The International Journal of Psychosocial Rehabilitation

Social Adjustment of Persons with Schizophrenia
 in Rural Areas - An Intervention Study


L. Ponnuchamy
Assistant Professor of Psychiatric Social Work
 Department of Social Work
 School of Humanities
Adama University
P.O.Box. 1888
Adama, Ethiopia
 North East Africa


Citation:
Ponnuchamy L. (2015)  Social Adjustment of Persons with Schizophrenia in Rural Areas -
 An Intervention Study
 International Journal of Psychosocial Rehabilitation. Vol 19(2)  34-46


Abstract
Background: It is widely acknowledged that schizophrenic patients have major deficits in social functioning in the community.  The intervention to improve these deficits is inadequate in rural areas in India.  
Aims: The aim is to ascertain impact of structured social work intervention for management of social adjustment of persons with schizophrenia in rural areas.
Methods: The sample consisted of thirty persons with schizophrenia and significant family members. A proportionate sample covering heterogeneous socio demographic background was drawn using simple random sampling technique.  It was followed a Before-After Experimental Research Design Without Control Group.  The social adjustment was assessed before and after social work intervention using Katz Social Adjustment Scale.
Results: After social work intervention overall there were changes in social adjustment domains.  The performance of social activities of patient and free time activities of patient had increased significantly.  Further expectations of family members had decreased and satisfaction of family members had increased significantly.  The results have indicated that the social work intervention has contributed to improve the social functioning of the patients in rural areas.
Conclusion: Results have shown the changes in all the domains of social adjustment significantly. Conducting similar studies in different settings would contribute to the social work knowledge in future.

Key words:  Schizophrenia, Social Adjustment, Social Work Intervention, Families, Rural Areas.


Introduction:
Schizophrenia is one of the major mental disorders severely affecting both men and women predominantly between the ages of 15 to 45 years.  Schizophrenia may develop so gradually that no one realizes as something wrong with person for a long period of time.  Sometimes it may also develop suddenly with dramatic changes in behaviour occurring over a period of few weeks or even a few days.  Emil Kraeplin, who first term this illness as ‘Dementia Praecox’ described it as progressive and deteriorating course of illness.  Accordingly schizophrenia destroys the inner unity of the mind and weakens volition and drive that constitute our essential (Kraeplin, 1971).  The persons with schizophrenia are incapacitated to engage and sustain social bonds, and even the society reacts negatively to the social and personal deviance caused by the illness.  Because its manifestations are so personal, it elicits fear and misunderstanding in society instead of sympathy and concern.

Severe impairment is the result of symptoms (positive and negative) of schizophrenia.  This inturn affects the individual’s ability to understand and act according to social cues, and would diminish markedly.  Patients experience unemployment, social isolation, homelessness and dependency on family members.  The relationship of patients with their family members and peer groups changes partly because of their unexplained behaviours and the stigma associated with the illness.  Similarly, cognitive deficits like decreased attention, concentration and lack of motivation lead to deterioration in their work capacity and are responsible for unemployment among these patients.  This further leads to social maladjustment (Appelo, et al., 1992). 

Schizophrenia remains unparallel as a stigmatized disease with all the social consequences of personal shame, family burden, inadequate support for after care and rehabilitation.  Families of schizophrenic patients suffer heavy financial and emotional burdens (Thara and Joseph, 1995).  Families become frustrated and angry as their savings dwindle often about little improvement in the patient.  Family members are not sure of the right way of help.  Most of the family members continue to be unaware about the causes, treatment, factors related to relapse, aftercare and rehabilitation.  The management of social disability among schizophrenic patients in the community by the family members has been considered an important area by mental health professionals.  Efforts were being made by many researchers for the management of social disability among schizophrenic patients (Hogarty and Goldberg, 1973; Linn, et al., 1979; Stein and Test, 1980; Bentlay, 1990). 

Families in India are supportive to the mentally ill persons in general.  The persons with mental disorders are well accepted and tolerated by Indian families.  Relatives of patients with schizophrenia experience more burden and distress due to the patient’s symptoms, social and occupational dysfunctioning.  By family psychoeducational intervention and involving the family in the management of their patients, they can be helped to cope with the sorrows and problems faced by their patients.  Due to their relatives suffering from schizophrenia, the care givers have high expectations in terms of information about the illness, medication, side effects, management of unpredictable and disturbed behaviours at home, and training to handle day-to-day issues (Ponnuchamy, et al., 2005).

