05 02 02 05 24 02 07
Complained 64 34 03 11 09 15 01 010 20 12 02 00 about me Cared for my 131 20 07 01 04 02 00 0 11 00 04 00 property Made me valued 111 1 14 02 07 01 03 02 26 00 00 00
Expressed 122 00 02 01 17 04 00 00 10 00 32 00 concern for me Helped me find 107 09 13 00 07 00 02 03 19 05 13 02 good Distracted me 40 44 11 17 04 12 03 11 21 18 02 00 Encouraged me 103 08 13 03 05 04 02 01 21 01 15 04 not to give up Took care of my 118 17 10 00 01 00 03 00 17 07 06 01 property Generally 129 07 00 02 09 02 03 00 19 02 07 00 Satisfied
38
The data as revealed on table 6 above show the distribution of actual received support by the respondents across the various domains of social support. The respondent’s actually received support was from family systems and in general 129 (71.7%) to which majority stated that they were in general more satisfied with support from family even across all domains of actually received support yet cultural leaders scored worst in general,3(1.67%) even across all domains of social support studied.
Participant’s need for social support
The participants responded to various aspects in the study tool to ascertain their need for social support and their scores are as reflected on table six below;
Table 7
Participant’s need for social support
Low Moderate High
14 (7.77%) 166 (92.23%) 00(0%)
Like depicted on table 7 above 14 (7.77%) and 0 (0%) scored low and high in regard to need for social support in the various domains on the study tool.
Quality of life of different dimensions of the respondents
In order to answer objective three of this study, data was obtained concerning the various areas of quality of life to include levels of satisfactions in these aspects, (on how they spend their time, living conditions, food, clothing, transportation, sexual life ,safety),psychological wellbeing, physical health and social economic status. The information obtained scored and rated as low, moderate and high is as displayed on table 7 below;
39
Table: 8
Respondent’s levels of QoL across the various domains measured during the study
Low Moderate High
Level of satisfaction 69 (38.3%) 68 (37.7%) 43 (23.8%)
Psychological wellbeing 140 (77.7%) 37(20.5%) 03 (0.16%)
Physical health 00 77 (42.7%) 103 (57.2%)
Social economic status 06 (3.3%) 90 (50%) 84 (46.7%)
It is remarkable that following analysis of data the scores obtained for most of the respondents on level of satisfaction in various aspects of life such as how they spent their time, housing, clothing, sexuality just to mention a few, was low at 69(38.3%) and 43(23.8%) high however, the summation of moderate and high scores, 111(61.7%) when compared with the low score, 69(38.3) are suggestive of good QoL lived by the respondents.
There was reasonable scores in domain of physical health where all participants scored moderate
77(42.7%) and 103 (57.2%) even along the social economic status, where 90(50%) and only few
6 (3.3%) with low scores.
On the contrary very low scores were observed along the domains of psychological well-being with 140(77.7%) yet only 03(0.16%) scored high.
Source of income /social economic status of respondents In order to evaluate more on QoL of the respondents, the area of their source income was explored. This part was to further generate more data in the same regard so as to come up with concrete evidence so as to answer objective three of this study. The information generated is as reflected on table 8 below;
40
Table 9
Respondent’s source of income
Source of income Frequency Percent
Paid employment 38 21.1
Retired 01 0.56
Not employed 37 20.6
Others 104 57.8
Total 180 100
Like as displayed on Table 9 above 104(57.8%) had some source of income, to include self-employment and petty jobs, and only 01 (0.56%) retired.
Recovery from mental illness
41
Recovery among the respondents during data collection was measured using the Mental health recovery measure questionnaire-adult version (Young, Ensing, and Bullock 1999).
The respondents’ summary of scores which were categorised as low, moderate and high are as represented on table 10 below;
Table 10
Respondent’s recovery scores across the various domains of the above tool
Low Moderate High
07 (3.8%) 96(53.3%) 77(42.8%)
As displayed on Table 10 above, majority of the respondents scored moderate 96 (53.3%) and a very small number 07 (3.8%) in the category of low score on the recovery tool. Thus there is quite a significant degree of recovery with only 3.8% showing low recovery rate.
Inference statistical tabulations of the study variables
The study intended to establish the effect of social support, quality of life on recovery from mental illness among the participants.
In order to determine the effect of quality of life, social support on recovery among the study population, both linear and multiple regressions were statically done in line with the objectives of the study. The results obtained are as shown on table 11, 12, 13 and 14 below;
Table 11
42
Effect of Social support (SS) on Mental Health Recovery (MHR)
Model Summary Model Predictor R R Square Adjusted R Square Std Error of the Variables Estimate Wisconsin .361a .130 .125 11.18358 a Predictors: (Constant),SS ANOVAb Sum of Squares Df F Mean Square Sig Regression 3328.486 1 26.612 3328.486 .000 Residual 22262.908 178 125.073 Total 25591.394 179 a. Predictors: (Constant), SS b. Dependent Variable: MHR Coefficientsa Unstandardized Coefficients Standardized Coefficients B Std Error Beta T Sig (Predictor) 78.820 5.736 . 000푎 SS .342 .066 .361 13.742 .000 a Dependent Variable: MHR
Considering R squared value (0.13) it also implies 13% of the variance in mental health recovery among the respondents can be explained by their Social support systems. The alternative Hypothesis is retained and state that, ‘Social Support systems are predictors of Mental
Health recovery in the study population’ However, recovery among the study population is also attributed to other factors as revealed by R value 0.361 (36.1%) which calls for further investigations.
