University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES PROVIDING MENTAL HEALTH CARE TO PATIENTS: EMOTIONAL, SOCIAL AND ECONOMIC CONSEQUENCES ON CAREGIVERS NAA ADOLEY ADDO ID: 10220470 THIS DISSEERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FUFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Naa Adoley Addo hereby declare that this proposal is a result of my independent work. References to other works have been duly acknowledged. I further declare that this proposal has not been submitted for award of any degree in this institution and other universities elsewhere. NAA ADOLEY ADDO …………………. …………….. (STUDENT) SIGNATURE DATE DR. FRANKLIN GLOZAH ……………….. ……………. (SUPERVISOR) SIGNATURE DATE University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to the memory of my late dad, Mr. Richard Mettle Addo, the brave warrior. You were happy to see me start the programme and went all out for me. Unfortunately, the Lord called you into His bosom before my completion. Your support and great faith in me pushed me even during the sad times of your demise. I know you are happy and proud of me. Your words, ―hard work breaks no bones‖ and ―you must learn very hard‖ will never depart from me. The work you started has only just begun, daddy. I will make you even more proud! God bless you daddy! You will forever remain in our hearts. Rest in perfect peace! University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I made it by the Grace of God and I am eternally grateful for His mercies and faithfulness. I would like to say thank you to my supervisor, Dr. Franklin Glozah, for his patience, understanding and constant support throughout the course of this wok and engaged me in useful discussions on various aspects of this study. To Prof. Philip Adongo, my head of department at the Department of Social and Behavioural Sciences(SOBS), School of Public health, University of Ghana, Legon, thank you. To My mum, Nina Angela de-Veer who has been of immense help. Her constant encouragement, love and support propelled me through this course. You kept me going To my husband and kids, thanks for your love, support and understanding. I cannot forget my siblings and extended family members who encouraged and supported me through to the completion of the course. My special thanks go to the Medical Director, Specialists, Medical officers, nurses and other staff of the Accra Psychiatric Hospital for their immense support during the data collection. Finally, to all my friends and course mates, especially my SOBS mates, I could not have done this without your support. I am eternally grateful. University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Mental illness is debilitating both to immediate families and the society at large. In Ghana, mental illness is not treated as a priority in healthcare. Persons caring for their mentally-ill relatives often feel burdened, helpless and sometimes ignored by other family members and the society. The main objective of this study is to examine the social, economic and emotional consequences on families as a result of taking care of mentally-ill relatives attending the OPD of the Accra Psychiatric hospital. Methodology: This study used a qualitative research method that purposively sampled 10 caregivers who accompanied mentally-ill patients to the psychiatric hospital. Caregivers (comprising seven males and three females aged between 29 and 69 years) were interviewed with the aid of an interview guide. Interviews were recorded on audio, transcribed and themes analysed. NVivo 11 was used to analyze the data and emerging themes were identified. Results: Themes related to emotions generated from the interviews were depression, strained marital relations, anxiety and psychological distress that could lead to physical ill-health such as hypertension. Economic related themes generated include loss of productive time, loss of economic value and a general reduced quality of life of both caregivers and their dependents. Social related themes that emerged from the interview are negative family effects, risk of isolation and stigmatization. Some additional themes generated included reduction in leisure, change in domestic routines and a reduction in physical activity. Mental illness often affects the caregiver‘s social life and economic problems arise frequently. Some of the consequences experienced were hard to bear and exerted considerable strain on care givers‘ lives. Despite this, majority remained committed to continuing to stay with and care for their patients. Conclusion: The burden of caregivers should not be overlooked by clinicians, policy makers and the government.The provision of adequate emotional, economic and social support will significantly reduce caregiver burden. University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ........................................................................................................................ i DEDICATION ........................................................................................................................... ii ACKNOWLEDGEMENT ....................................................................................................... iii ABSTRACT .............................................................................................................................. iv LIST OF TABLES ................................................................................................................... vii LIST OF FIGURES ............................................................................................................... viii DEFINITION OF TERMINOLOGY ....................................................................................... ix CHAPTER ONE ........................................................................................................................ 1 1.1 BACKGROUND .............................................................................................................. 1 1.2 PROBLEM STATEMENT .............................................................................................. 3 1.3 RESEARCH QUESTIONS: ............................................................................................. 4 1.4 MAIN OBJECTIVE ......................................................................................................... 5 1.5 CONCEPTUAL FRAMEWORK ................................................................................... 6 CHAPTER TW O ....................................................................................................................... 9 LITERATURE REVIEW .......................................................................................................... 9 2.0 Introduction ...................................................................................................................... 9 2.1 Gl obal mental health ........................................................................................................ 