Working with families in a systematic and purposive manner becomes an essential and integral component in the management of persons with schizophrenia in the community.  The inputs offered to the caregivers are education, providing information, support, problem solving and training etc.  However, providing these services to families in the institutions is expensive and stigmatized.  Decentralization of mental health services and community care has become a worldwide trend including India.  In India, the National Mental Health Programme (1982) advocates community care, in which the families continue to play a major role in care of the mentally ill member in the community.  Further the difficulties faced by the carers in the process of care giving are now well acknowledged by the mental health professionals.  The recent trend is also focusing on managing the psychiatrically ill person by the family within the community than in the hospital. 

Psychiatric Social Work as a professionalized activity that focuses on reducing the psychosocial problems of clients.  The social work practitioners have postulated that the psychosocial functioning or dysfunctioning was mostly determined by the interaction between the individual needs, aspirations and functional capacities on one side, and environmental (situations) expectations, opportunities and resources on the other side.  Hatfield et al (1979) emphasized on the modification of client system and the environmental system for better psychosocial functioning.  In summary, the review of literatures indicates the concept of social disability in terms of social adjustment is much relevant to the field of mental health as most of the mental illnesses contribute to the psychological, social disturbances to the patient and family members. Outcome researches in schizophrenia have shown long standing disabilities among the schizophrenic patients in the community.  Psychoeducation as well as Skills Training are conceptualized to be the essential element of social work intervention.  The social interventions provided by the social workers found to have meaningful benefits with persons with schizophrenia in the west.  In the Indian context particularly in rural settings, studies on the effectiveness of social work intervention with schizophrenic patients are inadequate. This attempt is made to focus in this direction. 

Materials & Methods
Many Psychiatric Social Work interventions have yet to receive adequate testing and scientific evaluation.  Recognizing suitability of particular interventions for particular practice situations must be supported by adequate scientific evidence, which will further contribute to the profession.  Further, recognizing that social work research especially in the context of service delivery is a prerogative for social workers.  The existing intervention studies (Hogarty and Goldberg, 1973; Linn, et al., 1979; Stein and Test, 1980; Bentlay, 1990; Viswanath and Padmavathi, 1992) in the areas of social work practice in mental health field are urban based and involves long duration of intervention.  Rural areas do not have sufficient inputs from the mental health professionals.  In India, the National Mental Health Programme advocates implementation of mental health services through District Mental Health Programme, in which a team of Psychiatrist, Psychiatric Social Worker, Psychologist and Psychiatric Nurse deliver the services.  In this context, it is needed that how far the management of social adjustment among schizophrenic patients in the rural areas is effective if it is done through Rural Mental Health Camp.  There is no intervention study through Rural Mental Health Camp in the rural areas in the field of mental health.  There is a lacunae in this area.  Hence, this study is designed for this purpose.

The aim of study was to ascertain impact of structured social work intervention for social adjustment of persons with schizophrenia in rural areas through rural mental health camp.  The present study was undertaken to understand the level of social adjustment both before and after the persons are exposed to the social work intervention package.  The course of study was aimed to develop and implement the social work intervention package with the patients and the significant family members in the conjoint sessions.  It was decided to test the efficacy of the intervention at the end of two months, fourth months and six month intervals after the intervention.  In view of this nature of research work, a “Before-After Experimental Research Design Without Control Group” was considered for the present study.  In this design a single test group was selected before the introduction of the intervention.  The intervention package was then introduced and its effectiveness was measured again.  The efficacy of the intervention was demonstrated by the changes that occur after the intervention was administered as against the baseline assessments.

