Study on factors leading to re-hospitalization and the care provided

People with mental illnesses are marginalized and socially excluded from many aspects of community life. Mentally ill patients and their family members/caregivers often face significant barriers when dealing with their illnesses. The goal of this study was to identify the factors affecting re-hospitalization and types of care given by the families. The sample includes selected psychiatric patients (Male-10, Female-10) from 20 different families. Primary data were obtained using semi-structured questionnaires, in-depth interviews with the caregivers. Hospital records, observation and case studies were used as secondary information. Family interventions were very much evident and proved to be very effective in reducing the impact of illness on the patient and family. Out of these 20 families, 13 patients were identified with supportive caregivers through the follow up. Case work activities revealed that, family members were aware of patients’ illness behavior and psycho-social changes.


INTRODUCTION
Re-hospitalization is a particularly concerning issue for patients and is associated with family members experiencing increased care burden and stress.As reported by the WHO (2001), surveys in several developed countries have revealed that more than 25% of ordinary persons manifest one or more mental disorders during their lifetime.Mental health problems often lead to personal distress, illnesses/uncleanliness, death, stigmatization, marginalization and economic deprivation to the individual or to the family.
Of recent, taking care of a mentally ill patient has become a serious problem, on account of increasing poverty, high cost of living, expensive medical treatment, loneliness, lack of companionship and social stigma Alan and Colin, 1983).Understanding the leading factors which are affecting re-hospitalization is very much essential to improving the quality of care.

Caring system of the family
A family, defined as a social unit/group characterized by common residence, economic cooperation and reproduction, is considered as the first attempt at social organization by humans.This social unit formed as a social institution with a purpose has been the focus of attention of the social scientists and behavioral professionals including social workers and counselors who intervene to effect constructive changes at different levels (Lena, 2004).The structure of the family which keeps transforming depends on many factors such as culture and needs of a society.It is also explained as a social arrangement developed to ensure the perpetuation and propagation of the species.
One of the major functions of the family is the caring for the female members of the family, as it is considered, in E-mail: herathchulani@yahoo.com.
the patriarchal way of thinking (Ife, 1997) that the primary role of a woman in a family is that of a wife and a mother, which includes bearing and rearing of the off springs and caring for all family members including the sick, elderly and the disabled.In the event, the familial caretaking function is not undertaken; the state has often stepped in to undertake the responsibility at a cost.In order to prevent the development of such situations, strengthening and improving the wellbeing of the family is normally advocated and supported by providing adequate support through supportive interventions.
Caring is a broad area which encompasses a variety of processes.Caring could be construed as a means to simply attune oneself to someone else's psychological wellbeing.It however relates to large amounts of emotional labor to maintain personal relationships.
Among the many caring systems, family based care is one.As a primary social institution, the family possesses distinct relationships with the society, state and market.Any concerns about the family therefore are directly connected to these relationships.As a dynamic organization, the family could become a problem when the conditions within it present threats to the basic values and interests.Families differ markedly in form and structure throughout the world.Their structure and functions have changed considerably over time and continue to change to this day.There have been occasions when changes in family organization and arrangement have been perceived as social problems, resulting in conflicting values and objectives.The core of the conflict often concerns the extent to which the changing nature of families and family organization results in the nonperformance of certain functions such as child care, and/or biological, social and cultural reproduction, that are necessary for the continuance of the existing society Margrit et al., 2003).
Traditionally, it has been the responsibility of families to provide long-term care to each and every individual in the family.This long-term care entails a variety of services that include medical and non-medical care for people with chronic illnesses or disabilities.Long-term care helps meet health or personal needs.Long-term care, however, can be provided at home, in the community, in institutions providing assisted living arrangements or in hospitals.Long-term "care" in reality is the provision of a complex array of services.In addition, the use of the term "chronic" may not include those consumers whose needs for services and supports are intermittent, meaning episodic or cyclical in nature.In the case of persons living with mental health problems, long term care is necessary as they are vulnerable.Helping people with mental health problems is a specialized service.

