FACTORS CONTRIBUTING TO RELAPSE AMONG MENTAL PATIENTS IN BUGIRI HOSPITAL DISTRICT

ABSTRUCT

Mental relapse means to “become ill again after apparent recovery; the return of ill health after an apparent or partial recovery”.  The study sought to establish the factors contributing to relapse among mental patients and the objectives were; to identify the Risk factors contributing to relapse among the mental patients in, to establish the Protective factors that prevent relapse among mental patients and to identify strategies that mental health nurses can use to reduce or prevent relapse among mental patients in Bugiri Hospital.

Cross sectional survey design was used and included all different categories of respondent like health workers at the hospital, mental patient caretakers and the study employed both qualitative and quantitative approaches to analyze the findings. The study was conducted at Bugiri Hospital in Bugiri district Uganda.

The results indicated that majority 21 (70%) of the respondents strongly agreed that abuse of drugs puts a mental patient at risk of relapse 18 (60%) strongly agreed that the history of previous readmissions while 16(53%) agreed that refusing to take treatment on regular basis can cause relapse. Majority of respondents  17 (56.7%) strongly agreed that support from family members and medication supervision protects mental patients from relapsing. Majority of respondents 18 (70%) strongly agreed that it’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms

The study concluded that perceptions of patients with mental illness and their caregivers about risk factors that mostly influence relapse were high. On one hand, the presence of poor drug adherence due to medication side effects, poor family support, stressful life events and substance use appear to be the factors mostly likely to increase the risk of relapse. On the other hand, family support, adherence to antipsychotic medication, employment and religion appear to protect patients from relapse.

COPY RIGHT

Copyright © (2017) Babirye Petra

AUTHORIZATION

RULES GOVERNING USE OF STUDENT’S WRITTEN WORK FROM PUBLIC HEALTH NURSES COLLEGE

Unpublished research report submitted to Public Health Nurses College, Kyambogo are deposited in the library, are open to inspection but are to be used with regard to the rights of the authors. The author and the school of nursing grant privilege of loan or purchase of microfilm or photocopy to accredited borrowers provided credit is given in subsequent written or published work.

Babirye Petra

Author Sign………………………….                       Date……………………………..

Bugiri district

Ms. Nagami Achan Suzan

Supervisor Sign.…………………                              Date: ……………………………

Public Health Nurses College

Kasujja Lwanga Gertrude (Mrs)

Principal’s Sign …………………                             Date: ……………………………

Public Health Nurses College, Kyambogo

DEDICATION

I dedicate this research report to my parents Mr & Mrs. Isabirye John Francis my sister and brothers. I thank you all.

ACKNOWLEDGEMENT

I appreciate the almighty God for enabling me to accomplish this research report

I would also like to recognize my supervisor Ms. Nagami Achan Suzan for guidance and direction.

My sincere gratitude goes to the administration of Bugiri hospital for accepting me to curry out my study at their facility. I will forever be grateful.

I would also like to recognize the combined efforts of my parents Mr. & Mrs Isabirye and to everyone whose support deserves mentioning for tireless efforts accorded to me during this course may the almighty God reword you abundantly.

TABLE OF CONTENTS

ABSTRUCT.. ii

COPY RIGHT.. iv

AUTHORIZATION.. v

DEDICATION.. vi

ACKNOWLEDGEMENT.. vii

TABLE OF CONTENTS. viii

LIST OF TABLES. xii

LIST OF FIGURES. xiii

LIST OF ACRONYMS. xiv

OPERATIONAL DEFINITIONS. xv

CHAPTER ONE: INTRODUCTION.. 1

1.1 Background of the Study. 1

1.2 Problem statement 2

1.3 purpose of the study. 3

1.4 Objectives of the study. 3

1.5 Research questions. 4

1.6 Justification. 4

CHAPTER TWO: LITERATURE REVIEW… 6

2.1 Introduction. 6

2.2 The Risk factors contributing to relapse among the mental patients. 6

2.3 The Protective factors that can prevent relapse among mental patients. 8

2.4 Strategies that mental health nurses can use to reduce or prevent relapse. 10

CHAPTER THREE: METHODOLOGY.. 13

3.1 Introduction. 13

3.2 Study design and rationale. 13

3.3 Study setting and rationale. 13

3.4 Study population. 14

3.4.1 Sample Size determination. 14

3.4.2 Sampling procedure. 14

3.4.3 Inclusion Criteria. 15

3.5 Definition of Variables. 15

3.6 Research Instrument 15

3.7 Data Collection Procedure. 16

3.7.1 Data Management 16

3.7.2 Data Analysis. 16

3.8 Ethical Consideration. 17

3.9 Limitations of the Study. 17

3.10 Dissemination of Results. 18

CHAPTER FOUR: RESULTS. 19

4.1 Introduction. 19

4.2 Socio-demographic Characteristics of the respondents. 19

4.3 The Risk factors for relapse among the mental patients. 21

4.4 Protective factors that can prevent relapse among mental patients. 26

4.5 Strategies that mental health nurses can use to reduce or prevent relapse. 30

CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS, RECOMMENDATION AND IMPLICATIONS TO NURSING PRACTICE.. 33

5.1 Introduction. 33

5.2 Discussion of results. 33

5.2.1 Risk factors contributing to relapse among the mental patients. 33

5.2.2 Protective factors that can prevent relapse among mental patients. 35

5.2.3 Strategies that mental health nurses can use to reduce or prevent relapse. 37

5.3 Conclusion. 39

5.4 Recommendation. 39

REFERENCES. 40

APPENDICES. 43

APPENDIX I: CONSENT FORM… 43

APPENDIX II:  QUESTIONNAIRE.. 44

APPENDIX III: INTRODUCTION LETTER.. 49

APPENDIX IV: MAP OF UGANDA SHOWING BUGIRI DISTRICT.. 50

LIST OF TABLES

Table 1 Showing Socio-demographic Characteristics of the respondents n=30. 19

Table 2 Showing Drug side effects that lead to nun adherence and relapse among mental patients. 22

