INTRODUCTION:

India is a secular and pluralistic society characterized by tremendous cultural and ethnic diversity. In India the family is the most important institution that has survived through the ages. India, like most other less industrialized, traditional, eastern societies is a collectivist (a sense of harmony, interdependence and concern for others) society that emphasizes family integrity, family loyalty, and family unity. More specifically, collectivism is reflected in greater readiness to cooperate with family members and extended kin on decisions affecting most aspects of life, including career choice, mate selection, and marriage¹.

When we look at the family as a unit, the following features are common across the globe: it is universal, permanent, nucleus of all social relationships, has an emotional basis, has a formative influence over its members, teaches its members as to what is their social responsibility and the necessity for co-operation and follows a social regulation².

In India, family is the key resource in the care of family members when they are ill and also even in patients with mental illness. Families assume the role of primary caregivers for two reasons. First, it is because of the Indian tradition of interdependence and concern for near and dear ones in adversities. Second, there is a paucity of trained mental health professionals required to cater to the vast majority of the population; hence, the clinicians depend on the family.

Mental illness can be defined as a clinical, significant, behavioural or psychological syndrome that occurs in a person and this is normally associated with impairment in one or more important areas in functioning, or an important loss of freedom³.

The society views the mental illness as something to be ashamed of and usually the members of the society initially recognize most of the mentally ill patients behaviour deviated from the social norms⁴.

In such a stage the families play an important role in caring of these mentally ill patients even though the family members of the mentally ill patients are less likely to label the individuals behaviour as mental illness. The core concept of the care giving consists of accepting the patient, encouraging and supporting the patient and assist in the daily activities of the patient⁵

The World Health Report 2001 has stated that nearly 45 crore of people suffering from mental and behavioural disorders globally⁶. In China, it is estimated that there are 16 millions of adults with mental illness; 30 millions of adolescents and children with emotional and behavioral problems and numerous old people with dementia and mental problems⁷. In India the prevalence rates for all mental disorder is 65.4/1000⁶.

Mental illness is increasing day by day due to competitive life, poverty, developmental changes and different physical disorder. An estimated 26.2% of American ages 18 and older about one in four adult suffer from diagnosable mental disorder in a year. About 6% or 1 in 17 suffers from serious 1 mental illness⁸.

Globally, it is estimated that 450million people are affected by mental disorders at any one time. These include 121million people with depression, 24 million with schizophrenia and 37million with dementia⁹. Mental illness accounted for about 12.3% of the global burden of disease in 2001 and it is estimated that by 2020 unipolar depressive disorders will be the second most important cause of disability. The burden of caring for mentally ill patients falls on the family members who provide all necessary support¹⁰.

Mental illness may cause a variety of psychosocial problems such as decreased quality of life for the patient’s family members, as well as increased social distance for the patient and the family caring for the patient. The family members who care for relatives with mental illness report feeling stigmatized as a result of their association with the mentally ill¹¹.

Persons with serious mental illnesses often engage in behaviours that are frightening, troublesome, disruptive, or at least annoying, and many relatives are obliged to control, manage, or tolerate these behaviours¹². Thus, psychiatric professionals often view the family members of a patient as people of support because they can act as informants regarding the patient and they can act as co-therapists at home¹³. The family members need to be in an optimal social and psychological state. It is reported that reduced function of one family member contributes to the burden of other members and this in turn leads to other family members assuming a critical attitude towards the patient¹⁴. Such criticism can in some cases lead to a relapse of the patient’s illness or to the family feeling overwhelmed by the patient’s disruptive behaviour^11,15.

A research finding reveals that families should assume major roles in supporting relatives with mental illness; and collaborative plans should include strategies to assist family members and consumers in dealing with stigma ¹⁶. There is a relationship between caregivers’ social support and stigma associated with relative with mental illness.

In a study investigating the links between stigma, depressive symptoms and coping amongst caregivers, it was found that stigma may erode the morale of family caregivers and result in withdrawal from potential supporters¹⁷.

Coping differs from one family to another for a variety of reasons. In developed countries, some researchers have emphasized coping as a key concept for the study of adaptation and mental health^18,19. However, the effects of age, duration of illness, living arrangements and other contextual factors on the coping styles of family caregivers, and on the recovery or rehabilitation of persons with mental illness are important factors to be considered¹⁹.

In this case, family caregivers have to learn and understand the patient’s characteristics and behavior. Coping with symptoms such as delusions, hallucinations, inappropriate behaviours, and violence may often require lengthy, complex, and distressing negotiations. Over burdened caregivers employ less effective coping strategies, report more frequent physical and mental health problems and use services more often²⁰.

