The International Journal of Psychosocial Rehabilitation

Home Care Services – the basic instrument of
support for the mentally ill in Poland.


Pawel Bronowski, Ph.D. (1)

 Maryla Sawicka, Ph.D. (1)

 Katarzyna Charzynska M.A. (2)

1. Academy of Special Education, Warsaw, Poland
2. Institute of Psychiatry and Neurology, Warsaw, Poland


Citation:
Bronowski P, Sawicka M, & Charzynska K (2012).Home Care Services – the basic instrument of support
for the mentally ill in Poland.  
International Journal of Psychosocial Rehabilitation. Vol 16(2) 78-87

Correspondence
Institute of Psychiatry and Neurology
Sobieskiego 9
02-957 Warsaw, Poland
e-mail: sierk@ipin.edu.pl
tel. 22 45 82 521
fax. 22 858 91 72



Abstract
The purpose of this study is to evaluate the functioning of home care services - the basic instrument of support for the mentally ill in Poland. Data was collected using a Sociodemographic Questionnaire, Map and Neighborhood Questionnaire and  Social Support Inventory. 103 ill people, mainly diagnosed with schizophrenia, from three districts of Warsaw were included in the study. The findings show that people included in the Home Care Services Program have weak and not very efficient social networks whose central places are occupied by professional  therapists providing most important support functions. Natural sources of support, such as neighbors or friends are rarely included in their social networks.
Key words: home care services, mental disorders, social support network, schizophrenia


Introduction
 The World Health Organization, despite several decades of efforts, could not develop an optimal model of psychiatric care that is adjusted to local environment due to the organizational and ideological pluralism in different countries. In a bid to overcome this phenomenon, in 2005 the European Commission published The Green Paper, a document outlining new common standards for health policy in the field of psychiatric care. Poland also joined this environmental movement introducing Mental Health Act in 2008. The primary goal of this reform is to disseminate the environmental treatment by shifting the burden of responsibility for the welfare of the patient and his family from the level of large psychiatric hospitals to that of mobile, multidisciplinary community units (Meder et al., 2008). The number of psychiatric day care centers has been steadily increasing.  In 1980, there were 53 day units, and by 2007 this figure has risen to 241. Similar increase was noted in the number of environmental treatment units – from 12 in 1990 to 35 over the following decade (Balicki, et al., 2000).

Nowadays more attention is being paid to ensure that the therapeutic treatment provided for the chronically mentally ill takes into account the entire situational context in which they live (Hoffman, Iserman, 2000). This requires a holistic approach encompassing different aspects: pharmacotherapy, family problems solving, unemployment and poverty prevention, offsetting poor social support networks and restoring hope for satisfying life. Majority of these problems arise after leaving an asylum which is a hospital. After their initial struggle to adopt to old life schemes, patients realize that they can no longer deal with new challenges (Kaszyński, 2005). The immediate support needed in this situation is psycho-social intervention whose primary objective is to improve social functioning of the patients. This aim is achieved by supporting the patients in complying with therapeutic recommendations, by monitoring their mental status in order to reduce number of hospitalizations, by helping them to develop ways of coping with persistent symptoms and by helping family in bearing the burden of mental illness (Roick, Fritz, 2007). Integrated therapeutic activities, rehabilitation and support programs for social functioning are now concentrated on the local level and form a standard in working with people suffering from mental illness. The environmental model, as compared to the asylum care which is based on the model of large psychiatric hospitals, has definite advantages: availability of numerous therapeutic programs, equality in distributing aid and greater efficiency in providing support. The environmental model reinforces the patients in the place where they live as well as sustains and develops their natural social networks by preventing marginalization  (Załuska, Paszko, 2005; Załuska, Suchecka, 2005).

In Poland, the social support systems include provision of daily support facilities such as self-help environmental homes for people suffering from serious difficulties in social functioning, occupational therapy workshops as well as prepare people to take up employment. These services are complemented with sheltered housing and home care services. While the creation of sheltered housing was not an entirely new concept in Poland, as it has been already established in the 70s, home care services are rather new development. Their main objectives are as follows:

  • to build or restore skills needed for independent functioning.
  • to support patients in their everyday activities.
  • to intervene and assist them in crisis situations.
  • to assist them in addressing important life issues.

