The International Journal of Psychosocial Rehabilitation

Evaluating the Effectiveness of Supported Apartment in Facilitating Community Integration and Mutual Help among Residents with a Chronic Mental Illness in Hong Kong: Some Preliminary Findings

Dr. Daniel Fu Keung Wong
Associate Professor
Department of Social Work and Social Administration
The University of Hong Kong
1317 KK Leung Building
Pokfulam Road
Hong Kong
E-mail: dfkwong@hkucc.hku.hk,
Tel: (852) 28592096, Fax: (852) 28587604

Mr. Stephen Yu Kit Sun
Lecturer
Division of Social Studies
City University of Hong Kong

Tat Chee Avenue, Kowloon Tong
Kowloon,Hong Kong


Mr. King Sin Lin Chiu
Social Worker
Department of Social Welfare,
Special Administrative Region, Hong Kong

Citation:
Wong, D.F.K., Sun, S.Y.K.S., & Chiu, K.S.L.  (2003)   Evaluating the
Effectiveness of Supported Apartment in Facilitating Community Integration and
Mutual Help among Residents with a Chronic Mental Illness in Hong Kong: Some
Preliminary Findings. International Journal of Psychosocial Rehabilitation. 7, 133-143


Abstract
Objectives: The effectiveness of supported apartment in enhancing community integration, mutual help and social support network among persons with a chronic mental illness was examined in this study.Methods:Three well-established instruments measuring the above-mentioned variables were administered to 14 residents in their first, sixth and twelve months of residence in supported apartment.Results:Positive changes in community integration, mutual help and social support network were found at twelve months. Only one resident had experienced relapse during this period of evaluation.Conclusions: The results provide some initial support for the effectiveness of supported apartment in facilitating community integration, mutual help and social support network among residents.