Studies have shown that in taking care of the mentally ill, the family caregivers have to face the stress and burdens which includes: feelings of insecurity sorrow and worry potential harm, aggression and also stigmatization by relatives and friends. Lastly social isolation fear in the future ²¹.

In the past 50 years, a shift towards community care and the deinstitutionalization of psychiatric patients has resulted in transferring of responsibility and day-to-day care to family members²². In part, this shifting of responsibility has been caused by a deficit in community support services. The profound psychosocial, physical, and financial impact on the family of individuals with severe mental illness is comparable to that of persons with other illnesses such as Alzheimer’s disease or cancer.

During the ward round with students and other team members the investigator observed the family members of long term hospitalized mentally ill persons such as separation from family and friends and source of gratification as well as loss of personal health control over the life circumstances as compare to the other families.

The investigator also felt to gain a preliminary understanding of the relationship between psychosocial problems and the coping strategies used by the family members in caring for mentally ill patient. Family members need to be educated to be open to reviewing and encouraged to updating their knowledge to face with psychosocial problems towards caring for mentally ill, and how to cope up with the stress and in order to make mentally ill person to lead an optimum level of life as an individual in the society.

OBJECTIVES:

1. To identify the psychosocial problems among significant family members of mentally ill patients.

2. To correlate the psychosocial problems of family members of mentally ill patients with their selected demographic variables.

3. To identify the coping strategies among significant family members of mentally ill patients

MATERIALS AND METHODS:

Research design and approach:

A descriptive research design and quantitative approach was used to conduct the study.

Setting of the Study:

The study was conducted at MHI (COE), SCBMCH, Cuttack.

Sample and sampling technique:

50 significant family members of mentally ill patients selected by non probability convenient sampling technique.

Description of The Tool:

The tool has three parts i.e part “A”, part “B” and part “C”

Part “A” consists of demographic variables of significant family members of mentally ill patients.

Part “B” consists of the questionnaire related to the psychosocial problems of significant family members of mentally ill patients. The questionnaire in this section was formulated in the form of likert scale, which consists of 30 items on a 4 -point Likert scale format (4=always, 3=frequently, 2= sometimes,1=never). The questionnaire was divided into six subheadings such as financial problem, disruption of routine family activities, disruption of family leisure, disruption of the family interaction, effect on physical health of the others in family, effect on mental health of others in family.

Part “C” The COPE Scale (Carver et al.,1989): The COPE is a 60-item measure comprising 15 subscales with 4 items each. The subscales are active coping, planning, suppression of competing activities, restraint coping, instrumental social support, emotional social support, positive reinterpretation and growth, acceptance, turning religious, focusing on and venting emotions, denial, behavioral disengagement, mental disengagement, alcohol disengagement, and humor. Each item is a statement worded in the first person that indicates the use of a particular coping response and is rated on a 4-point scale format [ 1=I usually don’t do this at all,2= I usually don’t do this a little bit,3= I usually don’t do this a medium amount, 4= I usually don’t do this a lot].

Validity and Reliability:

Validity refers to the degree to which an instrument measures what it suppose to measure. Content validity concern the degree to which an instrument has appropriate sample of items for the construct being measured and adequately covers the construct domain. The content validity of the tool (psychosocial problems) was established from various experts in the field of psychiatric, clinical psychology, psychiatric nurse specialist, and statistician.

Reliability of the tool was tested by test-retest method where co-efficient correlation was to find out (r =0.88), the tool was found to be more reliable.

Etical Committee approval:

Approval taken from Institutional Ethical Committee, S.C.B Medical College, Cuttack.

Data collection procedure:

Prior to the data collection, Written consent was obtained was obtained from the significant family members of mentally ill patients.

Planned data analysis:

The collected data were organized, tabulated and analyzed by using descriptive and inferential statistics.

FINDINGS:

Distribution of significant family members of mentally ill patients according to their demographic variables reveals that Highest Percentage (40%) of the family members were in the age group of 48–60 years. A majority (66%) of them were male and (92%) of them were Hindus and (8%) of them were Muslim. Majority (60%) of them were married (36%) of them were farmer.

Highest percentage (30%) of them were illiterate and majority (50%) of them were having income ≤

Rs.5000 and (56%) of them from nuclear family. Highest percentage (58%) of them were from rural area and (44%) of them were mother. Majority (38%) of them had >5 years of illness and (76%) of them were having no family history of psychiatric illness.

