الفهرس 
INTRODUCTION & AIM OF THE STUDYOnly 14 pages are availabe for public view
 |  | from | 224 |  |  |
| | | from | 224 | | |
Abstract
The stigma of mental illness has a negative effect on the patient, caregiver, healthcare system, and the whole community. Overcoming stigma would be beneficial to the whole society and not only the affected population. Targeting stigma of mental illness in caregivers is an under-researched area in the healthcare practice in the whole world in general and in the Middle East in particular, as shown in the literature review presented in the introduction of the current work. The main aim of the study was to evaluate an anti-stigma intervention program for caregivers of mentally ill patients in private psychiatric hospitals in Alexandria Governorate. Also, the aims included measuring the prevalence of stigma to mental illness and identifying the determinants of stigma among the caregivers of mentally ill patients, as well as designing and implementing an anti-stigma intervention program in order to assess mental health-related knowledge, attitude, and reported/intended behavior among caregivers with stigma before implementing the intervention program, immediately after implementation of the program and 2 months after termination of the program.
In order to achieve this aim, the study was conducted in two phases on primary adult caregivers of adult mentally ill patients, who were recently admitted to one of the mental hospitals, where the study was conducted. Before starting the study, a pilot study on 20 patients to determine the reliability of the chosen tools. In order to measure stigma-related constructs, local adaptation was needed due to the difference in the cultural manifestations of stigma. In other words, the ‘cultural validity’ of stigma indicators was stressed (Weiss, et al., 2001). The tools chosen included: DDQ to measure stigma of mental illness, MAKS to measure the knowledge about mental illness, AMIQ to evaluate attitude towards mentally ill patients, and finally RIBS to estimate the reported/intended behavior. All the tools were tested for reliability and validity.
The first phase was a screening stage to detect the prevalence of stigma of mental illness using the DDQ among this population and to identify determinants of stigma in caregivers, using a pre-designed sociodemographic structured interview questionnaire. Out of the 310 randomly selected participants in the first phase, caregivers with high stigma (81 participants: 26.1%) were offered the opportunity to participate in the intervention program, and the vast majority of the randomly selected caregivers accepted.
A pre-designed structured questionnaire was used to collect the following data:
The age of the caregivers ranged from 18 to 79 years, with a mean and SD of 37.78 ±14 years. The age group of ”25 to less than 35 years” was the most represented (29.7%).
Females represented 62.3% of the sample.
The majority of the participants were from Alexandria (78.7%).
Spouses were (33.9%) of the sample, followed by parents (30.3%).
Married caregivers were 40.3% of the sample, while 26.1% were divorced, and 24.2% were single. Widowed caregivers were only 9.4% of the participants.
Illiterate caregivers or those who could just read and /or write were 48.1% of the sample, whereas 22.5% were either university graduates or postgraduates.
More than half of the sample was not working (52.3%).
The crowding index of 2 to less than 4 was the most common, forming 73.5%.
Caregivers who stated that their income was enough were 41.3% of the sample. On the other hand, those who mentioned that their income was not enough and they were borrowing were 11.9% only.
Whereas 52.6% of the caregivers in the sample were suffering from physical illnesses, 23.9% of the sample was mentally ill.
The majority of the sample was not smoking cigarettes (71.6%). nor smoking shisha (85.2%), nor using illicit substances (81.9%).
The majority of the sample was getting enough sleep (58.7%). Those exposed recently to stress within the last 6 months prior to the interview were 62.3% of the caregivers. Of those who were exposed to stress, 55.4% were severely affected by stress. 53.2% of the sample does not receive any support.
Patients with severe mental illness aged less than 25 years were 32.6% of the sample, while those aged more than 55 years were 8.1% of the sample.
Male patients were the most commonly represented patients in the sample (75.2%).
The age of the patients at diagnosis was most commonly between 20 and 30 years (47.7%). Patients who were diagnosed when they were forty years or older were the least represented (4.8%).
Schizophrenia was the most common mental illness in the patients (35.8%), followed by bipolar disorder (33.2%). Depressive disorder followed by 21% and other mental diagnoses were the least represented, forming 10% of the sample.
Duration before diagnosis was usually less than 1 year (56.8%). Those patients, who stayed unwell for 5 years or more before receiving a mental illness diagnosis, were merely 6.8%.
Patients admitted to a mental hospital within 2 years from initial diagnosis were the most common in the sample (56.8%).
More than half of the patients (57.1%) had 1 to 2 previous admissions.
