December 2007 - Volume 1, Issue 6

THE EFFECT OF CONTINUING HOME NURSING SERVICES IN THE PREVENTION OF RECURRENCES AMONG SCHIZOPHRENIC PATIENTS IN TEHRAN

Dr M. Fallahi Khoshknab, Professor A. R. Kaldi University of Social Welfare and Rehabilitation, University of Social Welfare and Rehabilitation, Email: arkaldi@yahoo.com

ABSTRACT Introductions: Since recovery is not considered possible in the near future in chronic illnesses, and longterm hospitalization is not economic, nursing services should continue at home. Mental illnesses such as schizophrenia are more important since they have a recurring and debilitating nature. The aim of this research is to study the effect of continuing home nursing services on the recurrence rate in schizophrenic patients. Materials and Method: This study is semi-experimental, whereby the patients are placed into Test and Control groups, with the test group receiving home nursing services after being discharged from the hospital, and the control group did not, and instead of the usual way of the patient returning to the mental clinic to continue treatment followed, at the end, the two groups were compared for the recurrence rate. Patients with the criteria to be included in the study were randomly placed in the two Test and Control groups. The total number of samples in the two groups were 48 schizophrenic patients. To analyze the data, absolute and relative prevalence distribution tables were used and to study the relation between the variables, the Independent T Statistical Test and Chi-Square Test at meaningful level of 95 percent were utilized. Study tool was demographic questionnaire for registration of the recurrence rate. Results: The results showed that after 3 months follow up of the control group, 6 of the 24 patients (25%) had a recurrence, while this number was 0 in the test group (0%). Conclusion: This result indicates the importance of home nursing services in preventing the recurrence of the illness.

Key words: Schizophrenia, Schizophrenic Nursing, Home Nursing Services, Schizophrenic Recurrence.

INTRODUCTION

One of the problems and issues in today's civilized society is mental disorders. Mental illnesses have increased daily compared to the past, so that Robbins (1994) estimated the general prevalence of these disorders at 20 percent of the population. In the United States of America, seldom a family can be found that is not dealing with a mental patient (at one time of their life). One of every three adult Americans has a diagnosis of mental disorders, and in general at any given time, 20 percent suffer from mental illnesses (1). The above statistics indicate the need for study in this field. All mental illnesses such as anxiety disorders, compulsive disorder, depressions, personality disorders and especially psychosis and among them schizophrenia, have a chronic nature and need longterm care and rehabilitation. Mental illnesses, especially psychosis and schizophrenia have three important characteristics as stated below:

1. Chronic characteristic
2. Recurrent characteristic
3. Debilitating characteristic (in physical, mental, social, career, and educational dimensions).

All three above characteristics result in requiring more attention to prevent the third characteristic or rehabilitation of these patients. When continuing treatment and rehabilitation is mentioned, the role of nurses becomes very important. Chronic illnesses require long term care in the form of outpatient, hospitalization (in-patient) and/ or states in between the two. Due to the course of this illness, most of these patients are beset with economic poverty and homelessness, so that they live on the streets, in parks and public thoroughfares.

Schizophrenia, besides afflicting the person itself, affects the patient 's family and even disrupts the family structure, performance and duties, and in many instances results in separation and divorce. The normal recurrence rate of mental illnesses is 67 percent, so that these patients have a record of repeated hospitalizations in their files. The usual method of treatment for schizophrenia in Iran, in most instances, comprises hospitalization, medication and shock therapy, and some forms of psychotherapy. The patient is discharged after a relative recovery. Schizophrenic patients usually stop taking their medication sometime after being discharged and consequently the illness recurs and results in repeat hospitalization.

It seems that these recurrences are a result of the patient being released and non-continuation of care after discharge, such as home nursing care.

Stuart and Laraia (2001) write; in recent years, a specific need is felt to have mental health services at home. The increase in health care costs on the one hand, and the changing attitudes for a community based view of health care on the other, have an important role in generating and cultivating this philosophy (2). Lego (1996) says: mental care service at home is a strategy beyond treating mental patients. He quotes Buckwalter in this regard and says: home mental care is designed to facilitate transfer (of the patient) from the hospital the society in order to increase the person's performance level in society and decrease the economic load and national costs (3).