Introduction
Residential services for persons with psychiatric problems aim to assist the persons to live independently and to re-integrate into the community (Hong Kong Government, 1999). In Hong Kong, halfway houses and long-stay care homes are two major types of community-based residential programs to serve the above goal (Hong Kong Government, 1999). Long stay care homes intend to provide accommodations and basic skills training for chronic patients with psychiatric problems who require nursing care but do not need active medical treatment (Hong Kong Government, 1999). However, it has been suggested that only a few residents were able to move along the “residential continuum”, and many remained in long-stay care home (Carling & Curtis, 1997). Indeed, according to the statistics of a local agency running long stay care homes for persons with psychiatric problems, there were around 9.5% of residents living in these facilities who could be successfully discharged (New Life Psychiatric Rehabilitation Association, 1997, 1998, 1999). It has also been criticized that such a large institution with 200 residents creates segregation rather than integration, and dependency rather than independence (Yip, 1997).
Halfway houses provide transitional residential care for persons with psychiatric problems who are able to return home or live independently and to re-adjust to normal life (Hong Kong Government, 1999). Through small group living, various types of skills training and professional support, residents are expected to be able to maintain mental stability and develop skills and confidence for community living (Hong Kong Government, 1999).Studies conducted overseas (e.g. Rog & Raush, 1975) and in Hong Kong (Lai, 1986) reveal that halfway houses could reduce recidivism and enhance residents’ independence. However, halfway houses in Hong Kong have been criticized as another form of ‘community institution’ (Yip, 1997).With a capacity of 40 residents, halfway houses provide limited personal privacy (Nelson, Hall & Bowers; 1998) and depersonalized care practices (Kruzich, 1985) and possibly produce institutionalized residents (Yip, 1997). Indeed, local studies have found that psychiatric patients discharged from halfway houses were living in deprived situations and many were still in need of regular care and psychosocial support (e.g. Mak, Gow & Mak, 1993).
Drawing on the experiences of other countries, the Mental Health Association of Hong Kong has introduced supported apartment as an alternative residential facility for persons with psychiatric problems.This type of residential service is less structured, and encourages residents to draw on their own personal resources to help one another.As a home-like environment, this apartment has fewer residents, and employs mainly non-professional staff (i.e. 1 welfare worker and 2 caretakers, in the case of Hong Kong) to be responsible for house keeping, clerical duties and assistance to residents.  In Hong Kong, supported apartment is run according to the following principles:
1.Privacy and home-like environment
Privacy refers to ‘the ability to control access to one’s personal space and what happens to and in one’s private space and time (Wilson, 1991). Privacy includes the availability of personal space as well as the right to use one’s space. In the development of this supported apartment in Hong Kong, particular attention has been put towards ensuring that residents have freedom in the way they use their apartment space. They are free to keep a certain amount of personal belongings, and to decorate their own space. Moreover, they keep the keys to their rooms.
Our supported apartment service has two adjacent units.Each unit is decorated as an ordinary home with a sitting area, a kitchen and a laundry.The unit has single and three-person rooms and can accommodate a total of 10 residents.Besides common areas, each resident has about 70 square feet of personal space.With such a relatively small number of residents and a rather large area, it provides a sense of comfort and quietude for the residents.Since there are few rules that govern the daily routines of residents, residents can structure their own daily activities and enjoy normalized household practices such as cooking and laundry.
2.Minimal rules and maximum choices for residents
Residential services should create opportunities for making choices and decisions. Staff respect the decisions of residents in their choices of daily living schedules and activities unless these choices create inconvenience and/or are harmful to others. Supported apartment in Hong Kong aims to create an environment so that residents can be fully involved in choosing their living preferences: what they want to do and how they go about doing these. Minimal rules and regulations are set to ensure that individual choices do not interfere with the lives of others. Otherwise, residents can enjoy as much freedom and choices as they desire.
3.Residents’ initiated approach to programming
Unlike staff of a halfway house, staff of the supported apartment in Hong Kong do not attempt to actively engage residents in the planning and implementation of their rehabilitation plans. Nor do they purposefully organize activities for the residents. However, if and when residents raise personal interests that involve himself or herself or other residents, staff will assist them to fulfill their needs and interests. For example, a resident who wanted to learn to cook Chinese foods was assisted by a staff to learn to do so. Another example is that: a resident who wanted to watch a movie with other residents was assisted to approach other residents and to organize the event. While this approach helps residents to develop their own interests and fulfill their own needs, it also develops residents’ abilities to take initiative to deal with their own concerns.
4.Development of mutual help among residents
The availability and adequacy of social support are found to be a key condition for successful community integration (Froland et. al., 2000; Nelson et. al., 1998). Therefore, supported apartment in Hong Kong attempts to foster a sense of mutual support among residents. Through the monthly residents’ meeting and informal gathering organized by the residents themselves, residents were encouraged to develop friendship among each other. It is believed that such a kind of support is more appropriate for residents, as friendship developed may be enduring and stable.The role of staff is to link and facilitate the development of this mutual help among residents.
This study aimed to examine the effectiveness of supported apartment in facilitating community integration and social support of residents. As such, it is necessary to delineate how we conceptualized the concepts of community integration and social support.
Conceptual Understanding of Community Integration and Social Support
The concept of community integration
Community integration is a multi-dimensional concept that has not been well-defined (Carling, 1992; Kennedy, 1989). A review of the literature suggests that community integration may be defined according to the following dimensions:
1.Reduced rate of recidivism
A reduction in the rate of readmission to mental hospitals has been proposed as one-way of defining community integration (Rosenblatt & Mayer, 1974). Living in the community is, indeed, a pre-condition for community integration. This is particularly meaningful for people with a chronic mental illness because individuals with a chronic mental illness will have a greater chance of relapse should they be improperly managed in the community. Therefore, it is not surprising to find that community-based psychiatric services use recidivism as an important indicator of successful community integration (Kruzich, 1985, New Life Psychiatric Rehabilitation Association, 1998).
a) Social integration
Forrester-Jones and Grant (1997) suggests that social integration includes three dimensions:
a) Locational integration refers to the physical integration of individuals within community setting (Malin, 1987).  People with disabilities should not be placed in remote and segregated areas in the community, and should be present in accessible and visible areas in the community.
b) Environmental integration is defined as ‘the physical context in which individuals live, and the wider community in which people interact’ (Forrester-Jones & Grant, 1997). Individuals with disabilities should not be placed in large and institutional-like settings, but live in ordinary facilities with maximum opportunities to interact with people outside of the facilities (Davey, 1994, Hogan & Carling, 1992).
c) Participatory integration denotes ‘the frequency of clients’ participation or involvement in the ongoing activities of their community (Dilks & Shattock, 1996). These activities include: accessing to basic, personal and community resources; participating in family life, friendship relationship and community groups; and using community recreational facilities. These kinds of activities were regarded as normative social behaviors. An individual may be perceived as socially integrated if he or she participates in these activities on a regular basis (Shadish & Bootzin, 1984).
In this study, community integration was defined in terms of the rate of recidivism and the level of social integration found among residents living in the supported apartments.It was hypothesized that residents who had lived in the supported apartment after a period of twelve months would have lower rate of recidivism and be more socially integrated.
The concept of social support
Despite the diversities in the definitions of social support, researchers have generally agreed that social support consists of the following two dimensions (Barrerra, 1986; Newcomb & Chon, 1989; Sarason, Pierce &Sarason, 1990)
1.Social network
Social network is a specific set of linkages among a defined set of persons (Mitchell, 1969), and that individuals within this network have regular face to face interactions and a degree of commitment to one another (Broom & Selznick, 1973).  Essential characteristics of a network include such things as size (i.e. the number of people who make up the network); density (i.e. the ratio of actual links in the network) and multiplexity (i.e. the prevalence of certain types of ties). It is generally believed that the larger the network size and the broader the linkages, the greater the availability of social support.
2.Support function
Social support may be defined in terms of support functions exchanged by network members in a social relationship. House (1981) identifies four main functions of social support that include emotional support, appraisal support, informational support and instrumental support. Other researchers have suggested other functions of social support such as action-facilitating support and nurturant support (Cutrona & Suhr, 1990); material aids; and guidance (Barrera, 1981). Studies have found that these functions of social support can enhance the physical health and psychological well-being of an individual (Forrester-Jones & Grant, 1997). In the field of psychiatric rehabilitation, social support is also found to be a significant factor in enhancing community integration of persons with a chronic mental illness (Forland et. al, 2000; Caron et al, 1998).
In this study, social support was defined in terms of social network and support functions.It was hypothesized that residents who had lived in the supported apartment for a period of twelve months would have a larger social network with a greater exchange of support among residents.
Relationships between Community Integration and Social Support
for Persons with Mental Illness in Residential Settings
Studies have revealed that social support was found to be closely related to residents’ overall functioning, subjective well-being (Lehmann, 1982) and community integration in residential care settings (Nelson et. al., 1992; Caron et al, 1998). Particularly, Nelson, et al (1992) noted that residents in group homes and supported apartments had more supportive social network transactions with friends and professionals and greater frequency of support exchanged among people in the community. Lehmann (1982) also found that social support, which enhanced residents’ well-being and social contacts within and outside of a residential setting, were associated with greater satisfaction and better functioning of residents. To conclude, these studies show that a living environment with sufficient social support is beneficial to facilitating residents’ rehabilitation and social integration.
Objectives