Table 12
43
Effect of Social support (SS) on Quality of life of PWMI
Model Summary Model Predictor R R Square Adjusted R Square Std Error of the Variables Estimate SS .394a .155 .145 11.66219 a Predictors: (Constant), SS
ANOVAb Sum of Squares Df F Mean Square Sig
Regression 4427.127 2 16.275 2213.564 .000 Residual 24073.200 177 136.007 Total 28500.328 179 a. Predictors: (Constant), SS b. Dependent Variable: QoL Coefficientsa Unstandardized Coefficients Standardized Coefficients B Std Error Beta T Sig 푎 (Predictor) SS 49.073 8.171 6.006 . 000 a.Dependent .270 .01 Variable,QoL .285 .084 3.399
The R squared value (0.155) .15.5% of the variance in quality of life in the study population can be explained by existing Social support systems. Therefore Social support systems among the study population are a predictor of their Quality of life.The Hypothesis that,
“Social support systems are predictors of Quality of life in the study population” is retained. On the other hand however, considering R value 0.394 (39.4%) it also implies that other factors
44 other than Social Support systems that are responsible for QoL among the study population which need more investigation.
Table 13
Effect of Quality of life (Wisconsin) on Mental Health Recovery (MHR)
Model Summary
Model Predictor R R Square Adjusted R Square Std Error of the Variables Estimate Wisconsin .317a .100 .095 15.98862 a Predictors: (Constant), QoL ANOVAb Sum of Squares Df F Mean Square Sig Regression 5067.479 1 19.823 5067.479 .000 Residual 45503.181 178 255.636 Total 50570.660 179 a. Predictors: (Constant), QoL b. Dependent Variable: MHR Coefficientsa Unstandardized Coefficients Standardized Coefficients B Std Error Beta T Sig (Constant)QoL 5.901 8.200 .720 .473 aDependent Variable MHR .422 .095 .317 4.452 .000
The adjusted R squared value, 0.100 which is 10% variance in Mental Health Recovery can be explained by participants’ Quality of life .Thus , the Alternative Hypothesis is retained and state that ,”Quality of Life of the study population is a predictor of Recovery from Mental
45
illness” although to a magnitude not as expressed in literature review. Therefore among the study
population there must be other factors represented by R value .317(31.7%) that contribute to
MHR that call for more studies in this phenomenon.
Table 14
Effect of both social support and quality of life on recovery from mental illness (MHR) among the
respondents.
Model Summary Model Predictor R R Square Adjusted R Square Std Error of the Variables Estimate Wisconsin . 394푎 .155 .146 11.66219 BSS a Predictors: (Constant), Wisconsin, 퐀퐍퐎퐕퐀풃 Sum of Squares Df F Mean Square Sig Regression 4427.127 2 16.275 2213.56 .000 Residual 24073.200 177 136.007 Total 28500.328 179 퐂퐨퐞퐟퐟퐢퐜퐢퐞퐧퐭퐬풂 Unstandardized Coefficients Standardized Coefficients B Std Error Beta T Sig (Constant) 49.073 8.171 . 000푎 SS .285 .084 .270 3.399 .01 Wisconsin .137 .060 .183 2.301 .23 a Dependent Variable: MHR
The R squared value, .155 which is 15.5% variance in Mental health Recovery can be
explained by both Social Support systems and Quality of life of the participants in this study.The
alternative Hypothesis is retained and state that, “Social Support systems, Quality of life in the
46 study population are predictors of Recovery among PWMI” When we consider Beta value of
Social Support systems (SS) (b=.270) and QoL (Wisconsin), (b=.183), SS with a higher predictability value implies that Social Support Systems are better predictors of Recovery from mental illness than QoL within the study population.
47
Chapter Five
Discussion, limitations, Conclusion and Recommendations
Introduction
Mental health burden is a phenomenon with many questions that remain an unanswered in many domains including but not limited to, causes, manifestations and precipiting factors.
Therefore there is little wonder that it attracts and calls for research so as to gain insight and generate answers to such puzzles.
The purpose of this study was to establish and investigate some areas of the domains of mental illness, social support systems, quality of the life and how these variables affect recovery among PWMI readmitted in Butabika National referral mental Hospital. The specific objectives of the study intended to find out the, the available social support system, Quality of life and how these study variables affect recovery of PWMI. This chapter presents, discussion, conclusion and recommendations of the study as described thus.
Social support and recovery from mental illness
Social support is a salient component of life and this study intended to find out the available social support system, family, religious, political, cultural leaders, social leaders/significant others and Health worker systems of PWMI. The family support system was found to be the most available support system for the study population such as depicted on table
6, page, 38 and cultural leaders system was found least available for these patients.