Table 3 Showing the social factors that influence relapse among mental patients. 24

Table 4 Factors that can prevent relapse among mental patients. 27

Table 5 Family education on how to take care of a mental patient improves knowledge and promote improvement in patient symptoms. 30

Table 6 Promoting home visits by mental health nurses also prevents relapse. 30

Table 7 Mental patient education/teaching is also another strategy that Can prevent relapse among mental patients. 31

Table 8 it’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms. 32

LIST OF FIGURES

Figure 1 Showing whether abuse of drugs contributes to relapse. 21

Figure 2 Response on whether abusing drugs affects treatment and leads to relapse. 22

Figure 3 History of previous admissions influences relapse. 23

Figure 4 Showing whether refusing to take treatment on regular basis can cause relapse. 25

Figure 5 Showing whether Support from family promotes adherence. 26

Figure 6 Showing whether helping a patient adhere properly to the antipsychotic therapy can prevent relapse among mental patients. 28

Figure 7 Religion and spirituality can play an important part in recovery. 28

Figure 8 When a mental patient has a job and earns some income, they become independent which boosts their self-esteem and helps them recover quickly. 29

LIST OF ACRONYMS

MOH:             Ministry of Health

UBOS:            Uganda Bureau of Statistics

CBT:              Cognitive Behavioral Therapy

MDG:             Millennium Development Goals

WHO:             World health organization

OPERATIONAL DEFINITIONS

Mental relapse:     Relapse has been defined as a worsening of psychopathological symptoms or hospitalization in the year after hospital discharge.

Prevalence:           The percentage of a population that is affected with a particular

                                disease at a given time

Factors:                 A circumstance, fact, or influence that contributes to a result or

                                outcome; a number or quantity that when multiplied with

other produces a given number or expression

CHAPTER ONE

INTRODUCTION

This chapter presents the introduction, background of the study, problem statement, and purpose of the study, the Specific objectives, Research questions and Justification for the study.

1.1 Background of the Study

In the health profession, a relapse means to “become ill again after apparent recovery; the return of ill health after an apparent or partial recovery” (Pitschel-Walz, G., et al, 2015) defines relapse as “a worsening condition of a psychiatric outpatient”. Often, this is due to patients stopping medication on their own against the advice of a multi-disciplinary team.

According to, the World Federation for Mental Health & Eli, Lilly & Company, (2008), an international survey was done to shed light on experiences and insights of family caregivers of individuals with mental illness, bipolar disorders and schizoaffective disorder. Relapse was seen to have been a major concern for care givers because of its devastating consequences for family members of people living with mental illness. Bradley, J. C. (2016) further states that care givers from Australia, Canada, Germany, France, Italy, Spain, United Kingdom and United States participated in the survey. Of the 502 (51.12%) caregivers who said their family member stopped taking medication despite doctor’s advice, 91% claimed that this led to relapse for their family member. 838 (85.34%) caregivers said their family members experienced relapse. As a result of relapse their loved ones were unable to work (72%), were hospitalized (69%), attempted suicide (22%) and imprisoned (20%.)

A few studies regarding relapse by mental patients have been done in Sub-Saharan Africa. Studies done in South Africa have found that presence of a co-morbid depressed mood, poor adherence due to a lack of patient insight, and medication side-effects appear to be the factors most likely to increase the risk of a relapse (Velligan, D. I.,et al, 2017). Other factors that have been identified include: lack of social support, grief following the loss of a close family member, and lack of employment. Therefore this study intends to examine the factors influencing relapse among mental patients in Bugiri hospital in a bid to promote mental health and preventing relapse.

1.2 Problem statement

Globally the most common outcome of mental illness is a declining course with one or multiple relapses in 50-92% of cases (Sariah, A. E., et al (2014). Sariah found that the most common mental disorders among patients in primary health care (PHC) were depression (10%), anxiety disorders (8%) and alcohol abuse (3%). A major contributing factor in the relapse among psychiatric patients is non-compliance with treatment (Lanata, A., et al, 2015).

Despite the efforts carried out by the Uganda ministry of health through the national hospital’s Department of Psychiatry in availing antipsychotic drugs and operation of psycho wards in hospitals, they still about 150 patients with different psychiatric disorders per month: 15 (10%) of these are readmissions due to relapse in schizophrenia (Michel, M. 2014).

Relapse in mental health has a lot of effects to patients, care givers, the health sector and the country economy at large. Patients tend to deteriorate in their level of functioning with each relapse; hence their contribution to economic activities diminishes. Caregivers have to take care of the patient’s bills in the hospital once readmitted which becomes very costly. The health sector is imposed with a large burden and has to deal with the higher number of patients’ re-hospitalization.

1.3 purpose of the study

The purpose of the study was to explore factors contributing to relapse among mental patients in Bugiri Hospital in order to identify the gaps and find interventions required to overcome these challenges.

1.4 Objectives of the study

1. To identify the Risk factors contributing to relapse among the mental patients in Bugiri Hospital.
2. To establish the Protective factors that prevent relapse among mental patients in Bugiri Hospital.
3. To identify strategies that mental health nurses can use to reduce or prevent relapse in Bugiri Hospital.

1.5 Research questions

1. What risk factors contribute to relapse among mental patients in Bugiri Hospital.?
2. What protective factors can prevent relapse among mental patients in Bugiri Hospital.?
3. What strategies can mental health nurses use to prevent relapse among mental patients in Bugiri Hospital.?

