What Organizations Are Available to Family Members of the Mentally Ill?

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The psychosocial problems of families caring for relatives with mental illnesses and their coping strategies: a qualitative urban based study in Dar es Salaam, Tanzania

BMC Psychiatry volume 16, Article number:146 (2016) Cite this article

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Abstract

Groundwork

Mental illness may cause a diverseness of psychosocial problems such as decreased quality of life of the patient'southward family members as well every bit increased social distance for the patient and the family caring for the patient. Psychosocial challenges are enhanced past the stigma attached to mental illness, which is a problem affecting not merely the patient but likewise the family as a whole. Coping mechanisms for dealing with mentally ill patients differ from one family to another for a diverseness of reasons.

The aim of the study was to determine the psychosocial problems of mental illness on the family including the coping strategies utilized by family members caring for a person with mental disease.

Method

A qualitative written report was conducted, involving 4 focus group discussions and 2 in-depth interviews of family members who were caring for patient with mental illness at Temeke Municipality, Dar es Salaam. Purposive sampling process was used to select participants for the study. Sound-recorded interviews in Swahili were conducted with all study participants. The recorded interview was transcribed and qualitative content thematic assay was used to analyse the information.

Results

Financial constraints, lack of social support, disruption of family performance, stigma, bigotry, and patients' disruptive behaviour emerged equally the main themes in this report. Acceptance and religious practice emerged as the major coping strategies used by family members.

Conclusion

Familial care for a person with mental illness has its advantages, yet it has multiple social and psychological challenges. Coping strategies and skills are of import for the well-being of the caregiver and the patient. Addressing these psychosocial challenges requires a collaborative arroyo between the health care providers and government and so that the needs of the family caregivers and those of the patients can be addressed appropriately.

Groundwork

Globally, information technology is estimated that 450 1000000 people are affected by mental disorders at any one time. These include 121 million people with depression, 24 million with schizophrenia and 37 million with dementia [1]. Mental illness deemed for about 12.3 % of the global burden of disease in 2001 and it is estimated that past 2020 unipolar depressive disorders volition exist the 2nd most important cause of disability [2]. The burden of caring for mentally sick patients falls on the family members who provide all necessary back up.

Bear witness from developing countries is scarce; some countries show a higher prevalence of psychiatric patients living with families. In Uganda for instance, the Uganda National Health Statistics (UNHS) of 2005/06 reports that of all households with disabled members, 58 % had at least one person with a mental disorder. To date, Tanzania lacks established statistics on families afflicted past mental illness.

Nearly mentally ill patients unremarkably consult traditional healers and the reasons for not attention health facilities nevertheless remains unclear [iii]. Beliefs regarding the cause of mental illness may be one of the reasons for not seeking healthcare. Most family members view mental illness not equally affliction, merely equally a curse; a product of both witchcraft and evil spirits of which the patient himself is counted as the principal contributor [4]. It is likely that mental affliction is severely underreported resulting in many untreated patients. However, in all cases, family members bear much of the burden of the patient'due south mental illness and this affects them psychologically and socially [v].

Psychosocial problems

Mental illness may cause a variety of psychosocial bug such as decreased quality of life for the patient's family members, as well equally increased social distance for the patient and the family caring for the patient. The family members who treat relatives with mental illness study feeling stigmatized every bit a result of their association with the mentally ill [6].

Persons with serious mental illnesses often appoint in behaviours that are frightening, troublesome, disruptive, or at least abrasive, and many relatives are obliged to command, manage, or tolerate these behaviours [seven]. Thus, psychiatric professionals often view the family members of a patient equally people of support because they can act as informants regarding the patient and they can act as co-therapists at home [8]. The family members need to be in an optimal social and psychological country. It is reported that reduced office of one family member contributes to the burden of other members and this in turn leads to other family members bold a critical attitude towards the patient [nine]. Such criticism can in some cases lead to a relapse of the patient's illness or to the family unit feeling overwhelmed by the patient'south disruptive behaviour [6, 10].

Social support is important for the wellbeing of the family affected past mental illness. A research finding reveals that families should presume major roles in supporting relatives with mental disease; and collaborative plans should include strategies to assist family members and consumers in dealing with stigma [11]. There is a relationship between caregivers' social support and stigma associated with relative with mental illness. For instance, in a study investigating the links between stigma, depressive symptoms and coping amongst caregivers, it was constitute that stigma may erode the morale of family caregivers and result in withdrawal from potential supporters [12]. This statement supports the situation of families affected by mental illness in Tanzania as many families with mentally ill members hibernate the patient to avert stigma and being socially discriminated. It is not known what psychosocial problems bear upon family members caring for their relative with mental illness in Tanzania.

Family coping and accommodation

Coping differs from one family unit to another for a variety of reasons. In developed countries, some researchers have emphasized coping equally a fundamental concept for the report of adaptation and mental health [13, 14]. Nonetheless, the effects of age, elapsing of disease, living arrangements and other contextual factors on the coping styles of family caregivers, and on the recovery or rehabilitation of persons with mental illness are important factors to exist considered [14].