Social support systems were found a predictors of recovery among the study population but to a small percentage of 12.5%and thus not as anticipated that is, social support was thought to contribute a lot to recovery among the participants such as depicted in literature review yet results revealed a little the contrary. However the test hypothesis that ,’ Social support systems
48 are predictors of Recovery among PWMI readmitted in Butabika National referral Hospital was retained as revealed by the statistical interpretation(Table11,page43).
The findings of this study were in agreement with Corrigan and Phelan (2004) together with those of Duckworth 2008 and Robinson et al., 2008 who found out and stated that social support reduces readmissions in hospitals and acts as buffer, protective factor among people with sickness in general and those with mental illness in particular. However, the extent to which this factor plays a role in this respect was to a very small magnitude, 12.5% such as stated above.
Therefore the extent to which this variable plays a role in recovery of the study population was found not very satisfying. There should be other factors that needs more study that calls for more study in this field to ascertain the real cause of poor recovery rates among the study population
(Table11, page43).
In addition the study had the assumption that these patients had poor social support and this precipitates and perpetuates mental illness and hence their continued readmission, was found not to be true and little wonder they are ever in the hospital a view that differs from that earlier stated according to Corrigan and Phelan (2004).It implies therefore that there must be other factors other than social support that is at the centre stage of failure to recovery among the study population. The difference could be probably due to differences in cultural background among the study populations or otherwise the study design employed in these studies.
The results of this study much as social support was found a predictor of recovery in the study population but the level of predictability was to a very limited magnitude,12.5%, in way these results are more in agreement with those of Rovers, (2011) ,Alexander (2009) , Compton,(
2010), Hendryx, Green & Perrin, (2010); Muir-Cochrane, Barkway &Nizette,( 2010) and
Champagne 2012,who in their studies found out social support does not aid in rehabilitation
49 programs of PWMI much as it is key factor in recovery. It thus creates a paradoxical phenomenon as to why there is continuous readmission among the study population which creates room to explore more aspects to establish the factors prevailing around PWMI so as to get a lasting solution to this puzzle .Ssebunnya et al, 2009 stated that social relationships of
PWMI deteriorate very rapidly because of the sickness such as the case in Uganda. On the contrary, in this study this finding differs. In fact it was not really the case, instead readmissions were found not dependant on social support among the participant but rather on other factors probably the public perceptions towards these patient as dangerous, aggressive and violent which increases social distance of these patients which of course escalates the problem of mental illness as was stated by Stuart, (2003).
Readmissions is a common phenomenon in Butabika national referral mental hospital
(Birabwa et al, 2006; Butabika National Referral mental Hospital Records, 2009/2010; to
2014/2015 and personal observation and communication with staff, 2011-2012). Social support is cited as one factor that reduces this problem (Corrigan & Phelan 2004; Rogers, Anthony
&Lyass, 2004; Tartakovsky, 2011). However, the findings of this study in regard to this phenomenon, social support is available for these patients most especially from the family and close relatives, and in any case it is not the sole cause of the problem. There must be other pertinent variables that need thorough study and strengthening in order to achieve the desired goal of recovery among PWMI.
The continued readmissions of PWMI in Butabika National referral mental Hospital are not only suggestive of increase of psychological distress but also poor health wellbeing. This finding as indicated in this study is contrary to that found by Eshun &Gurung,( 2009),Kim et al,(2008),McCorkle, Rogers,Dunn,Lyass& Wan, (2008) who in their studies found out that
50 social support reduces readmissions and moderates and reduces psychological distress of PWMI.
In this case the patient were often readmitted regardless of the presence of social support implying that its availability is not enough to fix this problem. Some other ventures need to be addressed as to get a lasting solution to the problem.
In this study such as indicated on Table 1 page, 31, all the participants had a religious affiliation except 3(1.7%) individuals. Therefore their spiritual needs were being addressed in one way or the other. Cornah, (2006) noted that spirituality which is another dimension of social support influence recovery among the sick especially PWMI. The persistent readmission of
PWMI to hospital reveals failure to recovery, therefore it is likely that the spiritual component alone is not good enough to enhance affirmative recovery among PWMI or otherwise it is not meeting the core to influence recovery among the participants.
Social Support and Quality of Life of People with Mental Illness.
This study intended to establish the effect of social support on the quality of life among the participants and in a way to discover whether these variables are responsible for continued readmission of PWMI or otherwise ascertain their effect on recovery among the participants. The assumption in this regard was that social support affects quality of life which in turn promotes recovery or the contrary. The results of the study revealed that social support was a predictor of quality of life by 14.5%. Furthermore the alternative hypothesis was also retained and concluded that Social Support systems, Quality of life are predictors of Recovery among PWMI re- attending Butabika National Referral Hospital for Mental illness. Whereas social support was a predictor of quality of life among the participants as highlighted above, but the level of predictability was fairly small magnitude,14.5% as compared to what available literature poetries it. This implies little impact on the quality of life among the participants. Therefore
51 readmission or otherwise recovery among the participants is to such a limited impact dependant variable, QoL or otherwise recovery among the PWMI. Therefore in a way these findings did not fully support the assertion that social support promotes QoL of study population but rather the contrary. The results were thus not fully supporting those of Martin, (2009) and Sharir, et al,
2007), who stated that having friends which is a component of social support plays a role in attainment of good quality of life.