1.6 Justification

In Uganda, there is so far limited published data regarding factors contributing to relapse among mental patients. Mental health care services are faced with a lot of challenges which in one way or another affects mental health service users. This is made worse by patient’s social and environmental factors that can exacerbate symptoms which eventually lead to relapse. This study would help policy maker to improve that situation.

This study is important because it would bring about insight and shine a light on the factors contributing to relapse among mental patients in the current context. These findings would provide a foundation for designing effective nursing interventions and help shape nurses’ perceptions and their understanding of patients’ concerns and experiences about mental relapse.

Knowledge of these factors would help mental health service providers to improve the standards of mental health care and interventions that are currently applied in caring for in-patients and outpatients with mental illness at Bugiri hospital setting and the whole country at large.

This study would set a foundation for future research on relapse in mental patients. Basing on evidence based practice, future research will enable, mental health service providers to identify new interventions for caring for mental patients and thus reduce their relapse rates.

This study has the potential to help influence health policy makers in improving mental health and reducing the burden of relapse, their families and community as a whole.

This study would help the researcher attain a diploma in midwifery at Public Health Nurses College.

CHAPTER TWO

LITERATURE REVIEW

• Introduction

This chapter highlights the literature review cited by other scholars about the factors influencing relapse among mental patients. The literature is presented in sequence of the specific objectives thus risk factors, protective factors and strategies that mental nurses can use to prevent mental relapse.

2.2 The Risk factors contributing to relapse among the mental patients

Mental  patients all over the world  usually present a partial or complete inability to follow their maintenance therapy, which causes an increased risk of exacerbations and relapses, more visits to mental health centers (if available), frequent hospitalizations, and suicide attempts. Compliance with treatment is made more difficult when certain characteristics exist, such as lack of insight, cognitive deterioration, paranoid ideations, and the absence of familial or social support (Gutiérrez-Casares, et al, 2010).

According to Sariah, A. E.et al, (2014), noncompliance to antipsychotics was demonstrated to be an important factor that resulted in relapse among several patients. Previous studies have also found that non adherence appears to be one of the factors most likely to increase the risk of relapse in schizophrenic patients.

Bruni, A. (2014) laments that medication noncompliance and under-compliance continues to be a problem in the treatment of schizophrenia in the United States and Canada; the vast majority of hospital admissions for exacerbation of psychosis have been linked to noncompliance. In Germany it has been found that patients who tend to experience a relapse are less likely to have a positive attitude toward treatment adherence.

A history of previous admissions has been found to be associated with relapse and multiple psychiatric readmissions. Silva et al. (2009) in their case control study found that patients with a greater number of previous admissions were more likely to relapse and hence experience multiple admissions.

Mental Patients are more sensitive and more susceptible to the negative effects of even minor stressors. A study in Nigeria found that these stressors included lack of employment (17%), grief following loss of a close family member (20%), and lack of social support (20%). Others involved chronic interpersonal stress, stigma, poverty homelessness and criminal victimization (Kazadi et al., 2008).

Chabungbam, et al, (2007) found that mental patients who experience a higher number of life events during the previous 6 months are more likely to relapse. These life events include number of psychotic episodes, unemployment, psychological stress and inappropriate treatment.

Drug misuse is an important clinical problem associated with a poorer outcome in patients who have a diagnosis of mental illness. Seventeen people in Manchester, England with a diagnosis of mental illness and who had used street drugs were interviewed and asked to describe, in narrative form, their street drug use from their early experiences to the present day. Grounded theory was used to analyze the transcripts (Asher & Gask, 2010).

Most drugs available in the Psychiatric Unit are typical antipsychotics which have a lot of extrapyramidal side effects. These side effects have been found to be a reason why patients do not adhere to antipsychotic medication (Lanata, A., et al, 2015). Atypical antipsychotics with lesser extrapyramidal side effects are usually not available; hence patients have to buy the drugs for themselves.

Mental relapse is a major factor in generating high hospitalization rates and costs (Almond et al., 2009). Relapse among patients with schizophrenia is associated with substantial direct mental health costs that extend beyond the cost of hospitalization to other costly outpatient services and medication costs (Ascher-Svanum, et al 2010).

2.3 The Protective factors that can prevent relapse among mental patients

Koutra, K., et al, (2015), states the Importance has been given to the family environment as a contributing factor to the relapse or rehabilitation of the mental patient. The family is an important factor which affects the patient’s mental well-being and outcome. Support from family promotes adherence in patients with mental illness which aids recovery. The kinds of support they provide to clients include medication, supervision, monitoring the drug intake and taking the patients to mental health facilities regularly.

Ellison, N. et al 2014) stated in his study that  family support networks were reported as strong by more than half of the participants in this study. Patients were very grateful for the support they received from their care givers during their illness episodes, when attending the clinic for follow up visits, encouragement and supervision when taking their medication and in fulfillment of other basic needs of life like education, employment, and health in general.

These results are in agreement with a study of 121 patients and their family members in Japan which found that more than 70% of the families replied that they ‘often’ or ‘sometimes’ supported the patients in mental health management and daily living such as ‘observation of the condition’ and ‘taking drugs (Bowling, A., 2014)

Antipsychotic medication compliance was expressed by patients and their care givers to be a strong protector of relapse (Sariah, A. E., et al, 2014). It was found that the relapse risk was substantially lower when a patient was adhering properly to the antipsychotic therapy. Improvement in symptoms and the recognition of this improvement by patients may have led to improvement in their attitude to medication. Some patients reported fewer antipsychotic drug side effects than others.

Iseselo, M. K et al, (2017), said that Religion was also indicated by three patients and their caregivers to have beneficial impacts in the course of their mental illness. They added that religion, including singing in church choir, creates a sense of belonging, enables them to deal with difficult situations and gives them the strength to move on despite their mental conditions.