The vast majority of the patients were taking oral medications (98.7%). Patients who were sometimes compliant on medications were 48.1%, while 31.3% were never compliant on medications. Only (20.6%) were always compliant. Most of the patients (59%) did not have a family history of mental illness.
Cigarette smokers were 56.5%, while 38.4% of the patients were smoking shisha. Illicit substances were used by 22.9% of patients.
Physical illnesses were reported in 48.7% of the patients.
Multiple regression analysis had shown that out of the 12 significant variables, predictors of stigma in caregivers; only four variables (namely: age of caregiver, gender of caregiver, patient diagnosis, and time to admission). These four significantly predicted 31% of the DDQ score (i.e. level of stigma).
The second phase was the intervention stage, which was one group pretest-posttest design implemented on 60 participants. Assessment of mental-illness-related knowledge, attitude, and behavior among caregivers with stigma before, immediately after the program completion, and two months later as follow-up using the same evaluation tools.
A three-session anti-stigma intervention program was designed and implemented in the Arabic language on four groups of 11 to 17 participants. Each session was around 2 hours once weekly.
The program was effective in terms of changing the knowledge, attitudes, and intended behaviors of the participants, as evidenced by the significant increase in the means of scores of the tests after the intervention immediately and 2-months later. Although the means of the MAKS and the intended behaviors had shown a decrease in the follow-up measurements, it was still significantly higher than the initial levels.
CONCLUSION AND RECOMMENDATIONS
The current study provides evidence that stigma is prevalent in caregivers of patients with mental illness in Alexandria. It also proved the effectiveness of a group psychosocial intervention program in improving knowledge, attitudes, and behaviors in stigma-suffering caregivers of patients with mental illness in Alexandria. Findings indicated significant improvement holds up to two months after the implementation of the program.
And thus, the following could be recommended:
1. Recommendations to the community:
• Mass media awareness campaigns to educate the public about mental health. This could be through key figures like sportsmen, actors, and other social media influencers. These key persons could also help by fund-raising activities, creating events, and donations from volunteers to support sustainable programs already established by NGOs (e.g. Hotline or online support groups). Internet videos, films, or television serials should also focus on presenting positive views about psychiatrists and mental illness and illustrate appropriate behaviors in terms of dealing with mentally ill patients, and their caregivers.
• It is vital to take concerted actions across different sectors to ensure the provision of educative and preventive services as well as necessary non-stigmatizing services to meet the needs of the patients and their caregivers.
• from a cross-cultural perspective, further research must be conducted to test if differences in the percentages of stigma are better explained as cultural differences or as poor situations that require prevention.
• Awareness sessions in secondary schools, and universities for students targeting adolescents for early detection and hence early intervention to decrease the myths around mental illness. Younger generations could be targeted by cartoons or mobile apps.
• Establishment of a psychoeducation unit to offer the program. This could be affiliated to every mental healthcare unit in the private & public sectors in order to overcome the geographical barrier.
2. Recommendations to healthcare providers:
• Clinicians, who manage patients with mental illness, must not overlook the care of the psychological needs of caregivers, by focusing only on patients. They have to:
Request, recognize, and respect the caregivers’ role, expertise, and voluntarism.
Anticipate the caregiving distress and anxiety. Screening for stigma would help to identify those who suffer at an early stage.
Provide caregivers with advice and knowledge: timely, clearly, appropriately, and accurately (e.g. orally, and/or written). The healthcare professionals should take the bio-psychosocial considerations of the patient and the caregiver into account without general assumptions. It would be better to start the psychoeducation program for all caregivers at an early stage.
Evaluate the caregivers’ mental state from time to time, and treat any morbidity as fast as possible. This could be achieved by active listening, without bias or prejudice, while ensuring confidentiality.
Training of volunteers, who are successfully coping caregivers, to join the efforts to aid other caregivers.
• Training of Primary healthcare physicians, nurses & social workers would reduce stigma among healthcare professionals.
• Reactivation of family mental health services.
• Focus groups for female caregivers for patients with mental illness (e.g. health club).
• Training of healthcare providers to provide the program.
• Program to be repeated in other healthcare centers.
• It would be advised to deliver a booster session once every 3 months to maintain the long-term effect of the program continuously.
• Future research should consider:
Oversampling of male caregivers in order to study the potential effects of gender on stigma, in larger sample sizes.
Replicating the program in other healthcare settings.
3. Recommendations to the patients and the caregivers:
• Active involvement in the development and approving the patient’s care plan as well as the discharge plan. The care plan should be reviewed regularly. Enlisting sources of help and services which could provide continuous support in ordinary times and crises.
• Participation in smoking cessation programs