All the patients and significant family members who were availing the services of Monthly Community Mental Health Camp conducted by the Richmond Fellowship Society Sidlaghatta Rural Branch, Sidlaghatta, in rural Karnataka, India consisted the universe of the study.  About fifty three cases were diagnosed according to ICD-10 to have schizophrenia (all type) by the psychiatrist in the Monthly Rural Mental Health Camp during the period from January 2004 to till July 2005.  Out of fifty three patients, eight patients were not included in this study due to exclusion criteria.  Off these patients, the researcher has drawn thirty samples using Simple Random Sampling technique.  The size of the sample for this study consisted of 30 persons with schizophrenia and their significant family members.  A proportionate sample covering heterogeneous socio demographic background was drawn.  The inclusion criteria were person having a diagnosis of Schizophrenia (any type) as per tenth version of International Classification of Diseases – 10 (ICD-10) of WHO (1992) diagnostic criteria, and age group between 18 to 45 years.  The exclusion criteria were persons with any associated psychiatric problems like substance abuse, mental retardation, affective disorders or any other disorders,  and patient who is actively symptomatic.

The tools used for data collection were socio demographic data sheet and Social Adjustment Scale (Katz, et al., 1963).  The Social Demographic Data Sheet was intended to collect information on age, gender, education, religion, marital status, occupational status, income, duration of mental illness and the diagnosis of patients.  The profile of the family members consists of relationship with the patient, age, gender, education, types of family, occupational status and income.  The Social Adjustment Scale consists of two sets of 5 forms one set for the use with relative of the patients and another set for the use with patients.  Psychopathology, Socially expected activities and Free time activities are the main areas of adjustment.  The patient’s version of these forms is referred as ‘P’ and the relative’s version is referred to as ‘R’.  Thus P1 to P5 are the forms for the patient.  Similarly R1 to R5 are the forms for the relatives.  The relative’s version of measuring the adjustment in the areas of Socially expected activities and Free time activities of the patient (R2 to R5) were considered for the assessment of social adjustment of the patients.  Form R2 comprises of 16 items, which deals with the relatives’ assessment of the ‘level of performance of the patient in social expected activities’.  It covers a number of activities, which describe the family and social responsibilities, social activities, self-care, home adjustment and community activity.  The relatives are asked to indicate for each of the activities, whether the patient ‘is not doing it’, ‘is doing it some’, ‘is doing it regularly’ and ‘does not apply’ and correspondingly scores of 1,2,3,0, are given.  Form R3 consists of 16 items, which are about the ‘level of expectations of the relatives’ with performance of the patients in socially expected activities.  These items are identical with those in Form R2.  But here the relatives are required to indicate, whether they expected or did not expect a given activity to be done by the patient.  The ‘level of satisfaction with performance’ could be obtained by considering the discrepancy in the scores on Form R3 i.e., the expectations of the relative and the score on Form R2 i.e., actual performance of the patient.  Form R4 contains 23 items which deal with the ‘level of free time activities’ of the patients that include their hobbies, social and community activities, and the self-improvement.  On this form also, the relatives are required to rate whether the patient has been involved in an activity ‘frequently’, ‘sometimes’, ‘practically never’ and ‘does not apply’ which are correspondingly rated as 3,2,1,0.  Form R5 consists of 23 items and measures the ‘level of satisfaction of the relatives’ with free time activities of the patients.  But in this form the relatives have to indicate whether relatives are satisfied with what the patient is doing in this respect, or whether the relative likes to see the patient do more or do less of this activity.  The authors have provided scores for different rating points for each item of the forms.  Thus, the total sum of the scores on each item on a given form or scale, would constitute the score for the forms or scales.  The authors have elaborately worked on the reliability and validity of the Katz Social Adjustment forms, which was widely used by several researchers in recent times. 