Zhou, Y., et al,  (2017), in their study also found that when mental patients have a job to earn income they become independent. This boosts their self-esteem and helps them feel that they can contribute something to the family or society. The importance of having meaningful employment has been emphasized in reflecting patients’ needs to reach personal goals, hopes, and aspirations, as important components of well-being.

2.4 Strategies that mental health nurses can use to reduce or prevent relapse

Family education on schizophrenia has been shown to improve knowledge and promote improvement in patient symptoms. In a randomized controlled trial in China, 101 people with schizophrenia and their families were educated about schizophrenia and followed up. Nine months after discharge the relapse rate of the experimental group (16%) was lower than that of the control group (37%) (Caqueo-Urízar, et al 2015).

Another randomized controlled trial in England, Kinderman, et al., (2014) after 18 months of follow up of patients with first episode and early mental patient found that, patients receiving either cognitive behavioural therapy (CBT) or supportive counseling in combination with the usual treatment had better symptom recovery. This the study found no significant reduction in relapse compared with those who received the usual treatment alone.

Relapse prevention is a major challenge in the care of patients with schizophrenia which has a more deteriorating course of mental illness. A better understanding of factors influencing relapse is needed. Such knowledge can help mental health care providers, to set priorities and make appropriate interventions to patients and their families in relapse prevention and mental health promotion after hospital discharge. Given the gap in knowledge, the objective of this study is to explore factors influencing relapse among patients with schizophrenia in Tanzania Sariah, A. E.et al, (2014).

According to Srivastava, S., et al, (2014), mental patients and their caregivers emphasized the importance of home visits by mental health nurses. They urged that regular visits would enable them to receive psycho education on patient management, drug adherence and side effects.

According to Nguyen, P. H. (2016), regular psycho-education programs must be conducted in the community to educate the families about the nature of their relative’s illness and the need for sustained medical treatment. Community visits have been shown to help patients deal with their symptoms, promote relaxation, and help clients take medication regularly, improve client’s self-care abilities and improve interactions between clients and families.

Grey, M., et al (2013), emphasizes the purpose of mental patient education/teaching (or psycho education) which is to increase patients’ knowledge and understanding of their illness and treatment. It is supposed that increased knowledge enables patients with schizophrenia to cope more effectively with their illness.

Toohill, J., et al, 2014) in their study revealed that  Caregivers suggested the importance of educating families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms.

CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter  presents the methodology which includes the study design and rationale, study setting and rationale, study population, sample size determination, sampling procedure inclusive criteria, definition of variables, research instruments, data collection procedure, data management data analysis, ethical consideration, limitation of the study and dissemination of results.

3.2 Study design and rationale

The study design was a cross sectional and descriptive, employed both quantitative and qualitative data collection methods. This design was selected because it would save time resources.

3.3 Study setting and rationale

The study was conducted at Bugiri Hospital in Bugiri district which is approximately 150 km from Kampala Uganda’s Capital. It has a population estimated at 426,800 people as per 2012 national census. It is bordered by Namutumba District and Butaleja District to the north, Tororo District to the northeast, Busia District to the east, Namayingo District to the southeast, Mayuge District to the southwest and Iganga District to the west. The major means of transport is taxi and boda boda to Bugiri hospital. It offers the following services to its clients: HAART services; ANC, PNC, OPD, Nutrition, Deliveries, Immunization services, Family Planning, cervical cancer screening, radiography services and many others. The study area is the best selection because of the convenience of this area and it is where the researchers’ workplace.

3.4 Study population

The study targeted health workers at the hospital, mental patient caretakers in Bugiri Hospital in Bugiri district Uganda.

3.4.1 Sample Size determination

A sample size of 30 respondents who were health workers at the hospital and mental health patient caretakers at Bugiri Hospital. This is because this is the number acceptable by Uganda Nurses and Midwives Examination Board (UNMEB) as the minimum standard number.

3.4.2 Sampling procedure

The researcher used purposive sampling procedure to get the required respondents for the study. In this procedure, the researcher simply selected respondent whom she thought would provide the necessary information pertaining the study. She also asked the selected respondents to voluntarily participate in the study.

3.4.3 Inclusion Criteria

The study included nurses, doctors working at Bugiri Hospital and relatives / caretakers of mental patient.

3.5 Definition of Variables

Variable is an item or feature that the researcher would like to look at or study during the research study.

The research included both dependent and independent Variables

The dependent variables:

These are the social economic and cultural factors, Knowledge and attitude of caretakers and relatives associated with taking care of mental patients.

The independent variables:

These are variables that don’t depend on the other properties e.g. The relapse among mental patients.

3.6 Research Instrument

The researcher used semi structured questionnaires to collect data from the respondents which consisted of both open and closed ended questions and was written in English for the educated respondents. The researcher sought the services of an interpreter to interpret for those who don’t understand English. This study tools was be pretested first on 5 people of similar setting but outside the study area to prove their accuracy and reliability. The questions will be based on the research questions in the study.

3.7 Data Collection Procedure

After the approval of the research proposal by the supervisor, an introduction latter was obtained from PHNC that the researcher presented to the medical superintendent of Bugiri Hospital seeking permission to carry out the study.

The researcher administered the self-administered questionnaires to respondents in the mental clinic where they get these services. This was done to increase efficiency and privacy during data collection.

3.7.1 Data Management

Data management included data editing before leaving the area of study to ensure that there are no mistakes or areas left blank. Any mistakes found were corrected before leaving the area of study. Filled up questionnaires were put in an envelope stored under lock and key only accessed by the researcher to avoid loss of information and to keep the respondents’ confidentiality. The results were stored on a flash disc for easy retrieval.