Since the results of this study revealed the contrary among the respondents, then the reason for their continued readmission is not centred on social support and quality of life but rather other factors which are better accounted for by R value, 0.394(39.4%) as indicated on Table 11, page
43 above. Most of respondents had been at home prior to admission to the Hospital as indicated on Table 4, page, 36 above. One may be right to conclude that the respondents might be having perception of their own rights and interaction with family/friends that is good with self-perceived satisfaction of QoL that would help as therapeutic enough as Wu, (2013) and Slade, (2009) asserts. It is unfortunate that much as this concept is as the results revealed, yet these patients are continuously readmitted, meaning that they do not attain recovery basing on this variable alone even when they seem to have both social support and QoL that is usually expected (Table 5,6,7 and 8,pages37,38,39 and 40 respectively). There must be other reasons for this continued phenomenon in Butabika National referral Hospital which ought to be investigated a furthermore.
Whereas Eklund and Hansson (2010) together with Martin (2009) found out that good social support among the sick especially PWMI and developed social network promotes QoL, the results of this study revealed the quite the contrary, in that social support among the respondents was predictor of QoL but such a very small magnitude of 14.5%(Table 11,page43).
52
It is no wonder that recovery rates among the respondents was high such as reflected on Table 2, page, 33, showing high numbers of readmissions vis-à-vis the time lag between discharge readmissions, thus cases of 114(63.3%) in a period of between 0 to 12months across all cases interviewed during the spell of the study. This implies that social support and quality of life are not the only aspects impeding recovery in PLWMI but other factors that need further scrutiny.
The results of this study did not support those of Slainte, (2007) to the best as one would anticipate in that study revealed social support as a low predictor of QoL. In this case social support impacted on quality of life but a very less extent and if anything these variables were not exponentially correlated to each other. Little wonder therefore recovery among the participants such as reflected on the regression analysis on Table 11 page 43 of chapter four above was at such a low level. The differences to this effect may be attributed to the difference in the country in which the two studies were done. Furthermore this difference may not be due to socio- economic status (money) such as mentioned by, Corrigan et al, Rush et al (2005) &Ssebunnya et al (2009) because a significant number of the respondent, 38(21.1%) had paid employment, yet many among the category of others, 104(57.8%, Table 8 page 40) had some form of petty income and simple jobs, yet others had businesses and some form of none dependant income including simple self-employment. This implies that failure to recover is not only accounted for basing on quality of life, socio-economic status (money) but rather on other factors which need more investigation which are better accounted for by R,Value,31.7% depicted on Table11 page
43 above.
The study sought to find out the effect of social support on quality of life. As already noted above, social support was found a low predictor of quality of life among the respondents.
This finding implies that in spite of strong social networks among the study population, quality
53 of life is not guaranteed. Hence contradicted with the findings of Hansson and Björkman,
Hansson (2006) and Coutts (2007) who stated that strong social networks is a predictor of quality of life and promotes recovery respectively.
All the respondents had a religious affiliation such as depicted on Table 1, page 31, implying that the spiritual components of the respondents is taken care of which would likewise advance not only QoL but also recovery (Al Showkan, 2012 and Cornah, 2006).It is unfortunate that the respondent are many times in the hospital even when such facilities are available.
Therefore it is not social support neither QoL that precipitates this problem but rather other factors that need more investigations.
Table 1, page, 31 is reflective of marital status of the respondents and it shows such significant values of the respondent’s marital status, that is, 37(20.6%) married and 22(12.2%) committed relationships. The question about marital status being responsible for poor quality of life is not justifiable given the above values. Many of the respondent’s needs such as, love, support and acceptance by spouses, and extended family were being met evidencing good quality of life as stated by Martin, (2009) even as reflected QoL scores, Table 7, pages 39 above.
Regardless of the availability of such a factor among many of the respondents, a readmission rate is high and spell of time spent after every discharge is so short, with total returns of 77(42.8) after about, 0-6 months as depicted on Table 2, Page 33, this implies that social support and how it impacts on QoL of the participants is not the sole reason for failure to recover, otherwise the trend would be the exact opposite. Therefore other factors that ought to be investigated further could be the reason for such portrait and ought to be investigated to come up with a lasting solution to the problem of recovery among PWMI.
54
The results of the study revealed that social support does predict quality of life to a magnitude of 14.5% of the respondents. Since this level of predictability is thus small, Therefore it is not very true to assert that perceived social support from both significant others and various aspects of QoL to include, life satisfaction, increased freedom and independence is responsible for readmission (failure to recovery) among the respondents, but rather attributed to other factors like cultural beliefs and drug adherence, which this study did not study and hence the need for more research in area to resolve this problem.
Ozbay et al (2007), Chand et al (2004), Courtney and Browne, (2005), McCorkle, et al,(
2008) Bronowski & Zaluska,( 2008) , Young (2004), Corrigan et al, (2005) and Compton (2010) cites that social support is exponentially important in maintenance of good physical and mental health. The findings of this study to a certain extent contradict this school of thought in that social support was found not a very strong predictor of quality of life. Therefore continued readmission among respondents is not social support and how it impacts on quality of life
(physical and mental health) but possibly other factors need more studies to make more affirmative conclusions.