This study had the following objective:

1.To evaluate the effectiveness of supported apartment in facilitating community integration, social support network and mutual support among residents with mental illness

Method

Research design

A time series research design was adopted, and residents were individually interviewed according to a structured questionnaire in the first month of having resided in the apartment, at the sixth and twelfth months. The questionnaire contained questions on demographic characteristics of residents and three well-established instruments:

1.External Integration Scale aimed to examine the level of community integration of residents, (Segal & Aviram, 1978). A five-point scale, with “5” denoting “Most Frequently” and “Very Easily” and “1” being “Never” and “Very difficult” was used. The Cronbach’s alpha scores for the full scale and their domains achieved in this study were 0.90; 0.61; (frequency of daily outdoor activities); 0.92 (level of independence in accessing public facilities); 0.83 (level of independence in handling issues of personal care); 0.75 (degree of easiness in maintaining contact with family members); 0.43 (degree of easiness in maintaining friendship); 0.83 (frequency in performing voluntary work) and 0.50 (frequency of leisure activities).

2.Lubben Social Network Scale attempted to tap the frequency of contact initiated by the resident towards his/her family members and friends (Ma, 1990), and it had two subscales: social support network-family members and social support network-friends. Residents were given six choices regarding how often they had contacts with family members and friends and how many times they had such contacts. The Cronbach’s alpha scores for the full scale and their subscales were 0.73; 0.63 (social support network-family members) and; 0.92 (social support network-friends).

3.Mutual Support Network Scale was used to measure the perceived instrumental support and social companionship obtained by residents from other residents of supported apartment (Fung, 1999). Residents were asked the extent to which they found certain elements of instrument and social companionship support as sufficient or not. It was a five-point scale with “5” denoting “Very Insufficient” and “1” being “Very Sufficient”. The Cronbach’s alpha score achieved in this study was 0.88.

Samples

All residents living in the supported apartment who met the following criteria were included as subjects of this study.
1) Residents must have continuously resided in the apartment for twelve months prior to post-test,
2) Residents had to be between 18 and 60 and had a diagnosis of a serious mental illness such as schizophrenia.
Data collection procedures
All incoming residents were informed of the purposes of the study prior to admission to the supported apartment. Three ratings were taken: within the first month, at the end of the sixth month and at the end of the twelve months of residence at the supported apartment. All residents were personally interviewed according to the structured questionnaire designed by the researchers. A student research assistant was recruited and trained to conduct these structured interviews.
Results

Table 1 shows the profile of the residents. There were more male residents than female residents living in Clara House. Many were single, with an average age of about 45 years old, and suffer from chronic schizophrenia. Most of them had multiple admissions to the hospitals in the past.The majority of residents worked in sheltered workshops. Since some had income below the level set by the government, they received income supplement through social security.