3.7.2 Data Analysis

The study data was analyzed manually for completion of questionnaire edited and after the it was transferred to Microsoft Excel 2010 for the graphical presentation of results and was presented in both figures and tables.

3.8 Ethical Consideration

A letter of introduction was obtained from Public Health Nurses College, introducing the researcher to the administration of Bugiri Hospital, Bugiri District seeking permission to carry out the study. After permission was granted, the Health Centre administrator introduced the researcher to the in charge who introduced her to the respondents. The study commenced after the objectives of the study had been clearly and well explained to participants and when they understood and voluntarily consented to participate in the study. Respondents were assured of maximum confidentiality of all the information they give.

3.9 Limitations of the Study

The limitations faced were from the respondents who might not be co-operative and some might find hardship in answering the questionnaire. In addition some caretakers might  fear to share their views and in this case respondents were reassured of the confidentiality and the researcher explained to them the purpose and future benefits of the study which she believes convinced them to respond positively.

The researcher also faced a challenge lack of enough resources in terms of finance and human resource to help in transport, logistics and distribution of the questionnaires to health workers and mental patient caretakers and in this case the researcher’s budget lobbied for funds for relatives and some from her salary to cater for this challenge.

Lack of enough time to interview all the respondents, but the researcher followed her work plan properly

3.10 Dissemination of Results

The result of the study were compiled and three copies produced one for Bugiri Hospital another for PHNC and another for Uganda Nurses and midwives Examinations Board. The researcher also got a copy for future reference.

CHAPTER FOUR

RESULTS

4.1 Introduction

This chapter presents and describes the study results using tables, figures and text data was collected from 30 respondents using a questionnaire

4.2 Socio-demographic Characteristics of the respondents

Table 1 Showing Socio-demographic Characteristics of the respondents

According to the findings in the table above, most 16 (53.3%) of the respondents were females and minority 14 (44.7%) were males.

Half of the respondents 15 (50%) said the clients were their children while the least of them 2 (6.7%) said the clients were their spouses.

The study from table above indicates that majority of the respondents 21 (70%) were from rural area while minority 6 (20%) were from urban areas.

According to the table above, more than a third majority 13 (43.3%) of the respondents were in the age bracket of 26-35 years of age the least 2 (6.7 %) who were above 45 years

The findings from the table above indicates that majority 18 (60%) were Christians, while least (3.3%) of them mentioned other religion.

According to the table above, more than half of the respondents 16 (53.3%) had attended secondary school while minority 2 (6.7) had attended tertiary education

The table above further reveals that majority of the respondents 17(56.7%) were peasant farmers while minority 2 (6.7) had sheltered employment.

4.3 The Risk factors for relapse among the mental patients

Figure 1 Showing whether abuse of drugs contributes to relapse

(n=30)

The findings in the figure above show that nearly thirds of the respondents 21 (70%) strongly agreed that abuse of drugs puts a mental patient at risk of relapse while minority 2 (6.7%) disagreed.

Figure 2 Response on whether abusing drugs affects treatment and leads to relapse                                                                           (n=30)

The findings in the table above revealed that most of the respondents 27 (90%) strongly agreed that abuse of drugs by a mental patient affects their adherence to tretment hence relapse while a minority 3 (10%) disagreed.

Table 2 Showing Drug side effects that lead to nun adherence and relapse among mental patients                                                                                       (n=30)

The results in the table above indicate that half of the respondents 15 (50%) strongly agreed that drug side effects like  Dry mouth, Tremors, Fatness, Stiffness and Fatness lead to nun adherence and relapse among mental patients while 3 (10%) disagreed.

Figure 3 History of previous admissions influences relapse

(n=30)

The findings in the table above revealed that majority of respondents 18 (60%) strongly agreed that the history of previous readmissions influences relapse among mental patients while minority 12 (40%) disagreed.

Table 3 Showing the social factors that influence relapse among mental patients.

The table above shows that majority of the respondents 18 (60%) strongly agreed that Lack of employment can influence relapse among mental patients, 21 (70%) the said Grief following loss of a close family member 27 (90%) showed lack of social support, 22 (73.3%) mentioned stigma and 18 (60%) said homelessness and criminal victimization cause relapse among mental patients.

Figure 4 Showing whether refusing to take treatment on regular basis can cause relapse                                                                                           (n=30)

According to the findings in the figure above, majority of respondents strongly 16 (53%) agreed that refusing to take treatment on regular basis can cause relapse while 2 (7%) strongly disagreed.

4.4 Protective factors that can prevent relapse among mental patients

Figure 5 Showing whether Support from family promotes adherence

(n=30)

According to the findings in the table above, majority of respondents  17 (56.7%) strongly agreed that support from family members promotes adherence while minority 4 (13.3%) Disagreed.

Table 4 Factors that can prevent relapse among mental patients

(n=30)

The table above revealed that majority of respondents 17 (56.7%) strongly agreed that medication supervision can prevent relapse among mental patients, 18 (60) said monitoring the drug intake and 21 (70%) said taking the patients to mental health facilities regularly prevents their relapse.

Figure 6 Showing whether helping a patient adhere properly to the antipsychotic therapy can prevent relapse among mental patients                                (n=30)

The results in the pie chart above indicate that majority of respondents 22 (73.3%) strongly agreed and agreed that helping a patient adhere properly to the antipsychotic therapy can prevent relapse among mental patients while minority 8 (27%) disagreed

Figure 7 Religion and spirituality can play an important part in recovery

(n=30)

The findings in the figure above revealed that most respondents 16 (53.3%) strongly agreed that Religion and spirituality can play an important part in recovery while minority 14 (47%) disagreed.

Figure 8 When a mental patient has a job and earns some income, they become independent which boosts their self-esteem and helps them recover quickly

(n=30)

Most of the respondents 20 (66.7%) strongly agreed that When a mental patient has a job and earns some income, they become independent which boosts their self-esteem and helps them recover quickly while minority 1 (3.3%) were uncertain.