In this example, family caregivers accept to acquire and empathize the patient's characteristics and behaviour. Coping with symptoms such as delusions, hallucinations, inappropriate behaviours, and violence may often require lengthy, complex, and sorry negotiations. Over-burdened caregivers employ less effective coping strategies, written report more than frequent concrete and mental health problems and use services more than ofttimes [15].

In the Tanzanian context, however, it is unclear how family members cope with the mental affliction of their relatives.

It is important to know how the family struggles to cope with the stressful situation then equally to be able to help the family with mental illness. This report examined the psychosocial problems and coping strategies of families living with a person with mental illness within Temeke Municipality, Dar es Salaam.

Methods

Study design

The study used an explorative qualitative arroyo. Information was obtained from individual families living with mentally ill persons regarding the problems and coping strategies utilized.

Setting

The study was conducted in Dar es Salaam, which is the largest commercial city in Tanzania. The city has a population of more than 4 million and has diverse socio-cultural characteristics as a result of pregnant rural to urban migration. This region consists of a mixture of tribes mainly from southern Tanzania.

Sample size and sampling procedure

Fourteen participants were recruited using purposive sampling on the dispensary days at Temeke Municipal Hospital in the Outpatient Clinic of Mental Health and Drug Corruption. Family members escorting the patient with mental illness to the clinic and who met the criteria were asked to participate in the report. Temeke Municipal Infirmary does not acknowledge psychiatric patients; therefore those patients who demand access are referred to Muhimbili National Hospital, which is besides situated within Dar es Salaam. Sampling was washed to the bespeak at which no new information was obtained from participants and redundancy was achieved, referred to as information saturation. During the interview nosotros identified two participants who seemed to exist reserved, and were not agile participants. Nosotros interviewed them separately after the Focus Group Discussions in order to obtain their views and experiences.

Choice criteria

Participants were selected according to the post-obit criteria:

1. 1.

   Caregiver living with relative who had been suffering from mental illness for more half-dozen months.

2. 2.

   Caregiver is 18 years or older

3. 3.

   Caregiver is the main caretaker.

He/she was explained briefly the nature of the report before beingness asked to participate. All who agreed to participate were asked to provide contact information to decide on an appropriate mean solar day for the interview.

Ethical blessing

Ethical clearance was obtained from the Muhimbili Academy of Health and Allied Sciences Ethics and Publication Committee. Further permission and approval was obtained from the Temeke Municipal Medical Officer in charge. Before the interview started, the informants were given a full caption of the data drove procedure. Each participant was fully informed and understood the nature of the report and voluntarily agreed to participate. The written consent form was read, understood, and signed by the participants. Those who were not able to write were requested to provide verbal consent. However, all were able to read and write and therefore signed the consent grade. Participants were informed that they could continue to use the wellness service as usual. Confidentiality was guaranteed by maintaining anonymity of all caregivers who participated in the study. Freedom to withdraw from the written report at any time was ensured.

Information collection

Iv focus group discussions (FGD) and two in-depth interviews were carried out due to the fact that more detailed information was needed in order to go the psychosocial problems and coping strategies of families caring for patients with mental illness. Information were nerveless through audio-taped interviews, which lasted for 55 to threescore min for focus groups discussions and 30 to 45 min for in-depth interviews. Four FGDs were conducted at the hospital. Each FGD consisted of iii–4 members. The aim was to get at least 6–eight people but information technology was not possible for a variety of reasons including problems with transportation There was no categorization of the group participants. Both sexes were mixed during the interview and they were from different areas of the Dar es Salaam region. The in-depth interviews were conducted in the participants' home environments. This provided an opportunity for the researcher to discover the living situation of the caregiver and the patient. The participants in this category were identified during the interview equally those who were not actively sharing their views in the group discussions. They were then asked to participate in an interview in their home environment.

Data collection was guided by the post-obit 5 structured questions.

1. 1.

   What is the experience of caring for your mentally ill relative?

2. 2.

   What problems practise you face when caring for the mentally ill relative?

3. 3.

   How do other relatives help you to intendance for the mentally ill relative?

4. iv.

   What are the attitudes and views of the people around y'all concerning caring for a person with mental illness?

5. five.

   How do y'all cope with such problems?

The structured questions were followed by specific probing questions in order to obtain more information or clarification. The discussions and interviews were conducted in Kiswahili, the national language which was easily understood by all informants. During group discussions, the principal investigator moderated the give-and-take while a research assistant was taking notes, operating the sound recorders and taking care of any interruptions. Observations of non-exact reactions were collected during and after the discussion. Field notes were blended with the recorded information during analysis.

Data analysis

Content thematic analysis was used in order to gain a deeper and clearer understanding and a formation of themes. Audiotaped focus group discussions and in-depth interviews were transcribed verbatim in the original Kiswahili linguistic communication. The principal investigator transcribed the audiotaped data past typing directly into the reckoner using the Microsoft Word program. This helped the researcher to correlate the tone of the informants in the sentence with the feelings and emotions, which were of importance to the analysis. In the procedure of transcription, the informants' words were captured as closely as possible. To make certain that the data were transcribed correctly, the transcripts were checked against the audiotape so reviewed by a person who was also proficient in Kiswahili. Interview notes and ideas were jotted down and the transcripts were read several times and so that the researcher could be immersed in the data.