Table No. 1. Percentage of Scores revealing psychosocial problems

Sl. No.	Psychosocial problem	Psychosocial problem Score	Number	%
1.	No problem	1 - 30	0	0
2.	Mild problem	31 - 60	4	8
3.	Moderate problem	61- 90	42	84
4.	Severe problem	91 - 120	4	8
Total			50	100

Table: 1- Depicts that that that 84% of the significant family members of mentally ill patients having moderate problem whereas 8% of them having mild and also 8% of them also having severe problems. Hence it can be interpreted that highest percentage of them having moderate problems

Table No.2: Means, Mean%, standard deviations, and internal reliabilities for the COPE Inventory according to problem focused, emotion focused and dysfunctional coping.

Sl. No.	Coping strategies	Mean	Mean %	SD	Cronbach alpha coefficients
	Problem focused Coping
1	Active coping	12.74	79.63	1.68	0.6
2	Planning	13.24	82.75	1.9	0.55
3	Suppression of competing activities	13.32	83.25	2.08	0.63
4	Restraint coping	15.64	97.75	0.66	0.41
5	Instrumental social support	15.64	97.75	0.52	0.90
	Emotion focused coping
1	Emotional social support	10.9	68.13	3.71	0.93
2	Positive reinterpretation	10.6	66.25	2.42	0.61
3	Acceptance	13.5	84.38	2.54	0.87
4	Turning to religion	12.78	79.88	3.02	0.87
5	Humor	4.04	25.25	0.28	0.70
	Dysfunctional coping
1	Focus on and venting emotions	9.48	57.25	4.18	0.81
2	Denial	6.16	38.5	6.64	0.57
3	Behavioral disengagement	5.74	35.86	1.61	0.72
4	Mental disengagement	5.94	37.13	2.38	0.80
5	Alcohol disengagement	4.88	30.5	1.01	0.54

The coping strategy most often used by the significant family members of mentally ill patients was restraint coping and instrumental social support (M=15.64) and the least used was humor (M=4.04) and Alcohol disengagement (M=4.38). Hence it can be interpreted that the highest percentage of significant family members was used Restraint coping and Instrumental social support (M=15.64).

The internal consistency of COPE Inventory exhibited Cronbach’s alpha (α) coefficients ranging from 0.93 (Emotional social support) to 0.41 (Restraint coping). However, the Restraint coping scale exhibited a lower alpha coefficient (0.41).

CONCLUSION:

From the findings of the present study, it can be concluded that the Most of the significant family members of mentally ill patients (84%) under this study had moderate problem whereas (8%) of them had mild and also (8%) severe problems. The coping strategy most often used by the significant family members of mentally ill patients was restraint coping mean score (15.64±0.66) and instrumental social support mean score (15.64±0.52) and the least used was Humor mean score (4.04±0.28) and Alcohol disengagement mean score (4.38±0.28). The internal consistency of COPE Inventory exhibited Cronbach’s alpha (α) coefficients ranging from 0.93 (Emotional social support) and Instrumental social support (0.90) to 0.41 (Restraint coping). However the (Restraint coping) shows lower alfa (α). Mostly Problem focused coping strategies (14.12±1.37) was used by the significant family members of the mentally ill patients.

IMPLICATIONS:

Nursing Practice:

The mental health care professionals to actively work with the family members of patients with psychiatric illness to decide suitable psychosocial intervention and coping strategies to address their psychosocial problem associated with mental illness, to improve their quality of life and enhance their coping skills Regular in-service education programme can be conducted to refresh, up-to-date knowledge and skill on psychosocial problems and coping strategies of family members can help the family members in patients care

Nursing Education:

Recommendations for nursing education include that psychiatric nurses should receive training on the strengths of family members in supporting their mentally-ill family members

Family interventions should focus on expanding training to patients and key relatives about wellness recovery, skills training, and task sharing of household and self-care chores.

Nursing Administration:

The Administrator should motivate the staff nurses, to learn how to identify the psychosocial problems and their coping strategies of family members as well as patients; it will help in providing quality care.

Appropriate teaching skills in the form of problem solving and communication are needed to promote the coping abilities and lessen the psychosocial problems of the family members

Nursing Research:

Many more innovative studies have been conducted on psychosocial problems and coping strategies of family members. The research design, findings and the tool can be used as avenues for further research. This study will serve as a valuable reference material for future investigators.

RECOMMENDATIONS:

A large- scale study can be carried out to generalize the findings. A comparative study can be conducted with other chronic patients in different settings.

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Received on 24.04.2022 Modified on 10.05.2022

Int. J. Nur. Edu. and Research. 2022; 10(3):244-248.

DOI: 10.52711/2454-2660.2022.00057