Homan (1996) writes that a wide spectrum of mental health staff deliver services at home but nurses constitute the basic column of the system delivering these services and have the main role in the coordination of health services at home. Delivering nursing care services at home, at present is being performed in many countries, considering technological progress, ever increasing population rates and rising costs of treatment and rehabilitation, it may be considered a suitable solution to help those patients who require special care. Nurses may deliver care services at home because of the overall knowledge they have of the patient problems and issues, and play an important role in expanding care, treatment, educational and rehabilitation programs, while supporting the patient and his family (4).

Today, the rising hospitalization costs, separation from family, and hospital originated infections result in the ever-increasing popularity of home health care. On the other hand, in chronic illnesses, since recovery is not conceivable in the near future, continuation of care at home is becoming noteworthy. Mental illnesses such as schizophrenia are not an exception. Especially schizophrenia as due to its recurring and debilitating nature, it is even more important. Since as mentioned before, the recurrence rate after being discharged from the hospital and without follow up is 67 percent, the importance of follow up of patients in the form of continuous care at home, becomes evident in the follow up and rehabilitation of chronic mental patients especially schizophrenics.

Thus, by designing research, the effect of home care on preventing recurrences among chronic schizophrenic patients in Tehran was examined.

THE ECONOMIC BURDEN OF MALARIA IN PREGNANCY:

There are two possible approaches to estimating the economic burden of malaria in pregnancy. Microeconomic approaches are used to measure the effect of the disease on an individual or household, while macroeconomic approaches measure the effect of the diseases on an entire society. Taking a traditional micro level approach, economic cost can be categorized as direct, indirect and intangible and can be measured from the perspective of the government (mainly Ministry of Health ) ,and households.

The direct costs of malaria in pregnancy can be divided into:
1. the cost arising from interventions targeted at all pregnant women in malaria endemic settings.
2. the additional costs arising as a consequence of malaria infection in pregnant women .

Direct cost to the health service arising from specific interventions for preventing or treating malaria in pregnancy include the cost of the Intermittent Preventive Treatment in Pregnancy (IPTp). Direct costs associated with malaria infections in pregnant women include the immediate costs of maternal infection and also the immediate and long term costs of treating the consequences of maternal infection on the infant, most of which relates to mitigating the consequences of low birth weight. Immediate costs are those of additional outpatient consultations, hospitalization, staff time, diagnostic tests, drugs and other supportive treatment. The cost incurred by the mother (or her household) include those of obtaining additional health care such as transport, drug costs and consultation fees.(3)

RESULTS

The most important results of the study were as follows:

1. The average age of the patients in two groups was 29 years. T- test did not show a meaningful statistical relationship between the mean ages of the patients in the two groups, showing that the two groups are similar (match) in this regard (P= 0.961). (Table 1)

2. Regarding marriage status, 22 (91.4%) of the patients of the test group were single and two (8.6%) married. The rate of married patients in the witness group was the same. Chi-Square test did not show a meaningful statistical difference between the two groups, and in this respect the two groups are similar. (P= 1.000) (Table 2)

3. Regarding previous hospitalization records, all 24 patients in the test group had a previous record of hospitalization (100%). In the witness group 22 persons (91.7%) had previously been hospitalized and 2 had not. Chi-Square Test between the two groups did not show a meaningful difference in this regard. (P= 0.916). (Table 3)

4. Research data shows that within 3 months after discharge, no recurrence occurred in the test group but the recurrence rate in the witness group was 25 percent (6 out of 24) and within six months after discharge, recurrence rate in the test group was 21 percent (5 out of 24) and in the witness group 46 percent (11 out of 24), and the Chi-Square test with more than 99 percent accuracy considers this difference meaningful (P= 0.002) (Table 4).