Quality of Life and Recovery from Mental Illness
The results on Table 11 page 43 show that failure of recovery from mental illness among the respondents was to some extent due to QoL since this variable was found a predictor of recovery among the respondents although to a limited extent, 9.5%. Therefore other factors which are accounted for by the R value, 31.7% must be playing a big role to explain recovery phenomenon among PWML attending this facility. This study finding therefore correlates to a certain extent with Kazarian& Evans, (2001) who stated that socioeconomic status of people which is a component of quality of life correlates with disease burden and morbidity follows a
55 gradient across socioeconomic classes. One possible reason for the disparity may be attributed to differences in culture among the study populations or otherwise the priority given to PWMI across different areas of the world (Prince et al, 2007; Robinson et al, 2008; Skeen, et al,2010
&The MHAPP Research Programme Consortium, 2010).
Socioeconomic status varied among the respondents such as depicted on table 8 page 40 and as already explained above that QoL was a predictor of recovery though to a less extent, it is rather true that QoL was to a certain extent responsible for recovery but other factors as earlier stated above must not be under looked that accounted for by R value of 31.7% as reflected on table 11 page 41. However the results contradict with those of Hendryx et al, (2009) whose research reveals no relationship between socioeconomic status and recovery from mental illness.
Employment type of, workplace dynamics and unemployment such as indicated on Table
8,page 40,which are cited by Coutts,(2007),Sariah(2012) ,AlShowkan(2012) and Cortes
(2004)as factors of QoL among PWMI were to a certain level responsible for failure of recovery since QoL among the study population was found a predictor of recovery though to a limited extent,9.5% such as depicted on table11,page 43.However ,other factors ought to be studied to establish the actual cause of poor recovery among respondents beyond QoL.
Whereas some of the respondents seemed like their socio-economic status were not very good in that very few had paid jobs, (Table 8, page 40) results did not suggest so and therefore did not agree with, Basu, (2004); Funk et al, (2012); and Sharir et al, 2007); who suggested that
PWMI lack money to access health care as to attain QoL to facilitate recovery. Most of the respondents had source of income as shown on Table8 Page 40.It is likely that those who do not go to hospital are the ones with no care or otherwise may be the ones with very low social economic status and QoL respectively. In any case their recovery much as their recovery may be
56 tagged QoL but it is important to appreciate that the sole problem is not their QoL per say but more to other factors as already stated above. The study finding contradicted with Eshun, Gurung
(2009), and Ssebunnya et al,(2009) who stated that PWMI are in persistent poverty- a factor that deters them from accessing treatment.
A big number of the respondents 75(41.7%) as shown on table 4, page 36 had been in the hospital thus in hands of professionals and health service providers. This implies reception of service satisfaction and good quality of life to enhance recovery (Slade, 2010, and Huxley
&Thornicroft, 2003).However the puzzle still remains in that after such attention these patients are not attaining satisfactory recovery and little wonder their continued and frequent readmissions such as depicted on Table 2,page 33 above. The study to certain extent was in support of the view that QoL is a predictor of recovery though to a less extent and the results were not in agreement with those of (Blenkiron &Hammil, 2003, Chaplin, 2007) who revealed that professional control is not a good predictor of quality of life among PWMI.
The study supported the concept that strong clinician-patient relationships, relational continuity, caring and collaborative approach in management of PWMI fosters recovery and leads to better quality of life among these patients but generally it was to a low level, 9.5%
(Green et al., 2008;Roh, Chang & Kim, 2012).The difference could be the quality of life and type of mental health services provided in Ugandan health systems differ from those of areas where these other studies were done.
Social support, quality of life and recovery from mental illness (MHR) among the respondents.
Table 13, page 45 depicts the overall picture of the effect of both social support and
Quality of life (QoL) and their total effect on recovery of PWMI. The results revealed that social support combined with QoL are to a certain extent predictors of recovery among PWMI to a
57 level of 15.5% a value which is small and in way the inference is that, social support and quality of life are not the sole reason for this phenomenon. There must be other factor responsible for the problem of failed recovery among the respondents that is better accounted for by the R value,39.4% on the same Table above that calls for further study in order to come up with more lasting solution to this problem. Relatedly, the Beta values,(b=.270 )and(b= .183),reveal that social support has a more predictability of recovery among the respondents than Quality of life.
It is however unfortunate that there was no literature found combining these two variables, Social support and Quality of life discussed anywhere to compare and contrast with the findings of this study.
Limitations of the study
I’m humbled that this study reached this far much as it was not that on smooth road but rather characterised some challenges like it does occur in studies such this. In this regard some of the limitations encountered included some of the following;
It was difficult to realise the required sample size given the type of clients from whom the study was conducted. A good number could be disqualified as the interview was going on as you would often realise others mental statuses not sound depending on how they would answer particular questions.