The unit of measurement of assay was the themes expressed in the text almost social and psychological problems found in families caring for persons with mental illness. Iterative reading of the interview transcripts was done. Pens, highlighters and memos were used during analysis. Different colours were used to highlight the patterns in the text, which corresponded to the preconceived category derived from the study objectives. In both margins of the hard copies of the transcripts, the patterns were jotted down in a crystallised meaning (condensed significant) which were so transferred to a unlike sail of paper for farther analysis. Memos were used to summarize the patterns of the condensed meaning before transferring to the master canvass. To identify the source of information in the memo and in the text, identification numbers of informants were used when transferring the condensed meaning to the chief sheet, so that the source could be easily traced and accessed. On this sheet of paper, coding schemes were developed with the abstracted categories and themes. Dissimilar categories, condensed meaning units, or codes were compared for underlying meanings and relationship at the estimation level, which formed the themes (Table 1).

Table 1 Some excerpts of coding scheme resulted in theme formation

Full size table

Field notes were also analysed separately whereby the patterns and categories were compared to those from the FGDs and in-depth interviews.

The ii lists of categories were generated and compared and adjustments were made to the words used in the labelling of the categories. Transcripts were read again alongside with the list of the categories to ensure that the interviews had been transcribed. All the transcripts were then coded according to the list of categories and the coded sections of the transcripts were collected and and so sorted. Verbatim examples were used every bit evidence for each theme and categories.

Results

Characteristics of informants

A total of xiv family caregivers (informants), whose age ranged from 35 to 60 years, were interviewed. Five informants were men and 9 were female. Four informants identified as Christian and x identified as Muslim. Most of the informants had gone to primary school and a few had received secondary level education. Five informants were housewives, that is, they were married with no source of income except that of their husbands while five participants were niggling traders' i.e. were doing small concern (Table 2).

Table 2 Characteristics of informants

Total size table

Characteristics of patients

The informants who participated were caring for ill relatives with different types of mental disease including schizophrenia, bipolar disorders, autistic disorders and epilepsy with psychosis. The duration of relatives' illness ranged from 7 months to 27 years. All the caregivers were living with the patient in the same household and most of them were parents.

Themes identified

After analysis, seven main themes emerged from the information.

Fiscal constraints

Financial constraints were a business concern for almost all participants. They said they had limited fourth dimension to piece of work in guild to earn money because well-nigh of their time was spent caring for their relative. The amount of coin earned from limited working time was used to assist care for the relative, such as buying bus fare to the hospital, purchasing medications, and other activities for the patient.

Cost for ship

Nigh informants expressed concerns about fiscal strain acquired by increased cost for patient intendance, which was coupled with decreased working hours. Most of the participants were living a considerable distance from the hospital, they had to travel either by taxi or by public transport for patient follow-up. This acquired most caregivers to have multiple financial crises with the small amount of coin they had. For psychotic patients, some used to accept taxi merely the easiest and most attainable send was public buses (daladala). The most important concern was how to get the coin for the transport. Some failed completely to come up to the hospital for more two or more months and other caregivers sometimes used their other relatives to collect the medication at the dispensary as reported by i of the respondents caring for her elderberry sister with schizophrenia:

"Like that twenty-four hours I sent my blood brother-in-constabulary, and told him; accept this patient's register book because you are going there, I don't have the bus fare for going to the hospital only to collect the medicine." (46 year former sis).

Toll for medication

In addition to toll of transportation, it was revealed that shortage of medicine in the hospital compromised the treatment system of the patient. Medication was expressed as a major contributor to a patient's improvement. For case, the informants whose ill relative used more than than 2 types of medication were rarely getting the second medication from the infirmary and consequently had to buy it in private pharmacies. As a result of lack of money, they used only 1 type of medication due to the carer's disability to purchase the second drug. This was reported by an informant caring for his son with schizophrenia:

"……and when yous come up the next calendar month, yous are told; again, we don't have this type of drug, and then you are given the only one, okay! Then the patient uses the one blazon of drug considering no money to purchase the second drug." (58 years sometime father).

The psychotropic medications are ordinarily provided free of accuse past the government infirmary. Withal, not all are available in the government pharmacies and thus patients need to buy from private pharmacies. In this case patients reported that drugs were and then expensive that those who managed to buy them had to cede other household needs then that the patient could get the drug to prevent the disruptive behaviour:

"My main trouble is coin to buy the drug. They (doctors) have changed the medication, just imagine, a unmarried monthly dose now costs forty g shillings (40,000/=) and she uses three dissimilar types of drugs……we ought to abandon other household issues to purchase the medication because if she does not use the drugs for 2 or iii consecutive days, you find that no peace at home". (51 years former mother).