Table 1: Demographic characteristics of residents of supported housing (N=14)
Characteristic
Frequency (%)
Sex
Male 
Female
 
8 (57.10%) 
6 (42.90%)
Age
29-40 
41-50 
51-60 
Mean (S.D.)
 
5 (35.70%) 
6 (42.80%) 
3 (21.30%) 
44.93 (7.46)
Marital status
Single 
Divorced
 
11 (78.60%) 
3 (21.40%)
Type of illness
Schizophrenia 
Other
 
13 (92.90%) 
1 (7.10%)
Duration of illness
Under 5 years 
6-10 years 
11-15 years 
Over 20 years
 
1 (7.10%) 
1 (7.10%) 
3 (21.30%) 
9 (64.50%)
Number of hospitalizations
Once 
Twice 
Three times 
Four or more times
 
3 (21.40%) 
4 (28.60%) 
4 (28.60%) 
3 (21.40%)
Income source (more than one type)
Open employment 
Sheltered employment 
Supported employment 
Social security assistance
 
2 (14.30%) 
11 (78.60%) 
1 (7.10%) 
6 (42.90%)
Table 2 indicates that residents had made some improvement in community integration, social support network and mutual support over a one-year period. At twelfth month, a slight improvement in the overall score in community integration was noted. Specifically, residents achieved a higher level of independence in accessing public facilities, attending to personal care, and feeling easy in maintaining contact with family members and friends. In terms of network size, it is noted that residents had expanded their overall social network size, as well as in family and friendship networks. The sense of mutual support among residents had also increased from time 1 to time 3. Lastly, only one resident experienced a relapse at time 2. On the whole, although changes were modest and did not achieve a statistically significant level, residents’ community integration, social support network and mutual support had improved over a one-year period.
 
Table 2   Residents’ change in scores in community integration, social
support network and mutual support (N=14)
Items
1 month
6 months
12 months
Overall community integration (CI)
2.70
2.80
2.76
CI- frequency of daily activities 
2.94
3.06
2.85
CI- level of independence in accessing public facilities 
 
3.07
 
3.32
 
3.28
CI- level of independence in handling issues of personal care 
 
3.25
 
3.55
 
3.46
CI- level of ease in maintaining contact with family members
 
2.63
 
2.75
 
2.69
CI- level of ease in maintaining friendship
 
2.62
 
2.62
 
2.82
CI- frequency of performing voluntary work 
 
2.29
 
2.14
 
2.14
CI- frequency of leisure activities
2.13
2.13
2.13
Overall social support network
2.50
2.74
2.75
SSN-family
2.52
2.71
2.60
SSN-friends
2.45
2.76
2.90
Overall mutual support 
2.97
2.95
2.81
Relapse
0
1
0

Discussion

Before embarking on a discussion of the findings, it is important for readers to realize the limitations of the present study. First, this study adopted a non-randomized time-series design and did not have a control group. In the initial stage of the process, the researchers did attempt to identify and recruit persons with a chronic mental illness who chose to live independently as subjects for the control group. However, the response rate was so low that the researchers had to forgo such an idea. In the absence of a control group, it was impossible to make an affirmative conclusion of the improvement found in residents in this study. Another limitation is that, this study was not a double-blinded design and both the researchers and the residents were aware of the purposes of the evaluation. Consequently, biased results might have occurred. Therefore, ideas discussed below should be considered as tentative, and require further examination.
 
This study reveals that there was only one resident who had relapsed and had to be hospitalized. The rest remained mentally stable. It has been argued that a reduction in the rate of rehospitalization is an indication of successful community integration (Rosenblatt & Mayer, 1974). Indeed, mental stability is a precondition for community living, and therefore, is also a necessary condition for successful community integration. Residents’ stable mental conditions may be related to the fact that supported apartment provided residents with a sense of comfort, ease and enjoyment in having personal space. Therefore, these positive elements in the living environment served as protective factors that maintained the mental states of residents (Nelson, Hall & Bowers, 1998).
 