Given the kind of the respondents that participated in this being with mental illness, there is a possibility that some individuals may have answered some questions out of context which may be the reason for outcome such as displayed in chapter four.
Some re atendances could be as a result of dependence in that some patients may be returning because of particular benefits they get in health facility. These patients qualified for inclusion and their enrolment might have affected the outcome of this study
58
This project was funded by the student himself and finances were such a big challenge during the study. However through it all with support from my significant others, the project reached its climax and thus this report.
Conclusion
This research was done to determine the available social support, quality of life and their effects on recovery from mental illness among patients attending Butabika National referral mental Hospital. It was
Conclusion
This research was done to determine the available social support, quality of life and their effects on recovery from mental illness among patients attending Butabika National referral mental
Hospital. It was discovered that social support and quality of life alone were predictors of recovery from mental illness among the respondents but to a low magnitude as described above. The major reasons surrounding the puzzle of readmissions and recovery among the respondents were found to be linked to these two variables of the study but to a less extent. There must be other factors that seem to have profound impacts for this puzzle that need further investigations. It is also probable that patients who attend hospitals have helping hands as opposed to those who do not.
The family system was undoubtedly found playing a pivotal role in providing social support to the patients with mental illness since most respondents loved being near their families
And respondents received more perceived social support from their family bonds such as reflected on Tables4 page36 and 6, page 38 respectively.
It is important at this point to high light the fact that the variable social support was in concordance with the convoy theory and the family system provided the most social support to the patients than any other social support system studied. There was no clear evidence linking to other theories mentioned above. The study revealed some degree of independence within the study
59 population since a number of the respondents had some form of personal source of income. On the other hand Abraham Maslow theory was found to relate with QoL since most participants were found willing to make a contribution to society in order to have their own needs met at the first level as stipulated in Abraham Maslow theory.
Recommendations
The government, policy makers and other stakeholders (NGOs) ought to strengthen mental health programs beyond the health facilities and in addition make these activities friendlier to every stakeholder and other users so as to enhance decongestion of Butabika National referral hospital for mental illness.
There is need to do more research on these variable so as to come up with the answer to this problem so as to enhance recovery among PWMI.A qualitative study is recommended or otherwise case studies may reveal more conclusive results.
It may also add value to the study if a comparative study which looks at the patients in hospital and those who are not and/or otherwise studying the community that shelters patients after discharge.
There is need to study and empower, train community service providers especially family members on their role in the management of PWMI. There is a need to start up mental health programs geared at management of PWMI at the community level. There is need to increase advocacy for mental illness holistically to make it known to everybody since every one of us among the living is candidates of mental health.
60
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Appendices Appendix 1: Work plan
Appendix 2: Budget
Appendix 3: Request to participate and consent form
Appendix 4: Research instruments
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Appendix 1: Work Plan
Work Plan 2013 2014
J M A M J J A S O N D F M A M J J A S O N A A P A U U U E C O E E A P A U U U E C O N R R Y N L G P T V C B R R Y N L G P T V
Topic selection
Proposal writing
Submission
Defense
Data collection
Data analysis
Report writing
Report
submission
Report defense
Dissertation
submission
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Appendix 2: Budget
ITEM COST IN SHILLINGS
Transport 1,200,000/=
Stationary 120,000/=
Research assistant 1,000,000/=
Internet 500,000/=
Air time 100,000/=
Printing costs 300,000/=
GRAND TOTAL 3,220,000/=
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Appendix 3: Research tool
MAKERERE UNIVERSITY
SCHOOL OF PSYCHOLOGY Research Tool
Introduction
The graduate school requires students pursuing graduate studies to engage in research projects as requirement to complete such a program of the University. In order to accomplish this requirement, Mr. Andrew Bamulumbye who is a graduate student pursuing a Master of Science
Degree, Clinical psychology is conducting a study in Butabika National referral hospital.
The topic of the study is social support, quality of life and recovery from mental illness of PWMI attending Butabika National referral hospital. The study is targeting people who are readmitted.
The Hospital records and some studies that have been done in this hospital such as that done by
Birabwa et al(2006) show high rates of readmission. This study is geared towards finding causes of such problem among these patients. The results obtained will help in scaling up management of mental health problems, which in turn may reduce on readmission, expenses and at the same time increase recovery rates among people with mental illness.
Therefore, you are hereby asked to participate in this study. If you do not mind, you can then respond to the consent form.
Thank you very much.
Andrew Bamulumbye
…………………………………………
Graduate student, MSc.Clinical Psychology Makerere University
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Consent Form
TITLE OF THE STUDY: Social Support, Quality Of Life, and Recovery from Mental Illness of
Patients Attending Butabika National Referral Hospital
Investigator: Mr. Andrew Bamulumbye
Makerere University
Introduction
I am conducting a research study in Butabika National Referral Hospital to investigate social support systems, quality of the life and how these variables influences each other so as to affect recovery of people with mental illness attending Butabika National referral mental
Hospital.
In order to find the role played by the research variables, social support, Quality of life and recovery from mental illness among PWMI, I am carrying out this study. The combination of these three factors will help us understand whether their availability or not are responsible for continuous readmission of PWMI attending Butabika National referral mental Hospital.