This theme occurred even in patients using one blazon of drug. Some informants expressed that even if the patient had one type of drug which was non available at the infirmary, the patient had to look until they get the money to buy it. This was expressed as a causative risk factor for frequent relapse of patients' symptoms as a upshot of inappropriate dosage regimen.

The informants expressed that their relative's confusing behaviour needed to be prevented by regular employ of medicine. Lack of money for transportation and medication for the patients was suggested to be the main impediment to the patient improvement.

Disruption of family performance

Family performance is the power of the family unit to continue with daily activities despite an internal or external threat. Most participants expressed disturbances in their normal routine equally a result of having a mentally ill person in the household as explained below:

Disrupted household routines

Disruption of household tasks and other responsibilities were important sources of distress revealed by many caregivers. Unpredictable patient symptoms seemed to be a deplorable factor which express caregivers' fourth dimension for other family responsibilities. Parents of patient with mental illness had multiple roles including caring for the patient besides equally making sure that other family members were getting their needs met. One caregiver whose ill relative was totally dependent said that she devoted most of her time doing activities for the patient. This affected the family caregiver income and hence made life more than difficult as expressed by ane of the respondents:

"And then far, I am no longer doing whatsoever work, my piece of work has been compromised by staying at home all the time caring that one (the ill daughter); no any more work to do. I accept to give medication, making sure she is safe and my backdrop are rubber" (51 years old mother).

Another ane added:

"Really I am affected …….y'all ought to remain at domicile to protect him probably unanticipated catastrophe may occur. If you attempt to go out to do your work, you become anxious because he (the patient) may be violent." (42 years one-time father).

Most parent caregivers stated that information technology is their responsibility to treat the patient because it is their child who is suffering and they cannot give to anyone else. Because they have to work, some caregivers reported locking in the patient when they needed to get out for daily activities. I caregiver anile 59 years onetime caring for her son with autism expressed that, "fifty-fifty this time I am here; I accept locked in my son in his room until I come back." She insisted that the patient is totally dependent on her and that he is unable to express his needs. Although some informants said that they have other family unit members living in the same household, they contribute lilliputian to care of the patient.

Lack of family harmony

Resilience in the family unit was also affected by the patient'south disruptive or by family members disagreeing nigh the direction of the mentally ill relative. One caregiver expressed business organization almost her husband past saying:

"...........He uses abusive language to my son because his is mentally sick only he does not show such behaviour to the children. We always quarrel for that reason" (50 years quondam mother).

Other informants revealed that a frequent source of misunderstanding revolved effectually how to discover solutions to the patient'south problems. It was revealed that i parent/member may seek out help from a traditional healer for treatment while the other may seek out spiritual handling. Withal, most caregivers resolved to seek out professional person treatment.

Disruptive behaviuor of patients

Problems in managing patients' symptoms

Participants had difficulties in managing patients' symptoms. They expressed concern that at that place was no one else who would be able to handle the unpredictable behaviour of the patient. They were the only i who had learned how to handle the patients' behaviour; therefore, they had to remain at domicile to protect the patient and other people from patient'south uncontrolled behaviour. The majority expressed fright of being attacked past the patient as well as concern for rubber of the patient as elaborated below:

"I have got many bug with my patient because, he is very strong and fatty and his intention is to kill me and his father. The problem which I get is that I can't even chop onions in public, I ever practice that in the locked room, and all knives and everything are hidden in the cupboard." (51 years old mother).

Some other informants expressed that they had to be modest and humble when talking with the patients. They revealed that some family members exercise not bother to learn virtually the patients' behaviour and how to handle him or her when agitated. Thus leaving care of the patient to the main caregiver despite the dangers to that person.

Patients' safety

A skilful number of caregivers expressed concern about safety of the patients who at times aimed to assail and impale others or themselves as echoed by a 35 year one-time man caring for his immature brother with paranoid schizophrenia:

"………at that place is a day he will succeed to impale, if not to impale him, he may be killed, because I tin can prevent him from attempting to injure me, unfortunately he can hurts himself." (35 years old brother).

Concern by family members for the safety of the mentally ill relative caused many to feel anxiety especially when the relatives become lost in the street or when they become confusing and violent. Parents caring for epileptic patients stressed that when their ill children get out, they did non recall to return domicile. The caregivers had to accept time and endeavour to await for the patient everywhere. Some patients were reported to get lost for several weeks.

"That day I told him to go home alone, simply he was lost for most a month, I mean he did not return dwelling house. Later looking for him for two weeks, I found him in the social beach near a deep water level" (56 years old father).

Participants reported that patients were more aggressive and violent when they practice not take their medication and this was a common problem provided that some medications had to be bought at private pharmacies. Furthermore, family resilience was as well disrupted when the patient interfered with normal family social life such as by preventing family members from engaging in basic activities such eating and watching television set.