The key to effective functioning of the program is its multidisciplinary team of professionals. Staff providing home care services should have specific qualifications  in the field of certain professions, such as  psychology, education, social work, occupational therapy or psychiatric nursing. Additionally, they should have long experience in working with the mentally ill and in conducting psychosocial interventions.
Home care services have been being carried out since 1997 and current study is the first attempt to evaluate the functioning of home care services for patients with schizophrenia.

Materials and Methods
Subjects
Home care services users fulfilling two criteria were included:
  • 3 or more months of home care services use.
  • Diagnosis of  F20 to F29 (ICD – 10).

Measures
The following set of instruments was used:
  • Socio-demographic Questionnaire (designed by the authors).
  • Map and Neighborhood Questionnaire (Bizoń, 2001). The tool enables measurement of the size of social support networks as well as their composition.
  • The Social Support Inventory (Bizoń, 2001). The tool enables the assessment of the type of support provided as well as defines the size and scope of the base offered.

All tests were carried out at study participants homes during the period from October 2008 to May 2009.

Results
A total of 103 people participated in the study. 59 (56.2%) were females and 46 (43.8%) were males. The average age was 52. About 7.6 % of the subjects had higher education and 44.8% secondary education.

Twelve of them (11.4%) were married, and others (88%) were single.

Over 87% of the respondents had disabilities or permanent benefits. Almost the entire group (97.1%) had been diagnosed with paranoid schizophrenia and the rest with delusional or paranoid syndrome. The average duration of the illness was 22 years, with average age of onset being 29 years. Almost all participants (97.1%) were regular users of psychiatric care. 99 people (94.3%) reported regular intake of medicines as prescribed by the psychiatrist.

This percentage should be considered high, as the standards consider 80% as a good level of compliance  (Seo, 2005; Mitchel, Selmes, 2007).

Individual social support networks
Individual systems of support  usually  included up to 6 people (table 1).

 Table 1. Overall size of individual social support systems.

Size

N

%

1 to  4 people

43

41,0

5 to 10 people

53

50,5

11 to 15 people

4

3,8

16 to 20 people

4

3,8

Over 21 people

1

1,0

Total

105

100,0



A significant group of people (41%) who had four or less persons in their systems are of special interest to this study. 

Table 2. The average number of persons providing support in each category of the support systems.
Category Mean SD
Therapists 1,90 1,292
Closest family 1,34 1,108
Flat mates 0,77 1,154
Other relatives 0,60 1,173
Other friends 0,51 1,020
Other significant people 0,40 0,909
Neighbours 0,37 0,624
Colleagues 0,18 0,585
 
As presented in table 2, therapists were most frequently present in the support system (1.90), followed by closest family (1.34).
Data on the extents of shortages in various categories of people constituting different systems of support shows that the largest shortage was in the category of "colleagues"; that is 89.5% of the respondents did not have any colleagues in their social surrounding. Other most commonly missing persons were "other significant people" (72.5%) and "friends" (72.4%) (table 3). 

Table 3. Composition of individual support systems

Category

Absent

Present in the system

N

%

N

%

Colleagues

94

89,5

11

10,5

Other significant people

79

75,2

26

24,8

Friends

76

72,4

29

27,6

Neighbors

72

68,6

33

31,4

Distant family

72

68,2

33

31,4

Flat mates

62

59,0

43

41,0

Closest family

21

20,0

84

80,0

Therapists

0

0,0

105

100,0

 

Scope of support systems
The scope of support system included eight functions: comfort, rescue, care, favoritism, unconditional support, advice, sparing, trust. As many as 96.2% of the respondents had access to all eight functions; no one complained of experiencing "selective" or "narrow" support (table 4).

Table 4. Scope of support

Scope

N

%

Selective (1- 2 functions)

0

0,0

Narrow (3– 4 functions)

0

0,0

Average (5 – 6 functions)

4

3,8

Wide (7 – 8 functions)

101

96,2

Total

105

100,0

 

Table 5 presents the data on the average number of people that provide support in various functions. It can be seen that "comfort" was provided by most numerous group of people, followed by "emergency assistance" and "care".