4.5 Strategies that mental health nurses can use to reduce or prevent relapse

Table 5 Showing whether family education on how to take care of a mental patient improves knowledge and helps mentally ill patients.

The findings in the table above shows that majority of respondents 17 (56.7%) strongly agreed that educating families on how to take care of mental patients improves knowledge and promotes improvement in patient symptoms while minority 1 (3.3%) were uncertain.

Table 6 Promoting home visits by mental health nurses also prevents relapse

The table above reveals that most respondents 17 (56.7) strongly agreed that Promoting home visits by mental health nurses also prevents relapse while minority 12 (40%) disagreed

Table 7 Mental patient education/teaching is also another strategy that can prevent relapse among mental patients                                                          (n=30)

The results in the table above indicate that most respondents 21 (70%) strongly agreed that Mental patient education/teaching is also another strategy that Can prevent relapse among mental patients while minority 9 (30%) disagreed.

It’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms

Table 8 it’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms                                                                                                 (n=30)

The results in the table above indicate that majority of respondents 18 (70%) strongly agree that it’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms while minority 9 (30%) said that its.

CHAPTER FIVE

DISCUSSIONS, CONCLUSIONS, RECOMMENDATION AND IMPLICATIONS TO NURSING PRACTICE

5.1 Introduction

This chapter presents the discussions, conclusions, recommendations of the study and implication to the nursing practice.

5.2 Discussion of results

5.2.1 Risk factors contributing to relapse among the mental patients.

The findings of the study revealed that nearly thirds of the respondents 21 (70%) strongly agreed that abuse of drugs puts a mental patient at risk of relapse while minority 2 (6.7%) disagreed which is in correspondence with Toohill, J., et al, (2014) who revealed in their study that  substance abuse  leads to mental relapse among mental patients. He further adds that   mental patients already possess weaknesses therefore adding drugs is most like to cause relapse

According to the results in the study half of the respondents 15 (50%) strongly agreed that drug side effects like  Dry mouth, Tremors, Fatness, Stiffness and Fatness lead to nun adherence and relapse among mental patients while 3 (10%) disagreed. This is in correspondence with antipsychotic drugs such as Olanzepine are among patients who were adherent to medications. This is consistent with a study which found that fewer side effects, as well as the effectiveness of atypical antipsychotic drugs in managing psychotic symptoms, make it more likely that persons will continue their treatment. Thus, the choice of antipsychotic drug affects adherence.

The findings further revealed that majority of respondents 18 (60%) strongly agreed that the history of previous readmissions influences relapse among mental patients while minority 12 (40%) disagreed. This is similar to Silva et al. (2009) in their case control study found that patients with a greater number of previous admissions were more likely to relapse and hence experience multiple admissions. A history of previous admissions has been found to be associated with relapse and multiple psychiatric readmissions.

The table above shows that majority of the respondents 18 (60%) strongly agreed that Lack of employment can influence relapse among mental patients, 21 (70%) the said Grief following loss of a close family member 27 (90%) showed lack of social support, 22 (73.3%) mentioned stigma and 18 (60%) said homelessness and criminal victimization cause relapse among mental patients. This is in line with Mental Patients are more sensitive and more susceptible to the negative effects of even minor stressors. A study in Nigeria found that these stressors included lack of employment (17%), grief following loss of a close family member (20%), and lack of social support (20%). Others involved chronic interpersonal stress, stigma, poverty homelessness and criminal victimization (Kazadi et al., 2008).Stressful life events are often associated with the onset of a psychotic relapse, usually in the 3 weeks prior the relapse (Kazadi et al., 2008)

According to the findings in the figure above, majority of respondents strongly 16(53%) agreed that refusing to take treatment on regular basis can cause relapse while 2 (7%) strongly disagreed as stated by Sariah, A.et al, (2014), that taking medication daily is a burden for these individuals, which is made worse by the side effects of these drugs. In an effort to get rid of these discomforts, individuals stop taking their regular medication which in turn causes them to experience relapse. Providing education with emphasis on the importance of medication would help these individuals to be responsible of the medication management process

5.2.2 Protective factors that can prevent relapse among mental patients

According to the findings in the study, majority of respondents  17 (56.7%) strongly agreed that support from family members promotes adherence while minority 4 (13.3%) Disagreed. This is similar to the study conducted by Koutra, K., et al, (2015), who stateded stated that the Importance has been given to the family environment as a contributing factor to the relapse or rehabilitation of the mental patient. The family is an important factor which affects the patient’s mental well-being and outcome.

Similarly, the results of the study majority of respondents 17 (56.7%) strongly agreed that medication supervision can prevent relapse among mental patients, 18 (60) said monitoring the drug intake and 21 (70%) said taking the patients to mental health facilities regularly prevents their relapse which is in line with Koutra, K., et al, (2015) who stated that support from family promotes adherence in patients with mental illness which aids recovery. The kinds of support they provide to clients include medication, supervision, monitoring the drug intake and taking the patients to mental health facilities regularly.

The study also revealed that majority of respondents 22(73.3%) strongly agreed and agreed that helping a patient adhere properly to the antipsychotic therapy can prevent relapse among mental patients while minority 8 (27%) disagreed. These results are in agreement with Bowling, A., (2014) in his study revealed in a study of 121 patients and their family members in Japan which found that more than 70% of the families replied that they ‘often’ or ‘sometimes’ supported the patients in mental health management and daily living such as ‘observation of the condition’ and ‘taking drugs.