Conflict with neighbours

The caregivers revealed that their relatives' uncontrolled behaviour such as temper tantrums, shouting in public, insulting people and neighbours and striking people had caused them to have difficulty in forming and maintaining good social relationships. Some caregivers had been blamed for their relative'south behaviour in court of police force causing endless misunderstanding between family with the sick relative and the neighbourhood family. Ane informant reported that:

"When yous make jokes of him several times, and so, he becomes aggressive of a sudden attacks yous even stabbing you if in access with a pocketknife; I have been arrested past police about two times to answer cases." (42 years onetime father).

It was said that most people do non know the nature of the mental illness and think that the person was pretending. Most of the family members tried to illuminate that their ill relative is not pretending and that he/she is suffering from mental disease.

Lack of social support

In this study many informants expressed lack of support from other people, both within and outside the family. Information technology was revealed that distance between other relatives and the caregivers increased as the patient's symptoms increased. Ignorance of family members in regards to the nature of mental illness was said to be a contributing factor to lack of back up as about of them thought that the affliction was of short duration. For example, if the patient'south symptoms lasted longer than they expected, they gave upwards and withdrew their support. Others reported that the patient'southward symptoms are caused past the parents trying to get wealthy by making their child mentally ill. 1 caregiver reported that 'no relative will come to give you lot annihilation rather than advising yous to go to the traditional healers.' Financial or material assistance was mentioned to be very important simply this was not always offered even though some have close relatives in good financial positions:

"She (the patient) has many siblings here in Dar es Salaam, her brother, sister; both are workers but not even phoning to know how you are progressing in that location. ……..they are educated with cars, oh, no even phoning." (46 years sometime sister).

Participants acknowledged that family dynamics are changing from that of an extended family system to more of a nuclear family organisation where the welfare of a kid is the sole responsibility of the parent. No one may accept function in taking care of 1's' child in health or in disease. A human being aged 58 years old caring for his son with epileptic psychosis said:

"When you lot become such problems deport in mind that it is yours; neither uncle, cousin nor whoever, according to the current state of affairs will aid you in anyhow." (58 years old man).

Caregivers described feelings of helplessness related to the fact that no one else was willing to help them care for their child and that they had to persevere with caring problems every bit living with such patients demand cooperation with other members of the families.

Need of self-assistance groups

Some caregivers reported a desire for social back up groups designed to ameliorate the quality of life of mentally ill individuals. These social groups could be of whatsoever nature including merely not express to educational or religious in order to assist their ill relatives in socializing and thus relieve whatsoever distress caused past loneliness. Too they were concerned about the deteriorating cerebral function of their mentally ill relative and expressed a desire to find educational groups.

"If we become such group which can aid to socialize and aid such children and intermingle with those who are mentally stable, could greatly help them. …….because nosotros toil to become here and in that location equally a upshot we become weary in vain." (A 42 years sometime father).

Furthermore, information technology was also revealed that in that location is a need for caregiver support groups to address physical and psychological bug developed past caregivers themselves as a result of caring for their mentally ill relatives. Professional or social support was frequently mentioned by caregivers while venting about their emotional distress:

"Y'all get tired of everything; y'all wish to have new ideas or people to help or group to mix with for getting new challenges……..you notice that we are also tired of thinking, tired of strength, at the aforementioned fourth dimension running curt of coin." (A 40 years old female parent).

Many informants suggested having this social group as a way to simultaneously improve the welfare of the patient and their own well-being. This was suggested as an alternative to admitting mentally ill relatives to mental health institutions, something some informants had seriously considered. Others suggested creating schools for mentally ill individuals with qualified teachers because some patients had improved their mental status simply were unable or agape to join public schools.

Stigma and discrimination

Many caregivers described people effectually them having negative attitudes toward their mentally ill relative. Most informants reported that the relative was more stigmatized than the caregivers themselves and that when they hear or run across their ill relative existence ostracized, they experience guilty and are psychologically disturbed. However, the feel of societal stigma and discrimination is worsened past negative attitudes from close relatives towards the caregivers, thus creating an increased distance amid them and the customs at large. Negative attitudes from close relatives were explained to occur on different occasions such as when using public transportation and at other social gatherings. One participant whose ill relative had cannabis induced psychosis complained that his neighbours shunned his son from social events:

"Because fifty-fifty if he sees them sitting and chatting, and if he decides to go at that place to sit with them, you find that they all stand and start leaving away. They perceive him equally insane and can't chat with them." (38 years erstwhile mother).

Some highlighted that stigma was nowadays amidst family unit members. This was credible after the onset of illness. This seemed to exist an unbearable burden to the caregiver every bit everything is left to him/her.

"Stigma is present even among united states, because, you find that initially, you will be with your family and the society in full general, but when the problem happens, none of your relative will come to know your progress with the patient." (38 twelvemonth old mother).

Stigma was said to be caused by lack of knowledge about the nature of mental illness. The caregivers expressed their belief that didactics regarding mental illness should be provided to people in lodge to forestall stigma and discrimination. Most caregivers had demonstrated interest in understanding the origins of mental illness and some had even obtained brochures from some mental health facilities with respect to their relative's condition. Patients were said to be more stigmatized than the caregiver probably due to awkward behaviour. Nonetheless, caregivers were blamed for causing the ill relative to be in that situation to begin with.