I am recruiting only patients that are hospitalized but the current admission should be because of relapse if you are to participate in this study. The total number of participants is 177 patients for which if you agree to participate, you will be one of them.
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Procedures
This is to ask you to participate in this study .This document is called a consent form. If you agree to get involved in this study, the following will occur:
1. You will sign as an acknowledgement that you have agreed to participate in this study.
2. You will answer some questions in study tool about yourself.
3. You will get counselling and all the care that goes with any issues arising out of the study especially by the hospital health service providers.
4 After the study, the results will be communicated to you if you so wish. These results will be availed to the hospital, government of Uganda and the community through publication and conference presentations.
5. There is no biological specimen that will be removed or examined from any participant.
Risks/discomfort
While answering the questionnaires, there may be some discomfort, however counseling shall be provided to any participant who may experience this.
Benefits
The information obtained from this study will avail information about the main reasons leading to poor recovery rates of PWMI attending Butabika National mental health Referral Hospital and there after this information will help in coming up with better management of PWMI both in the hospital and at the community level.
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Confidentiality
All records about you will be kept confidentially and your name will not appear on any of the papers we shall be using. Only authorized persons will have access to the information that will be got from you as a participant in the study.
Note that your participation in this study is voluntary. Even after enrolling in the study you can choose to withdraw your consent to participate in the study at anytime without any effect on your usual studies.
Costs/compensation
You will not be paid to participate in the study except, some participants that need psychological help, will be referred for further management.
Questions
If there are any questions that you would like to ask, you could do them right away or later.
Questions about your research rights can be addressed to Prof. Kikoma the Dean School of
Psychology, Makerere University and Dr. D. Kizza.(Phd) Head of Psychology, Butabika
National referral mental Hospital
The contacts are:
Andrew Bamulumbye
Tel;0772334094.
E mail: [email protected]
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Statement of consent
I______have been asked to participate in a research study entitled
,Social Support, Quality Of Life, To and Recovery from Mental Illness of Patients Attending
Butabika National Referral Hospital
The study has been explained to me. I understand what the study means to me including what I have to go through while in the study. I have had an opportunity to ask questions about the study and these have been answered in a manner I have understood. If there are any other questions that I have to ask later I will ask the study representative whose address I know very well. I also understand that my participation is voluntary and my consent can be withdrawn any time I wish to do so without effect on my usual studies.
I am appending my signature/thumbprint as my indication of consent to participate in the study.
(Signature/thumbprint of participant) (Date)
Signature of Witness (Date)
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Appendix 4: study tool
SOCIAL DEMOGRAPHIC CHARACTERISTICS (Wisconsin questionnaire of QoL2000 )
1. What is your date of birth______/______/______
2. Gender Male Female
3. What is your current relationship/marital status?
Single/Never married committed relationship
Married Separated
Divorced Spouse deceased 4. What psychiatric condition were you diagnosed with……………
5. How many times have you been hospitalized because of a psychiatric condition?
Once Twice Three times Others (Specify) ______
6. What is the source of your income? (Check all that apply)
Paid employment Unemployment compensation
Retirement. Other source (Specify):______7. During the past four weeks, you lived: (Check all that apply)
Alone With parents With children
With roommate/friend with significant other/spouse
with other. Please specify______
8. Who would you like to live with? (Tick all that apply)
Alone With parents With a friend with spouse
With children With other. Please specify______
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9. During the past four weeks, you lived primarily with: (Tick one)
At home at school/college In Hospital or nursing home Homeless In jail/prison other, please specify: ______
10. Where would you like to live?
At Home At school/college Hospital Homeless Other, please specify:______
Satisfaction level(Wisconsin questionnaire of QoL,2000 C’d)
For each of the following questions tick the appropriate statement in terms of personal satisfaction
Very Moderately A little A little Moderately Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied Satisfied
How satisfied or dissatisfied am I with the way I spend my time?
How satisfied or dissatisfied am I you when I’m alone?
How satisfied or dissatisfied am I with my housing?
How satisfied or dissatisfied am I with my neighborhood as a place to live in?
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How satisfied or dissatisfied am I with the food I eat?
How satisfied or dissatisfied am I with the clothing I wear?
How satisfied or dissatisfied am I with the mental health services I use?
How satisfied or dissatisfied am I with my access to transportation?
How satisfied or dissatisfied am I with my sex life?
How satisfied or dissatisfied am I with my personal safety?
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PSYCHOLOGICAL WELL-BEING(Wisconsin questionnaire of QoL,C’d 2000)
For each of the following questions, tick the most appropriate statement, strongly disagree (SD) Disagree (D)
Agree (A) strongly agree (SA) in the past four weeks.
SD D A SA
I’m pleased having accomplished something.
I’m very lonely or remote from other people.
I have been bored with life
Things about my life went well my way.
I was restless that I couldn’t sit long in a chair.
I’m proud because someone complimented me on something I had done.
I get upset when someone criticizes me.
I’m Particularly excited or interested in something I do.
I’m Depressed or very unhappy.
I feel am on top of the world.