This study has also found that residents became more socially integrated into the community. They had achieved a higher level of independence in accessing public facilities, handling issues of personal care, and feeling easy in maintaining contact with family members and friends.  A number of reasons might have accounted for the positive results in social integration. First, the positive changes in social integration may be related to the style of operation of the supported apartment. King and  Raynes (1968) have proposed two operational styles of residential service.  Institution-oriented style of operation denotes that residents living under this type of operation are often treated alike for ease of management.  As a result, rigid daily routine, block treatment and formalized skills training are often imposed on the residents irrespective of individual needs.  On the other hand, resident-oriented style of operation emphasizes individuality, and that services will try to accommodate to residents’ individual needs (Wilson, 1991). Under this type of operation, residents learn to take initiatives and make decisions to address their own needs. They tend to be more independent and maintain a greater sense of control over their lives. Supported apartment in Hong Kong operates according to a resident-oriented style of management, and the positive changes in social integration might have been a reflection of this style of operation. There were minimal rules and regulations that govern the operations of the apartment and residents were free to engage in daily and social activities outside of the residence. Consequently, there was a higher level of social integration achieved by the residents.
 
Another reason for a positive change in social integration is that, social companionship established in the apartment had encouraged residents to jointly participate in social and daily activities in the local community. It is not uncommon to find that residents went shopping together and accompanied one another to tea drinking, sports and other social activities. While it might be difficult to venture out on one’s own, it would be much easier to do so with others. Indeed, the positive effects of social companionship go far beyond the realm of social integration, it can promote health and well-being among the persons involved. Indeed, studies have found that social companionship was an important determinant of mood and well-being (Rook, 1987), and enhanced self-esteem through compassionate interactions (Hays, 1988).
 
This study reveals that residents expanded their size of social networks and perceived themselves as having sufficient instrumental and social companionship support from others at the twelfth month. The increase in friendship network size might have been due to the fact that residents had built up friendships among other residents. The questionnaire did not ask the source of friendship and therefore could not distinguish friendships established inside of the residence and in the community. Nonetheless, the increase in social support network can enhance the social integration of residents because residents receiving instrumental and social companionship support are likely to be motivated to participate in social and daily activities in the community. Moreover, a supportive and harmonious living environment is conducive to mental stability of the residents. Studies conducted by Breier and Strauss (1984) have actually found that the existence of supportive social network can protect residents from the impact of life stresses, reduce morbidity and provide the support that are important for community living.
 
The modest increase in family network size was a positive and encouraging sign because it has always been an objective of psychiatric rehabilitation to help persons with a chronic mental illness to be socially connected to their family members as much as possible.  Indeed, studies have found that family support was associated with improvement in well-being for persons with mental health problems (Sun, 1994). Besides, it has always been a Chinese virtue to foster a sense of family spirit of mutual sharing and support among family members. The tapering of the score at twelfth month can be explained in terms of the fact that, in the initial stage, family members might have been more involved in helping the residents to settle in the apartment. Once, the residents had adapted to the new environment, it was not uncommon for family members in Hong Kong to become less involved. This is a common phenomenon that happens to many residential services and often challenges the workers to find ways of helping residents and family members to be as connected as possible.
 
It is found that residents perceived themselves as having more and more mutual support from other residents at time
3.While it is understood that living together might have provided a platform for mutual support and help, it is more likely the atmosphere of the setting and the opportunities for interactions that had accounted for the perceived sufficiency of mutual support generated among residents.As supported apartment in Hong Kong aims at providing a home-like environment where residents can enjoy as much privacy and freedom to choose their own preferences, it has become a safe and comfortable place for residents to linger, wander and return (Copper, 1989). A safe and home-like environment might have encouraged the development of trust and mutual support among residents.
 
The opportunity for interactions among residents is essential to building residents’ mutual help and support.The staff of supported apartment encourage residents to raise ideas about social and recreational group activities and to implement these activities with the help of the workers. However, workers have also initiated some activities for residents from time to time, such as Lunar New Year celebration and Mid Autumn Festival. Through these activities, residents can build up friendships and mutual help among each other.   Besides, “old” residents are encouraged to help newcomers to settle in the apartment.  They escort residents to community walk and help them with shopping and etc. With these opportunities available for interactions, it is understandable why residents had an increased sense of mutual help and social support at the end of their first year of residence in supported apartment.
Conclusion

This study provides some initial evidence about the effectiveness of supported apartment in facilitating community integration and mutual help among residents with a chronic mental illness in Hong Kong. Findings suggest that at twelfth months, residents were more social integrated, and achieved a higher level of independence in accessing public facilities, attending to personal care and feeling easy in maintaining contact with families and friends. Moreover, they experienced an expanded family and friendship networks at the end of the twelve months.  However, these results will certainly be enhanced by the inclusion of a control group in future studies.



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