Coping and adaptation

Coping and adaptation are i of the important aspects to be applied when caring for a patient with chronic mental illness. Different types of coping and accommodation were reported by the participants.

Credence and faith were two of the most frequently cited strategies for coping. Caregivers had learned to accept and reconcile the disability or deviant behaviour in the mentally ill relative so every bit to avoid the dissatisfaction and disappointment that could have resulted from the patient's bizarre behaviour.

"Y'all demand to accept, no way, that is your child, whether your relative, your family fellow member. …….where would y'all ask help? That is your gift from Almighty God, you lot have to take." (58 years onetime begetter).

Some family unit caregivers took a positive step by utilizing problem solving strategies to accost their relatives' psychological, emotional and practical needs. Near family members brought their ill relative to the hospital after consulting different areas especially from traditional healers.

"So, information technology is the hospital services we are continuing with until now. It gives me hope and satisfaction I and the patient will never go to the traditional healer over again" (lx years old mother).

Other family caregivers sought religious support every bit the merely means of promise and encouragement. They said that their religious practice gave them peace of heed and helped them to endure the caregiving situation. They believed that praying was likewise likely to reduce the suffering of their ill relative besides, thus making their faith indispensable to continued caregiving of the relative, irrespective of their sorry behaviour.

"Whenever the aggressive behaviour of my son begins, I immediately enter into my room, lock the door, kneel down and pray for Almighty God; Oh God! Help me to touch on the Cross until my time of death!" (50 years old mother).

Some caregivers displayed signs of despair due to the difficult life situation caused by the patient's critical demands coupled with unrealistic daily income. They had no means of coping or adapting to manage their situation either due to persistent bizarre behaviour by the patient or their own lack of energy. However, they however had hopes due to their organized religion;

"That'south why sometimes y'all speak rudely to me, and I respond rudely to y'all too. What respect do I expect from yous I wonder! I always provide treat y'all so what! Information technology is simply my religion which makes me to be here." (46 years old sister).

Love, patience, and knowledge of the problem were other coping strategies mentioned past the family caregivers as important for difficult situations. Notwithstanding, none of the caregivers had abandoned his/her relative but near showed signs of desperation.

Discussion

This written report has offered insight into the social and psychological issues of caring for mentally ill patients on families' caregivers. Feelings and coping strategies experienced by family caregivers were revealed in the study. This study found that the main challenges faced by caregivers of mentally ill relatives were lack of social support, stigma, and conflict acquired by the patients. Like findings were reported in rural Ghana where caregivers reported financial difficulties, social exclusion, low, and inadequate time for other social responsibilities as their main challenges [16].

The financial constraints found in this study corroborate findings from other studies that explored the relationship betwixt mental disease and poverty [17]. In this study, it has been found that people with mental illness are frequently unable to generate income and that they often take to rely on the financial support of family unit members to run into basic living needs and to pay for whatever wellness expenditure associated with mental illness. Thus, family members may have to set bated a significant amount of their time to intendance for an ill family member. This can diminish caregivers' chances to become or keep a job or earn income, which further increases the gamble of poverty and poor mental health of the patient. This finding besides shows similar fiscal burden as reported by a study conducted in Nigeria that explored relatives caring for schizophrenic patients [18]. Nonetheless, our report did not explore the level of burden and its associations with caregivers' educational level, historic period of patient, employment condition of patients and global rating of difficulty in coping with caregiving.

In Mtwara region, the study from BasicNeeds in 2009 revealed that the shortage of psychotropic drugs resulted in commutation of patients' usual medicine with alternative ones that were not as effective. In our research, the shortage of drugs was reported to decrease the brownie of health facilities, which are the master source of support for many families with mentally sick members. Equally such there is a need to better mental wellness services including adequate provision of antipsychotic medication so that caregivers can continue getting them at the hospital costless of accuse every bit the policy stipulates.

Our findings demonstrate that there is a need for social support for the benefits of the family unit affected by mental illness. This unity helps to forestall stigma against the mentally ill patient in the family unit and the customs at big. In the United State (US) research findings reports that families assume major roles in supporting relatives with mental illness [10]. The report in United states is inconsistent with these findings probably because of different cultural background of Tanzania and Usa. However, education on the nature of mental disease can also exist a problem, which calls for more accent on customs awareness of mental illness in Tanzania. A qualitative report conducted in Thailand to explore the lived experience of Thai family unit caregivers found that extended family was a major source of support to caregivers physically, financially and emotionally [19]. This is not the instance in this written report because the caregiving was described to be occurring in a more nuclear family unit unit which resulted in decreased support to the family caregivers and may be due to the fact that the study was conducted in an urban setting. In essence, neighbours and the community are important components of social support. This research suggests that a strong social support system is critical for the improvement of mentally sick patients. However, a lack of this important component has hampered efforts to improve mentally sick patients' condition and is the drawback to the psychosocial rehabilitation of chronic mentally ill patients. This argument is supported by findings from Republic of india which revealed several reasons for difficulties encountered by patients cared for at home [twenty]. The most important way to amend the social support arrangement in Tanzania is to integrate mental health into the main health care system [21]. In main health intendance practice, family unit members with their mentally ill relative tin can access the wellness facilities easily and with low costs. Although mental health is addressed in the National Health policy of 2007, the pace of progress is too slow to cater to the increasing burden and demand of mental wellness care in the local setting. The government'south support is essential not merely in improving principal mental health care but likewise in ensuring adequate provision of free treatment and free medication. Nonetheless, effort is needed by the government to increase the number of training institutions in gild to create more mental health professionals.