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PHYSICAL HEALTH (Wisconsin questionnaire of QoL,2000 C’d)
Tick the phrase most applicable to you for the following questions
Poor Fair Good Very good Excellent
In the past four weeks, you would best describe your physical health as
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Very Moderately A little Moderately Very
dissatisfied dissatisfied satisfied satisfied satisfied
How do you feel about your physical Health care health?
Not at all Slightly Moderately Very Extremely
important important important important important
How important to you is your physical health? (Tick one)
How important is it to you taking psychiatric medications,
None Slight Mild Moderate Severe
If you are currently taking psychiatric medications, do you have side effects from them?
Very Moderately A little Moderately Very
dissatisfied dissatisfied satisfied satisfied satisfied
How do you feel about taking your psychiatric medications?
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Money(Wisconsin questionnaire of QoL, 2000 C’d)
Yes No
Are you paid for working
Very Moderately A little Moderately Very dissatisfied dissatisfied satisfied satisfied satisfied How do you feel about the amount of money you have?
How satisfied are you about the amount of control you have over your money? Not at all Slightly Moderately Very Extremely important important important important important How important to you is money?
How important is it to you to have control over your money?
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Never Sometimes Always Very Quite infrequentl often y How often does lack of money keep you from doing what you want to do?
BERLIN SOCIAL SUPPORT SCALE (SCHWARZER AND SCHUIZ,2000) Respond to the following statement by using the following phrases as applied to you. Strongly Disagree (SD), Disagree (d), Agree (A) Strongly Agree (SA) SD D A SA There are some people who truly like me
Whenever I am not feeling well, other people show me that they are fond of me. Whenever I am sad, there are people who cheer me
There is always someone there for me when I need comforting
(Instrumental) I know people upon whom I can rely
When am worried there is someone who helps me
There are people who offer me help when I need it
When everything becomes too much for me to handle, others are there to help me
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Actuality received support
This section includes all those individuals that proved to be instrumental in your life. Tick the most appropriate option and fill the blank spaces with the options below, for example 2 a);
1. Religious leader 2. Political leader 3. Family
a) Reverend/Pastor/Priest/Lay leader a) Local councilor a) Parents
b) Sheik/Imam b) Others b) Siblings
c) Others c) Other relatives
4. Traditional leader/Cultural leader 5. Social leader 6. Health service providers
a) King a) Teacher/Lecturer/Tutor a) Medical psychiatry officer
b) Chiefs b) Police b) Psychiatric clinical officer
c) Others c) Others c) Psychologists/Social worker
d) Nurse
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SD D A SA
This person ( ______) showed me that he/ she loves me
This person ( ______)was there when I needed him/her
This person( ______) comforted me when I was feeling bad
This person ( ______) left me alone
This person(______) complained about me
This person (______)took care of many things for me
This person (______)made me feel valued and important
This person (______)expressed concern about my condition
This person (______)assured me that I can rely completely on him
This person (______)helped me find something positive in my situation
This person (______)suggested activities that might distract me
This person (______)encouraged me not to give up
This person (______) took care of things I could not manage on my own
In general am very satisfied with the way this person behaved
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Need for Support
SD D A SA
When am down, I need someone who boosts my spirits
It is important for me to have someone who listens to me
Before making any important decisions, I absolutely need a second opinion
I get along best without any outside help
In critical situations, I prefer to ask others for advice
Whenever an down, I look for someone to cheer me up again
When am worried, I reach out to someone to talk to
If I do not know how to handle a situation, I ask other what I can do Whenever I need help I ask for it
I kept all bad news from him or her
I avoided everything that could upset him or her
I showed strength in his or her presence
I did not let him or her notice how bad and depressed I really felt I avoided criticism
I pretended to be very strong although I really did not feel that way
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MENTAL HEALTH RECOVERY MEASURE QUESTIONNAIRE-ADULT VERSION (YOUNG,
ENSING, AND BULLOCK 1999)
Strongly disagree Disagree Neutral Agree Strongly
agree
I am willing to work hard to recover
Even though there are hard days, I still know that things will continue to improve if I work hard
It is okay to ask for help when I am not feeling well
When I’m feeling low, I am able to rely on my religious faith, or on other people to give me the encouragement I need to continue
I do not have a serious or persistent mental health problem
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I want to take care of myself for my own good
I am willing to take risks to move forward with my recovery
I believe in my self
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I am not afraid to work hard to get better
My mental health problems are completely out of own control
I can sense when the symptoms of my mental health problems are getting worse
When having a bad day, it is okay to rely on habits like smoking or drinking to get out of a slump.
I am somehow to blame for my mental health problems.
Every day is a new opportunity for learning
I no longer know who I am because of my mental health problems.
I can still grow and change in positive ways despite my mental health problem
I have not lost all of myself to my mental health problems
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I am still capable of learning about the world around me
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I eat nutritious meals every day
I go out and participate in at least two enjoyable activities every week
I have less than three people I consider my friends
Most of the time, I stay at home and watch TV
I am good about taking my medications regularly
I make the effort to get to know other people.
I feel good about myself.
The way I think about things helps me to achieve my goals
I feel like my life is pretty normal
My life feels like it is out of control
I feel at peace with myself
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2