The process of social work intervention that thirty patients and significant family members involved in the study was divided into 3 groups.  The samples were divided according to the convenient of geographical areas with the help of staff of Richmond Fellowship Sidlaghatta Rural Branch at Sidlaghatta, Kolar District, Karnataka State.  Each group consisted of 20 members both the patients and significant family members.  Each group was exposed to two group sessions.  The intervention package consisted of two components such as psychoeducation and skills enrichment for a group of patients and families.  The period of intervention was 2 months i.e., two monthly sessions.  Each session lasts for 90 minutes were used.  The data was collected from patients and family members at the beginning of the intervention, immediately after intervention, second month after intervention and fourth month after intervention.  Quantitative analysis was carried out using Statistical Package for Social Sciences (SPSS Version 11).  The objectives of the quantitative analysis were to understand the distribution of the sample on the socio demographic and other variables, to assess the efficacy of the intervention package.  To meet these requirements, descriptive statistical techniques such as frequency, percentage, mean, standard deviation were used on the individual, family and illness variables.  Paired t-test was used to test the difference between baseline scores and immediately after intervention assessment, between baseline scores and second month after assessment, between baseline scores and fourth month after intervention assessment. In addition Repeated Measure Analysis of Variance was used to assess the extent of changes in the variables over the period of intervention and during second month after intervention and fourth month after intervention on social adjustment.  Enough freedom was given to the participants to either participate or not participate in the intervention programme.  Informed consent was acquired from all the participants after explaining the purpose of the study and procedures involved in this study.  Information collected was used only for research purpose and confidentiality was ensured.

Results

I.  Socio-demographic Characteristics of Rural Persons with Schizophrenia: (N=30)

Table – 1

Sl.No

Socio-demographic characteristics of patients

Number

 

Percentage

 

1

 

 

Age

     18 - 20 years

     21 – 30 years

     31 – 40 years

     Above 40 years

 

  2

11

11

  6

 

  6.6

36.7

36.7

20.0

2

Gender

     Male

     Female

 

18

12

 

  62.1

 38.9

3

Religion

     Hindu

     Muslim

 

26

 4

 

86.7

13.3

4

Marital Status

     Single

     Married

     Widowed

     Divorced     

 

  9

16

  3

 2

 

30.0

53.4

10.0

  6.6

5

Education

     Illiterate

     Primary

     High School

     Higher Secondary

 

14

  9

 5

 2

 

46.7

30.0

16.7

  6.6

6

Occupation

     Cooly (daily wages)

     Land owner (agriculture)

     Not working

 

  8

  4

18

 

26.7

13.3

60.0

7

Income (per month)

     Nil

     Rs. 1     - 200

     Rs. 201 - 300

     Rs. 301 - 500

     Rs. 501 - 1000

     Rs. 1001 – 2000

 

18

  3

  3

  3

  1

  2

 

60.0

10.0

10.0

10.0

  3.3

  6.7

8

Duration of illness (in years)

     Below 2

     2-4

     4-6

     6-8

     Above 10

 

  1

14

  3

  5

  7

 

  3.3

46.7

10.0

16.7

23.3

9

Diagnosis (ICD – 10)

     Simple Schizophrenia

     Catatonic Schizophrenia

     Hebephrenic Schizophrenia

     Paranoid Schizophrenia

     Undifferentiated Schizophrenia

 

  2

  2

  1

24

  1

 

  6.7

  6.7

  3.3

80.0

  3.3

Table 1 Social Demographic data of the patients displays that majority (73.4%) of the patients were between 21-40 years of age group.  Overall, 62.1% of the patients were male and 86.7% of them were Hindus.  Also shows that the majority (53.4%) of the patients were married and 46.7% of them were illiterate.  A majority (60.0%) of the patients were not working and had no personal income and 46.7% of the patients had mental illness for 2 to 4 years.  A majority (80.0%) of the patients had the diagnosis of Paranoid Schizophrenia. 

II. Socio-demographic Characteristics of Family Members of Rural Persons with Schizophrenia: (N=30)

Table 2 Social Demographic data of the family shows that majority (36.7%) of the family members were between 51 – 60 years old.  Around 53.3% of the family members were female and 46.7 of them were male.  Majority (50.0%) of the family members were illiterate. A majority (56.7) of the families were nuclear and 66.7% of the family members were coolies.  Majority (38.9%) of the families had a monthly income of Rs.1001 – 2000 per month. 

III.  Extent of Changes in Social Adjustment Domains:
1. Extent of Changes in Social Adjustment (Level of Performance of Patient’s Social activities) over different time periods among Rural Persons with Schizophrenia:
The results of Repeated Measure ANOVA conducted on Level of performance of patient’s social activities to verify the differences in the mean scores of at the four time intervals (1 – 2, 1 – 3, 1 – 4, 2 – 3, 2 – 4, 3 – 4 assessments).  It shows that the mean scores was increased significantly (P<0.001) on level of performance of patient’s social activities of social adjustment during this period.  Moreover it also indicates that improvement in this aspect of social adjustment was sustaining during the subsequent assessments followed by the social work intervention.  The overall change in mean value of this domain is shown in figure: 1.