Our study reported stigma every bit one of the biggest social challenges affecting families caring for patients with mental affliction. Similar studies accept shown that stigma may erode the morale of family caregivers and results in withdrawal of potential supporters [11, 15]. The report supports the finding in this written report that some caregivers lose the back up of their close relatives also every bit other sources of social support after the onset of their relative'due south mental affliction. However, a longitudinal study is required to establish a causal relationship between the stigma and the loss of social support for families caring for relatives with mental illness. Due to the fact that participants were concerned nearly their caregiving obligations in this research, there is a pregnant demand for education of the general population about the causes, presentation, and treatment of mental disorders. Although stigma and bigotry is a socially and culturally influenced miracle [3], increased instruction and understanding among the general population may decrease the stigma experienced by people who accept a mental disease, their caregivers, and their families. Stigma is acknowledged globally as one of the major problems to the success of community mental healthcare and it prevents a person from beingness fully integrated into social club. In Zambia, research found that stigma could be reduced if people with mental health problems were treated in chief health care settings rather than in mental or commune hospitals [22]. In Tanzania, most health care facilities in the local setting have non yet incorporated mental health into their basic wellness intendance packages; this could aid in reducing stigma. Furthermore, research suggests that the media plays a pivotal role in the stigmatization of mental affliction and therefore could besides play a role in the de-stigmatization procedure [23]. Media should exist effectively utilized to improve the full general population's agreement of mental disorders.

Family unit functioning has been afflicted past caring for patients with mental illness. There is modify in the office of family members every bit the parents get involved or more than consumed past patient's needs. The patient has many needs which must be fulfilled past the caregivers at the same time that they must engage in daily tasks to earn an income. This increases fact increases the overall burden on the caregivers. A large quantitative written report in Australia reported that higher levels of the burden of care were associated with lower levels of family unit functioning, which in turn were associated with higher levels of feet, depression and perceptions of poor health [24]. Our findings also demonstrated that in that location was a depression level of family functioning that was associated with patient's uncontrolled behaviour. The results of this research would further propose that families affected by mental illness feel less cohesive and perceive themselves to be less connected to one some other and less bonded as a unit than the normative family. In add-on, the families of the mentally ill felt dissatisfied with the performance of their family unit. This gives an impression that individual families should maintain their roles and relationships, thereby enabling the caregivers to maintain equilibrium. Any occurrence of mental illness of a family fellow member which needs caring at domicile results in psychological and emotional disturbances for the whole family [25]. In relation to the conceptual approach of family caregiving [26], these family unit behavior and relationships can be of great importance to understanding caregiving problems and any socio-cultural factors influencing family unit care of people with mental affliction. However, it is too important to examine further and distinguish between the availability of social support resources and the actual utilise of that resource to strengthen family unit functioning.

Violence and threatening behaviour displayed past patients in this study would seem to exist the issue of bereft symptom management. Proper direction is of importance not only to the family caregiver but to all people who come into contact with the patient. This research has institute that families are perplexed by violent patients. This is considering many trigger-happy patients fail to see their behaviour equally threatening and may actually perceive the family to be threatening. This threatening behaviour of patients comes at the toll of family unit caregivers who are often required to pay fines for destroyed property or pay compensation for injury caused past the patient. This phenomenon demoralizes the caregivers and further increases the stigma of mental affliction. Information in regards to approach and direction of violence are required when interacting with the mentally ill person.

Coping strategies are an important aspect of caring for a patient with mental illness. In this written report caregivers have shown a narrow range of strategies for dealing with patients' disruptive behaviours. Acceptance and praying are one of the virtually cited coping strategies. Some researchers have revealed dissimilar means of coping with distressing situations including cerebral, behavioural and abstention strategies [fourteen, 27]. This is not the instance in our written report as nearly of them were engaged in caring activities, even though with difficulties.

A research study which specifically examined differences in coping strategies among caregivers of different age, ethnic, gender, and instruction groups found some show that older people were more religious than younger adults [27]. In their written report, religious coping seemed to focus more on informal activities, especially breezy behavior, rather than on more formal religious activities. This is consistent with the findings in this study although we did non consider gender, historic period, ethnic and education background. Praying equally 1 of the coping machinery in our study, is similar to the findings from studies in Thai family caregivers [xix]. Nonetheless, there is a difference in religious beliefs in that Thai families were predominately Buddhist compared to mostly Christian and Muslim participants in Tanzania. In this research, both Christians and Muslims had developed a addiction of praying equally a way to deal with caregiving situation. Findings suggest that dissimilar consultation is sought as a fashion of finding solutions or treatments for their loved ane. Some were brash to seek treatment from traditional healers merely when they constitute no relief, they turned dorsum to God and sought hospital services. Most were satisfied with the hospital treatment after individual effort to seek data concerning the illness of their loved ones (cerebral coping). Maladaptive coping strategies were not described although though some did shown signs of agony in caring for their sick relatives as they were tired and did not know what to do to make their ill relative feel better.