DISCUSSION AND CONCLUSION

As the study data showed, the research theory was proved and home nursing care can prevent recurrence of the illness, therefore follow up of the schizophrenic patient after discharge and continuation of care at home is a key point in reducing the recurrence of the illness. The results of this study correspond to the results of Chan, Mackenzie and Tinfung (2000), who in a semi-experimental research of the before & after type, reviewed the mental situation and performance of 62 patients receiving home nursing services, and showed that the mental status and behavioral and social performance of the patients improved compared to before the intervention and was meaningful statistically, and also corresponds to the results of research by Kiviri (1981), Zander (1988), Davies (1992), Mac & Go (1996) and Jury (1998), that showed home nursing care affects the recovery of mental status and behavioral and social performance of schizophrenic patients (9).

Home nursing care services may be implemented in various forms; the most important of which are reviewed below:

Hospital Based Home Care Services

In this method, a unit is organized in the hospital under supervision of the nursing unit. Patient File, after discharge is sent to this unit and nurses establish services for the patient, based on the hospital routine and or according to the recommendations prescribed in the discharge summary form.

Community Based Home Care Services

In this method, the patient is referred or assigned to private institutions such as Home Consulting & Nursing Services and other centers performing home nursing services including clinics, health centers, health stations, health homes, delivering home nursing care (similar to a physically ill person being referred after discharge, to the related institutions for physiotherapy).

The general result being that through establishment of these kinds of services, patients and their families may be greatly helped in bearing lower expenses, so that by giving home nursing care services and timely identification of the recurrence signs in the patient, control of continuation of the medication, medication side effects, educating the patient and their family at home, that ultimately result in on-time intervention and referral of the patient to the psychiatrist on-time in order to have the medication or its dosage changed, repeat hospitalization is prevented, expenses resulting from hospitalization reduced and the patient's family relieved from paying the expenses for at least one month of hospitalization due to recurrence of the illness. And also because of the country's shortage of beds in mental hospitals and since most hospitalizations are repeat ones, by rendering home nursing care and preventing recurrence, the problem of bed shortage may partly be solved.

(P= 1.000)

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(P=0.916)

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(P= 0.002)

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ACKNOWLEDGEMENT

We would like to sincerely thank all the authorities of Razi Psychiatric Educational Treatment Center in South of Tehran, respected colleagues in psychiatry, psychiatric nursing, patients and their families, without whose help and assistance this study could not be conducted.

REFERENCES

1. Suggested draft of the State Program for Organizing Mental Patients, Tehran, Secretariat Office of the State Headquarters for Organization of Mental Patients, State Welfare Organization and University of Social Welfare & Rehabilitation Sciences, September-October 1999, p 10.
2. Stuart G. & Laraia M., Principles & Practices of Psychiatric Nursing.
   7th edition, Mosby Co. 2001. P 843-68.
3. Lego, S. Psychiatric Nursing: A Comprehensive Approach. J. B. Lippincott Co. 1996.
4. Homan, et al. Rehabilitation Nursing, 2nd Edition, Mosby Co. 1996, p 145-78.
5. Kaplan H. Sadok B. Comprehensive Text Book of Psychiatry. 6th edition. William & Wilkins Co. 1995, p 130-133.
6. Barati Sadeh, Farid, Review of Positive & Negative Signs of Schizophrenia in Schizophrenic Patients and Their Relations, Tehran, Allameh Tabatabaie University, 1998, (Thesis).
7. Farhadi, Yadollah & Colleagues, Review of the Effect of Clozapin on Schizophrenic Patients' Recovery, Tehran, University of Social Welfare & Rehabilitation Sciences, 1997.
8. Fallahi Khoshknab, Masoud, Effect of The Application of Multi-Dimensional Rehabilitation Model on Recurrence Rate of Chronic Schizophrenic Patients, Scientific-Research Journal of Shahid Sadooghi University of Yazd, Fall 2002.
9. Chan S, Mackenzie A, Tinfung D. an Evaluation of the Implementation of Case Management in Community Psychiatric Nursing Services. Journal of Advance Nursing. 2000; 3(1): 146-54