Table 5. The average number of people providing support within different functions.

Support function

Mean

SD

Comfort

2,43

2,561

Emergency assistance

2,20

1,852

Care

2,08

1,426

Favoritism

2,08

1,296

Unconditional support

1,95

1,992

Advising

1,86

1,014

Sparing

1,75

1,167

Trust

1,74

1,563

 


Table 6 presents the data on the average number of services provided by different categories of people constituting individual systems of support. It can be seen that the category providing the largest number of functions was that of the "therapists" (an average of 5.9 functions), followed by "closest family" (an average of 2.4 functions).

Table 6 The average number of support functions provided by different supporters

Supporter

Mean

SD

Therapists

5,9143

2,05274

Closest family

2,4667

2,65687

Flat mates

1,7048

2,67439

Other friends

0,5619

1,48663

Other relatives

0,5524

1,65687

Other significant people

0,4381

1,26281

Neighbors

0,3619

1,13615

Colleagues

0,1048

0,63434

 
Table 7: Composition of the support system by the support functions.

 

Supporters

Support functions

Advising

Sparing

Favoritism

Care

Emergency help

Comforting

trust

Unconditional support

N

%

N

%

N

%

N

%

N

%

N

%

N

%

N

%

Therapists

 

68

64,8

54

51,4

65

61,9

57

54,3

60

57,1

65

61,9

60

57,1

43

41,0

Closest family

23

21,9

24

22,0

20

19,0

25

23,8

25

23,8

22

21,0

25

23,8

39

37,1

Flat mates

19

18,1

14

13,3

16

15,2

14

13,3

16

15,2

10

9,5

13

12,4

21

20,0

Other friends

 

6

5,7

5

4,8

1

1,0

3

2,9

7

6,7

7

6,7

3

96,2

1

1,0

Other relatives

 

4

3,8

5

4,8

7

6,7

5

4,8

7

6,7

6

5,7

6

5,7

8

7,6

Other significant people

4

3,8

4

3,8

4

3,8

7

6,7

6

5,7

3

2,9

2

1,9

6

5,7

Colleagues

2

1,9

1

1,0

1

1,0

1

1,0

1

1,0

1

1,0

1

1,0

1

 

1,0

Neighbors

1

1,0

1

1,0

3

2,9

2

1,9

4

3,8

6

5,7

5

4,8

4

3,8

 

Table 8. Number of people providing specific support functions

Supporters

Support functions

Advising

Sparing

Favoritism

Care

Emergency help

Comforting

Trust

Unconditional support

average

sd

average

sd

average

sd

average

sd

average

sd

average

sd

average

sd

average

sd

Therapists

 

1,09

0,67

0,84

0,76

1,24

0,75

1,13

0,90

1,03

0,77

1,25

0,83

0,87

0,71

0,55

0,69

Closest family

0,31

0,56

0,32

0,56

0,31

0,61

0,38

0,64

0,43

0,70

0,39

0,67

0,35

0,58

0,67

0,79

Flat mates

0,24

0,56

0,40

0,75

0,25

0,57

0,29

0,68

0,28

0,63

0,19

0,50

0,18

0,45

0,32

0,61

Other friends

 

0,08

0,39

0,06

0,28

0,03

0,30

0,19

0,13

0,14

0,51

0,13

0,46

0,11

0,46

0,00

0,09

Other relatives

 

0,05

0,23

0,09

0,40

0,09

0,38

0,04

0,21

0,11

0,42

0,09

0,35

0,07

0,09

0,10

0,39

Other significant people

0,03

0,19

0,02

0,21

0,03

019

0,06

0,25

0,07

0,30

0,08

0,37

0,09

0,40

0,09

0,35

Colleagues

0,01

1,13

0,0

0,0

0,01

0,19

0,00

0,09

0,00

0,00

0,00

0,09

0,00

0,98

0,09

0,35

Neighbors

 

0,00

0,09

0,03

0,19

0,02

0,16

0,01

0,13

0,03

0,19

0,05

0,23

0,04

0,21

0,11

0,48

 

Analysis of the data in Tables 7 and 8  indicates that the fundamental groups of society which provided support functions were "therapists" and "closest family members." Other categories played relatively insignificant role with the exception of “flat mates.”. The dominance of "therapists" in certain functions of support is clearly visible. Only in case of "unconditional support", the number of people from "closest family" was slightly higher than the average number of "therapists".