Limitation of the study

There are several limitations in this research. Firstly, the sample was too small with few participants in each FGD. This might have an effect in a normal interaction during the interview and consequently contributed to express information. Secondly, the FGD groups were not homogenous which might accept affected the liberty of expression among the participants.

Thirdly, only one primary caregiver and who spent most of the time with the patient was recruited. There could be variety in the types of problems associated with caregiving amongst different caregivers, due to dissimilar family roles and perceptions of caregiving. Finally, the study was hospital-based which means the findings are not generalizable to a community-based sample.

Conclusion

Family caregiving for persons with mental illness has its advantages, yet it has multiple social and psychological challenges for both family unit caregivers and mental health professionals. Coping strategies and skills are important to the well-being of the caregiver and the patient.

Tackling of these problems needs a collaborative arroyo between wellness care providers and the government so that the needs of the caregiver and the family unit in general tin can be addressed.

Replication of the study with a larger sample based on age, gender, education groundwork, occupation will be useful for further enriching the knowledge base of operations of the phenomenon and in providing a foundation for time to come inquiry in clinical exercise.

Ideals approval and consent to participate

Ethical clearance was obtained from the Muhimbili Academy of Wellness and Allied Sciences Ethics and Publication Committee. Further permission and approval was obtained from the Temeke Municipal Medical Officer in charge. Before the interview started, the informants were given a total caption of the data collection procedure. Each participant was fully informed and understood the nature of the report and voluntarily agreed to participate. The written consent form was read, understood, and signed past the participants.

Consent for publication

The participants were informed that the findings of the study would be published in dissimilar journals and that their names would not appear in the publications. The participants agreed and signed the consent course.

Abbreviations

FGDs:

Focus Group Discussions

MUHAS:

Muhimbili University of Health and Allied Sciences

UBS:

Uganda Bureau of Statistics

UNAIDS:

The Joint United Nation Programme for HIV/AIDS

UNHS:

Uganda National Wellness Services

WHO:

World Health Arrangement

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Acknowledgement

Much appreciation goes to the Ministry of Wellness and Social welfare for financial support for this study. A lot of thanks go to Dr. Edith M. Tarimo and Ms Renee for the important part she played in editing the manuscript, Mr. Joel Ambikile Seme helped in data collection and conducting interviews. Finally, cheers go to Temeke Municipal Hospital where the study was conducted.

Funding

The research was funded by Ministry building of Health and Social welfare of Tanzania.

Author information

Affiliations

1. Department of Clinical Nursing, Muhimbili Academy of Wellness & Allied Sciences (MUHAS), P.O.Box 65004, Dar es Salaam, Tanzania

   Masunga K. Iseselo

2. Section of Psychiatry and Mental Health, Muhimbili University of Health & Allied Sciences (MUHAS), P.O.Box 65001, Dar es Salaam, Tanzania

   Lusajo Kajula

3. Tanzania Committee for Science & Technology (COSTECH), Ali Hassan Mwinyi Road, Kijitonyama (Sayansi) COSTECH Building, P.O. Box 4302, Dar es Salaam, Tanzania

   Khadija I. Yahya-Malima

Corresponding author

Correspondence to Masunga Yard. Iseselo.

Boosted information

Competing interest

The authors declare that they accept no competing interests.

Authors' contributions

MKI did all the work from research proposal development, information collection and analysis, and study writing. KIYM supervised the whole piece of work from proposal evolution, ensuring proper information drove instruments, relevant information assay method, and adherence to ethical issues and paper writing skills. LK was involved in the footstep past step procedure of data analysis and germination of themes. All authors read and approved the final manuscript.

Authors' data

MKI is the Assistant Lecturer at Muhimbili University of Health and Allied Sciences. He has Masters of Science (MSc) in Mental Health and Psychiatric Nursing. MKI teaches mental wellness for both undergraduate and postgraduate students at the university.

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Iseselo, One thousand.M., Kajula, L. & Yahya-Malima, K.I. The psychosocial problems of families caring for relatives with mental illnesses and their coping strategies: a qualitative urban based study in Dar es Salaam, Tanzania. BMC Psychiatry 16, 146 (2016). https://doi.org/ten.1186/s12888-016-0857-y

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• Received: 28 February 2015

• Accepted: 10 May 2016

• Published: 14 May 2016

• DOI : https://doi.org/x.1186/s12888-016-0857-y

Keywords

• Relatives
• Mental illness
• Psychosocial issues
• Caregiver

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