The situation of the mental illness
Mental illness is fast developing to become the number its members, particularly vulnerable members of the family.In practice, the caring role is mainly handled by one cause of morbidity in the world (WHO 2001).As reported by WHO (2001), surveys in several developed countries have revealed that more than 25% of ordinary persons manifest one or more mental disorders during their lifetime.Mental health problems of different degrees are common, and can affect anyone.Recent trends in mental illnesses have been the cause for concern worldwide including Sri Lanka (James, 1988).Research by Sri Lankans have shown that at any given time about 10 percent of people suffer from significant mental disorders and about 2% suffer from serious mental illnesses (Chamindra and Suman, 2009).Mendes (2001) in his research has pointed out that the social changes experienced recently are caused (Richard, 1979) by Middle East migration, war, unemployment, rising rates of suicide and alcoholism.More and more people in Sri Lanka are suffering from mental illnesses on the average; one in every four families has persons with mental health problems, needing clinical attention (Sahanaya, 2003).Mental health problems often lead to personal distress, illnesses/uncleanliness, death, stigmatization, marginali-zation and economic deprivation to the individual or family.
Normally, a short term or even a brief episode of several mental disorders experienced is likely to have long-term consequences for both the patient and family.The disruptive influences through mental disorders may cause paranoid delusions, rage or severe depression tearing apart the most cohesive families.There are many studies on short-term follow-up on patient's characteristics and treatment regimes leading to favorable results but studies on long-term illnesses and their impact on the patient and families are relatively few.
Some of the research on long-term illnesses has indicated outcomes related to persons who manifest the basic thought disorder of schizophrenia in adolescence, for example, and who have been constricted in their relationships with others, tend to be the most chronically impaired in later life, even though they may be able to function episodically in certain types of social roles (Olsen and Micklin, 1981).
Many studies, including that of Wansborough and Cooper (1980) have indicated the importance of employment for the rehabilitation and resettlement of those who have suffered from a mental illness (Gerald, 1961).The loss of employment brings with it not only economic repercussions but a number of social and psychological ones as well: loss of self esteem and identity, lack of structure and purpose in life and reduced contacts with friends and former workmates.

Objectives
The objectives of this study were to identify the factors affecting re-hospitalization and the types of care given by the families.

METHODOLOGY
A sample of psychiatric patients (Male-10, Female-10) as diagnosed psychiatrically ill per the International Classification of Disease (ICD-10) undergoing acute mental illness for more than 2 years from 20 different families Sri Lanka were selected for this study.This area of study is very specific; therefore, to accomplish the objectives of the research, directly selected purposive sampling method was used.Primary data were obtained using semistructured questionnaires, in-depth interviews with caregivers.Hospital records, observation and case studies were used as secondary information.The semi-structured questionnaires were used to assess the socio-demographic and economic background of the family members and the caregivers while in-depth details of psychiatric patients and the family care givers were obtained from informal interviews of selected patients.They were all one-to-one personal interviews, the duration of which depended on the severity of the illness.The technique of participant observations were used to observe patients and care givers at the Hospital and Clinics as well as during the home visits.

RESULTS
Family interventions were very much evident and proved to be very effective in reducing the impact of the illness on the patient and family.Twenty patients and their families were recruited for the study.Out of these twenty patients, 16 patients were suffering from schizophrenia and 04 patients were suffering from bipolar-affective disorder.
From this 20 sample, 13 patients identified with caregivers.The rest of them do not have any caregivers to take responsibilities continuously.For this evidence based practice, social case work was best method to help people to help themselves (Allen and Anne 1973).
Psycho education programme for the family members/ caregivers were more effective activity.It was revealed that, family members were aware of patients' illness behavior and bio-psycho social changes.Counseling sessions helped them to reduce the burden and stresses of the family members/ caregivers.These changes of the family members/ caregivers help patients to reduce their relapses.

DISCUSSION AND CONCLUSION
Lack of awareness on mental illnesses and lack of knowledge on taking care of such patients lead to problematic conditions for caring for the mentally ill.People are caring for their mentally ill patients in different ways.They face challenges, sometimes they struggle with these additional responsibilities.Income is a major problem of these families.There is a contradiction between patients' illness behavior and day to day activities of their families.Therefore, it is a burden to the families to take care of such patients.
Social stigma is another main reason which has highly influenced such families in our culture.It seems not only in the rural villages but also in urban societies such conflict situations can be observed.Family and home environment successfully predict treatment outcome and relapse rates.Caregivers' stress levels and attitude can predict the quality of care for patients and the risk of increased re-hospitalizations.
In hospital settings, families of patients are often frustrated by a system that claims to include them, but hardly keeps them informed.This lack of communication disconnects family members, leaving them feeling helpless and unsupported in their own concerns and unable to help their loved one.As a result of this disconnection and social stigma, the patient is often discharged to a family who does not know how to help or what to do to facilitate recovery, increasing the likelihood of relapses.
Family factors seemed to aggravate mental illnesses sometimes leading to family dysfunction and disorganization.Lack of awareness on mental illnesses and the resultant neglect of the patient may have led to the development of the illness into chronic conditions.This study underscored the necessity to start the preliminary medicals as early as possible followed by early interventions by the family.As social work intervention, family intervention is very necessary for the long-term mentally ill who are the vulnerable individuals and need continuous support.Introducing social work practice methods to manage mental illnesses at primary care level and in community is effective to develop good practices.
Therefore, the social worker in the mental health setting should be concerned about the medical model and social model to enhance capacities of person with mental health problems and their families; and micro, macro and mezzo level social work intervention is very much essential to help them to help themselves.