Figure 1


2.  Extent of Changes in Social Adjustment (Level of Expectations of Family Members) over different time periods among Rural Persons with Schizophrenia:

The results of Repeated Measure ANOVA conducted on Level of expectation of family members to verify the differences in the mean scores at the four time intervals (1 – 2, 1 – 3, 1 – 4, 2 – 3, 2 – 4, 3 – 4 assessments).  It indicates that there was a significant (P<0.001) reduction in the mean scores on level of expectation of family members of social adjustment during this period. Moreover it also indicates that improvement in this aspect of social adjustment was sustaining during the subsequent assessments followed by the social work intervention.  The overall change in mean value of this domain is shown in figure: 2.

Figure 2

3.  Extent of Changes in Social Adjustment (Level of Free time Activities of Patient) over different time periods among Rural Persons with Schizophrenia: (N = 30)

The results of Repeated Measure ANOVA conducted on Level of free time activities of patient to see the differences in the means scores at the four time intervals (1 – 2, 1 – 3, 1 – 4, 2 – 3, 2 – 4, 3 – 4 assessments).  It shows that the mean scores was increased significantly (P<0.001) on level of free time activities of patient of social adjustment during this period.  Moreover it also indicates that improvement in this aspect of social adjustment was sustaining during the subsequent assessments followed by the social work intervention.  The overall change in mean value of this domain is shown in figure: 3.

Figure 3



4. Extent of Changes in Social Adjustment (Level of Satisfaction of Family Members) over different time periods among Rural Persons with Schizophrenia:

The results of Repeated Measure ANOVA conducted on level of satisfaction of family members to see the differences in the means scores across the four time intervals (1 – 2, 1 – 3, 1 – 4, 2 – 3, 2 – 4, 3 – 4 assessments).  It shows that the mean scores was increased significantly (P<0.001) on level of satisfaction of family members of social adjustment during this period.  Moreover it also indicates that improvement in this aspect of social adjustment was sustaining during the subsequent assessments followed by the social work intervention.  The overall change in mean value of this domain is shown in figure: 4.

Figure 4


Discussion
 I.  Socio-demographic Characteristics of Rural Persons with Schizophrenia:
Majority (72 %) of the samples were in the age range of 18 – 40 years. Among these samples 36% of them were in the age group of 21 – 30 years and highlighting the fact that most individuals affected by the schizophrenia were in the economically productive age group.  The gender wise distribution of the sample indicated that sixty two percent of the samples in the study were male patients.  Several studies have documented the reason for the under utilization of health services by women in India was lack of access to health care (Ramalingaswami, 1987; Khan et al., 1982).  With regard to marriage, 53% of the samples in the study were married while 30% were never married.  A majority of the patients were Hindu (86.7%) and Muslim contributed 13.3% of the sample.  The unequal representation of the sample is due to national characteristics.  Majority (30%) of the subjects in the samples were primary school educated.  On the whole the highest educational qualification among the respondents was higher secondary which was done by 6% of sample.  Majority of the respondents 46% were illiterate.  Educational impairment was well documented in literature on Quality of Life in patients with schizophrenia (Calvocoressi et al, 1998).

The occupational status of the respondents is also an indicator of disability related issues.  Around 60% of the sample in the study was unemployed due to schizophrenia and 26.7% of the samples were coolies.  Many of the respondents who employed are performing poorly and may be in danger of losing their jobs.  As far as the income of the respondents is concerned 60% of the respondents did not have any income of their own, 30% percent of them had a monthly income of below Rs.500 and only 6.7% had a monthly income of Rs. 1001 – 2000.  The group was characterized by low educational levels, poor occupational status and low income levels.  These findings reflect the low per capita income of unorganized sector in our country.  Lower income can also intensify the problems in the family following the diagnosis of Schizophrenia.    With regard to duration of illness 46% of the samples had illness for 2-4 years, 16% of them had illness between 6-8 years and 23% of the subjects had illness more than 10 years.  Majority (80%) of the respondents had the diagnosis of paranoid Schizophrenia.