Discussion
In the current study the number of individuals constituting social support systems was 6 on average and thus can be considered as scarce. In Pattison study the support systems were defined for 8 to 12 people, but in the case of very severe disease, the number was reduced to 6 people (Pattison, Pattison 1981). In the study group, if therapists engaged in home care services are excluded, the number of individuals in the support system decreases to as few as 4.9 persons. In Polish studies on social networks of the participants of rehabilitation centers, the average number of people forming support system was significantly higher (10 people) (Bronowski, Załuska, 2008; Bronowski, et al., 2009b, 2009).

It is also worth mentioning that as many as 41% of the respondents had 1 to 4 people in their social networks. In the earlier studies of support systems for patients with day rehabilitation facilities, as few persons in the system were found for only 10% of the respondents (Bronowski, et al., 2008a). In those very few systems of social support, the most numerous group was constituted by "therapists". In individual systems, it was an average of 1.9 people.  Second most largest group were "closest family members” with an average of 1.3 people. Other categories were very sparse and did not add much to the individual systems of support.

 Although eight core functions of support ("comfort," "emergency aid", "care," "favoritism," "unconditional support", "advice", "sparing", "trust") were fulfilled by limited number of support systems members, they turned out to be surprisingly efficient. 96% of the sample had access to the all eight functions. This result is slightly different from those obtained through similar studies of the populations of mentally ill people using the facility of daily support. The implementation of the "trust" involved many more people in the daily support (Bronowski et al., 2008b). In the case of participants of this study group covered by the program of home care services, implementation of this function, in terms of ‘trust’ and ‘close emotional contact’, has been much more difficult.

The analysis of different functions of support provision showed interesting findings. Among all the functions of support, except for one, the “therapists” provided the greatest support. The only function in which the respondents included more people from the category of "closest family", rather than the "therapists", was the function of "unconditional support". Despite the dominant position of "therapists" in the system, the respondents were aware that in terms of definitive commitment, "institutional support" might not be forthcoming in adequate measure and hence they might rely more on people from close family circle. It can be concluded that the participants avail themselves of very few systems of support of home care services, which is confirmed by the results of other studies on the chronically mentally ill (Bronowski, et al.,  2008b).

The experience of other countries, such as the Netherlands and England, underscores the importance of congenial and tolerant environment in the implementation of therapeutic treatments, which are essential for the mentally ill (Amaddeo, 2007; LGA, 2006; Boardman, 2007). Research on Poland reveals that its local communities are not adequately prepared to adopt the mentally ill (Wciórka, 2008). This finding was confirmed in the current study where the social support networks were built primarily on the basis of the professionals.

The results obtained are important for the ongoing psychiatric system reform in Poland. They not only provide data on the participants of the support system, but also could be of use while preparing social environment for similar projects implementation.

Analysis of the collected data allows for the following conclusions:
1.    The study group’s characteristics (chronically mentally ill people, single, living only on disability benefits and diagnosed with paranoid schizophrenia) shows that home care services, designed specifically for the most disadvantaged patients, are being provided to target users.

2.    Majority of the people surveyed were under regular psychiatric care and taking medications prescribed by the psychiatrists. It can be assumed that this is related to the support in the treatment process provided by the therapists.

3.    Therapists constitute the largest category of people working with the home care services users. They are of the highest relevance to the support systems, and their presence makes the process of obtaining various functions of support easy. The second largest category, in terms of number and relevance to the systems, was the "closest family members." Other categories of people (neighbors, friends, colleagues, other relatives) were not numerous in the support systems.  The program of home care services significantly strengthens the social networks of individual subjects, thus demonstrating its usefulness.


 

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