The findings in the figure above revealed that most respondents 16/ (53.3%) strongly agreed that Religion and spirituality can play an important part in recovery while minority 14 (47%) disagreed. This is in correspondence with Iseselo, M. K et al, (2017), who said that religion and spirituality can play an important part in recovery. Religious activities have been shown to be helpful in dealing with psychiatric symptoms. Individuals with mental illness who experience greater symptom severity and lower overall functioning engage more in religious activities as part of coping with mental problems which enhances recovery.

Most of the respondents strongly agreed that When a mental patient has a job and earns some income, they become independent which boosts their self-esteem and helps them recover quickly while minority 1 (3.3%) were uncertain. This finding concedes with  Zhou, Y., et al, (2017), in their study also found that when mental patients have a job to earn income they become independent. This boosts their self-esteem and helps them feel that they can contribute something to the family or society

5.2.3 Strategies that mental health nurses can use to reduce or prevent relapse

Majority of respondents 17 (56.7%) strongly agreed that educating families on how to take care of mental patients improves knowledge and promotes improvement in patient symptoms while minority 1 (3.3%) were uncertain. This is also in line with Toohill, J., et al, 2014) in their study revealed that  Caregivers suggested the importance of educating families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms.

The finding further reveals that most respondents 17 (56.7) strongly agreed that Promoting home visits by mental health nurses also prevents relapse while minority 12 ( 40%) disagreed which finding is seconded by Srivastava, S., et al, (2014), who suggested in his study that  mental patients and their caregivers emphasized the importance of home visits by mental health nurses. They urged that regular visits would enable them to receive psycho education on patient management, drug adherence and side effects.

The finding from this study revealed that majority of respondents 18 (70%) strongly agree that it’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms while minority 9 (30%) said that its.  This is in line with Srivastava, S., et al, (2014) who said that it’s important to educate the families about the nature of their relative’s mental condition and the need for sustained medical treatment. Community visits have been shown to help patients deal with their symptoms, promote relaxation, and help clients take medication regularly, improve client’s self-care abilities and improve interactions between clients and families.

The results of the study revealed that most respondents 21 (70%) strongly agreed that Mental patient education/teaching is also another strategy that Can prevent relapse among mental patients while minority 9 (30%) disagreed. This is in line with Grey, M., et al (2013), who emphasizes the purpose of mental patient education/teaching (or psycho education) which is to increase patients’ knowledge and understanding of their illness and treatment. It is supposed that increased knowledge enables patients with schizophrenia to cope more effectively with their illness. Patients were concerned that medications only would not reduce the problem of relapse. They urged mental health nurses to also provide more counseling and psycho education sessions which would help improve their condition. Patients who understand their illness, medications, and treatment expectations consistently demonstrate better adherence

5.3 Conclusion

This study highlighted the perceptions of patients with mental illness and their caregivers about risk factors that mostly influence relapse. On one hand, the presence of poor drug adherence due to medication side effects, poor family support, stressful life events and substance use appear to be the factors mostly likely to increase the risk of relapse. On the other hand, family support, adherence to antipsychotic medication, employment and religion appear to protect patients from relapse. In addition, psychoeducation, community home visits and good nurse-patient, psychiatrist-patient therapeutic relationships were emphasized to help reduce relapse.

5.4 Recommendation

The study recommends that Management of patients with schizophrenia can be improved by addressing the factors influencing relapse as highlighted in this study. The findings call for improvement in mental health care service delivery to patients with mental health problems. It is important that mental health nurses strengthen their therapeutic relationships with patients and their caregivers. This enables patients and their caregivers to express their needs and concerns to the nurse, and the nurse to plan proper interventions in caring for the patient; meanwhile working with other mental health professionals as a team.

REFERENCES

Bowling, A. (2014). Research methods in health: investigating health and health services. McGraw-Hill Education (UK).

Grey, M., Whittemore, R., Jeon, S., Murphy, K., Faulkner, M. S., Delamater, A., & TeenCope Study Group. (2013). Internet psycho-education programs improve outcomes in youth with type 1 diabetes. Diabetes Care, 36(9), 2475-2482.

Iseselo, M. K., & Ambikile, J. S. (2017). Medication challenges for patients with severe mental illness: experience and views of patients, caregivers and mental health care workers in Dar es Salaam, Tanzania. International Journal of Mental Health Systems, 11(1), 17.

Koutra, K., Triliva, S., Roumeliotaki, T., Basta, M., Simos, P., Lionis, C., & Vgontzas, A. N. (2015). Impaired family functioning in psychosis and its relevance to relapse: a two-year follow-up study. Comprehensive psychiatry, 62, 1-12.

Sariah, A. E., Outwater, A. H., & Malima, K. I. (2014). Risk and protective factors for relapse among individuals with schizophrenia: a qualitative study in Dar es Salaam, Tanzania. BMC psychiatry, 14(1), 240.

Srivastava, S., Sharma, I., & Bhatia, M. S. (2014). Home Past Issues About IP About IAP Author Information Subscription Advertisement Search. Indian Pediatr, 51, 991-995.

Sundsted, K. K., Mohabbat, A. B., Regan, D. W., Salonen, B. R., Daniels, P. R., & Mauck, K. F. (2016). Update in perioperative medicine: practice-changing evidence published in 2015. Hospital Practice, 44(3), 157-163.

Toohill, J., Fenwick, J., Gamble, J., Creedy, D. K., Buist, A., Turkstra, E., & Ryding, E. L. (2014). A Randomized Controlled Trial of a Psycho‐Education Intervention by Midwives in Reducing Childbirth Fear in Pregnant Women. Birth, 41(4), 384-394.

Velligan, D. I., Sajatovic, M., Hatch, A., Kramata, P., & Docherty, J. P. (2017). Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient preference and adherence, 11, 449.