II. Socio-demographic Characteristics of Family Members of Rural Persons with Schizophrenia:

In this study, majority (56.7%) of the caregivers belong to nuclear family, reflecting the changing structure of families in the Indian society and changes in the social support system networks that can result to this. Indian families are in a state of transition and the joint family structure is undergoing radical changes resulting in the nuclear households as a means of adaption.  This shrinkage of the family size also results in narrowing down the supportive networks that is essential in the coping process with schizophrenia more during the symptomatic stage.  With regard to the age distribution of care givers of the respondents, majority (36.7%) of the family members were between 51 – 60 years, and about 53.3% of the care givers were female and majority (66.7%) of them were working as coolies.  Care giving is a complex and challenging phenomenon and women often face the dual challenge of care giving and dealing with their own vulnerability.  As Bharat (1995) pointed out, in countries like India, care givers would either be the elderly parents, often physically and financially weaker, or wives or partners who mainly occupy position of dependency.  Thus, on the whole the subjects in the study are heterogeneous in nature covering several background variables.

III. Effects of Social Work Intervention on Social Adjustment among persons with Schizophrenia in Rural Areas:

The persons with schizophrenia are known to have severe social adjustment problems in addition to their clinical symptoms.  Hence, it is often stressed that the interventions with such patients must focus on reducing the severity of their difficulties and improves the social adjustment in the community.  It is proved that the social work interventions would help the patients to resolve their problems (Perlman, 1957).  Weissman, et al., (1973) and Chandrasekhar-Rao (1994), who have reported the impact of social work interventions on social adjustment of patients with mental disorders.  The results of these studies indicated that the patients who received social work services than who received the alternative clinical services have showed significantly more change in the severity of social adjustment during the period of experimentation.  The present study was focused on social adjustment through monthly social work intervention for persons with schizophrenia in rural areas.  There was a significant reduction in the level of expectations of family members after social work intervention, and it showed that there was an improvement in the care givers’ expectation.  There was a higher level of improvement in the area of patient’s performance after exposing them to social work intervention and it showed that the level of performance of the patients had increased significantly.  The level of satisfaction of the family members was increased significantly after improvement shown by the patients with schizophrenia.  The social work intervention increased their level of satisfaction and also it was sustained in the following assessments at the time of second month after intervention and fourth month after intervention.  There was an increased level of improvement in the free time activities of patient after exposing social work intervention and it showed that the level of free time activities of the patient had increased significantly.  These improvements were sustained in the subsequent assessments such as second month after intervention and fourth month after intervention.  

Overall, after the Social Work Intervention, there was a significant in the mean scores of all the domains of Social Adjustment like Level of Performance of patient’s Social Activities, Level of Expectation of Family Members, Level of Free Time activities of Patient, and Level of Satisfaction of Family Members.  This proves that the Social Work Intervention could improve the social adjustment and social functioning of persons with schizophrenia in rural areas.  These findings are similar to the earlier studies in the community (Hogarty and Goldberg, 1973; Linn, et al., 1979).

LIMITATIONS OF THE STUDY:
The limitations of the present study are first the sample size for the intervention group was only thirty patients and significant family members, and this size is not big enough for generalization of the findings; second the inclusion criteria of the sample ensured that only patients who were not actively symptomatic included in the study.  This excludes a number of patients who have serious symptomatology.  Whether social work intervention is useful for them or not, cannot be gauged from the study.  Thirdly owing to time constrains, the assessment after intervention was restricted to 2nd month and 4th month assessments only.

Conclusion
The purpose of this research work was to establish Psychiatric Social Work Intervention model for social adjustment of persons with schizophrenia in the rural areas.  In doing this, factors that are associated with the development of the intervention model and the outcome in terms of social adjustment were specifically studied.  It is evident from the findings that social work intervention is effective in helping the persons with schizophrenia in improving their social functioning and reducing their family member’s problems.  The study established the usefulness of a group work approach in dealing with patients suffering from schizophrenia in rural areas.  Conducting similar studies in different settings, would contribute the social work knowledge so as to make this profession more meaningful in future.

 



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