Zhou, Y., Rosenheck, R., Mohamed, S., Ning, Y., & He, H. (2017). Factors associated with complete discontinuation of medication among patients with schizophrenia in the year after hospital discharge. Psychiatry Research, 250, 129-135.

Bradley, J. C. (2016). The Psychopharmacological Treatment of Individuals at Risk of Recurrent Suicidal Behavior. The Oxford Handbook of Behavioral Emergencies and Crises, 449.

Michel, M. (2014). Adherence and Treatment Outcomes among Patients with Comorbidity of Depression and Other Mental Disorders attending Psychiatric Hospitals in Rwanda (Doctoral dissertation, Kenyatta University).

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Caqueo-Urízar, A., Rus-Calafell, M., Urzúa, A., Escudero, J., & Gutiérrez-Maldonado, J. (2015). The role of family therapy in the management of schizophrenia: challenges and solutions. Neuropsychiatric disease and treatment, 11, 145.

Nguyen, P. H. (2016). A psychoeducation and supportive program for Vietnamese caregivers of relatives with severe mental illnesses: A grant proposal. California State University, Long Beach.

APPENDICES

APPENDIX I: CONSENT FORM

STATEMENT O F CONSENT

I am Babirye Petra, a student from public health nurses’ college Kyambogo carrying a research on the factors contributing to relapse among mental patients in Bugiri Hospital. This research study is for the fulfilment of requirements of a Diploma in Midwifery.

I’m kindly requesting for your consent to participate in this study. Information obtained from the study will be treated with confidence and no one else besides the investigator will have access to it, except for research purposes. Codes will be used instead of names to ensure confidentiality and protection of participants. The questionnaire will last approximately 20 minutes and you are free to withdraw from the study at any time or decline to participate in this study and your decision will be taken in to consideration without dispute. The questionnaire includes questions on personal information, Risk factors contributing to relapse among the mental patients, Protective factors that prevent relapse among mental patients and strategies that mental health nurses can use to reduce or prevent relapse in Bugiri Hospital. For any questions pertaining to this study, you can contact me during the week on telephone 0785908851.

I have read (or this consent form has been read to me) and I have understood this consent form and voluntarily consent to participate in this study.

Respondent’s signature…………………………………….. Date……………………….

Investigators’ signature……………………………………. Date………………………………

APPENDIX II:  QUESTIONNAIRE

SECTION 1: DEMOGRAPHIC DATA OF THE RESPONDENTS 

(This section relates to information about you). [Tick    the most appropriate answers]

1. Gender

Male

Female

2. Relationship to client
3. Parent
4. Guardian
5. Relative
6. Child
7. Spouse
8. Home
9. Rural
10. Urban
11. Informal settlement
12. How old are you?
13. 18 to 25 years
14. 26 to 35 years
15. 36 to 45 years
16. 45 years and above
17. What is your marital status?
18. Single
19. Married
20. Divorce
21. Widowed
22. Separated
23. Religion
24. Christianity
25. Traditional
26. Muslims
27. Apostolic Faith
28. Others (specify) ………………………………………………………………
29. Level of education
30. None
31. Primary
32. Secondary
33. Tertiary
34. Source of income?
35. Formal Employment
36. Sheltered employment
37. Disability grant
38. Market vending
39. Peasant farmer

SECTION 2

The statements below refer to Risk factors contributing to relapse among the mental patients. Please evaluate each statement by using the following keys:

1 = SA (Strongly agree)

2 = AG (Agree)

3 = UC (Uncertain)

4 = DA (Disagree)

5 = SD (Strongly disagree)

Place a tick √ under the relevant answer.

The Risk factors for relapse among the mental patients

9. Abusing drugs contributes to relapse
10. Abusing drugs affects treatment hence relapse
11. the following drug side effects affects adherence hence relapse:

• Dry mouth
• Tremors
• Fatness
• Stiffness

12. signs and symptoms causes non adherence
13. History of previous admissions influences relapse
14. The following social factors also contribute to relapse among mental patients

• Lack of employment
• Grief following loss of a close family member
• Lack of social support
• Stigma
• Homelessness and criminal victimization

15. He always refuses to take treatment on regular basis

SECTION 3

The statements below refer to Protective factors that can prevent relapse among mental patients. Please evaluate each statement by using the following keys:

1 = SA (Strongly agree)

2 = AG (Agree)

3 = UC (Uncertain)

4 = DA (Disagree)

5 = SD (Strongly disagree)

Place a tick √ under the relevant answer.

16. Support from family promotes adherence
17. The following support activities prevents relapse among mentally ill patients

• Medication supervision,
• Monitoring the drug intake
• Taking the patients to mental health facilities regularly

18. Helping the patient adhere properly to the antipsychotic therapy prevents relapse

19. Religion and spirituality can play an important part in recovery
20. When a mental patient has a job and earns some income, they become independent which boosts their self-esteem and helps them recover quickly.

SECTION 4

The statements below refer to Strategies that mental health nurses can use to reduce or prevent relapse. Please evaluate each statement by using the following keys:

1 = SA (Strongly agree)

2 = AG (Agree)

3 = UC (Uncertain)

4 = DA (Disagree)

5 = SD (Strongly disagree)

Place a tick √ under the relevant answer.

21. Family education on how to take care of a mental patient improves knowledge and promote improvement in patient symptoms
22. Promoting home visits by mental health nurses also prevents relapse
23. Mental patient education/teaching is also another strategy that

Can prevent relapse among mental patients

24. It’s also important to educate families with mentally ill individuals on risk factors of mental illness so as to protect those who have not developed symptoms.

APPENDIX III: INTRODUCTION LETTER

 APPENDIX IV

MAP OF UGANDA SHOWING BUGIRI DISTRICT

APPENDIX V

A MAP OF BUGIRI DISTRICT SHOWING BUGIRI HOSPITAL