9 2.2 Mental health in Africa .................................................................................................. 11 2.3 Mental health in Ghana .................................................................................................. 13 2.4 Caregiver Factors that affect c  onsequences................................................................... 14 2.5 S ocial consequences   of caring for mentally-ill patients. ............................................... 16 2.6 Economic consequences   of caring for mentally-ill patients. ........................................ 18 2.7 Emotional c onsequences   of caring for mentally-ill patients. ........................................ 21 CHAPTER THREE ................................................................................................................. 24 METH OD OLOGY .................................................................................................................. 24 3.0 Introduction .................................................................................................................... 24 3.1 STUDY AREA ............................................................................................................... 24 3.2 DESIGN ......................................................................................................................... 26 3.3 P OPULATI  ON AND SAMPLE ................................................................................... 26 3.4 SAMPLING TECHNIQUE ........................................................................................... 26 3.5 INCLUSI  ON AND EXCLUSI  ON CRITERIA ............................................................ 27 3.6 DATA C  OLLECTI  ON TOOLS ................................................................................... 27 3.7 ETHICAL ISSUES ........................................................................................................ 27 University of Ghana http://ugspace.ug.edu.gh 3.7 DATA ANALYSIS ........................................................................................................ 28 CHAPTER F OUR ................................................................................................................... 31 RESULTS ................................................................................................................................ 31 4.1 Introducti on .................................................................................................................... 31 4.2 Characteristics   of participants ....................................................................................... 31 4.3 Summary  of themes ....................................................................................................... 34 4.3.1 Emotional consequences   of caring f  or mentally-ill relatives ................................. 34 4.3.2 Social consequences   of taking care   of mentally ill relatives .................................. 39 4.3.3 Economic consequences   of taking care   of mentally-ill relatives ........................... 45 CHAPTER FIVE ..................................................................................................................... 49 DISCUSSION .......................................................................................................................... 49 5.1 Intr oducti on ................................................................................................................... 49 5.3 Emoti onal c onsequences  of caring f or mentally-ill relatives ........................................ 50 5.4 Economic consequences  of caring f or mentally-ill relatives ......................................... 51 5.5 S ocial c onsequences  of caring f or mentally-ill relatives. ............................................. 53 LIMITATI ONS  OF THE STUDY ...................................................................................... 55 CHAPTER SIX ........................................................................................................................ 56 SUMMARY  OF FINDINGS, C ONCLUSI ONS AND REC OMMENDATI ON .................. 56 6.1 Intr oducti on ................................................................................................................... 56 6.2 Summary  Of Findings .................................................................................................... 56 6.3 C onclusi ons ................................................................................................................... 57 6.4 Recommendati ons .......................................................................................................... 58 REFERENCES ........................................................................................................................ 61 APPENDICES ......................................................................................................................... 66 APPENDIX 1: INTERVIEW GUIDE ................................................................................. 66 APPENDIX 2: V  OLUTARY C ONSENT F ORM .............................................................. 67 Appendix 3 ........................................................................................................................... 69 Appendix 4 ........................................................................................................................... 70 APPENDIX 5: ETHICAL APPR  OVAL ............................................................................. 71 University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Details of caregivers(N=10) ...................................................................................... 33 Table 2: A Table representing the c  odes and pseud  onyms   of participants ............................ 69 University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: A c onceptual framew ork f or em oti onal, s ocial and economic consequences  on caregivers  of mentally-ill patients. ..................................................................................... 7 Fig 3.1: The   out-patient department   of the Accra Psychiatric hospital .................................. 25 University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMINOLOGY 1. Mental disorder: A medical condition that disturbs an individual's reasoning, feeling, mood, disposition, ability to relate to others and every day functioning. 2. Lack of insight: The lack of ability of the affected individual to appreciate that symptoms of a mental illness are unreal or that the signs are as a result of the sickness. 3. Hallucination: A perception without an external stimulus. Hallucinations can happen in relation to any of the five senses. That is, the sense of touch, smell, taste, sight and hearing. 4. Delusions: An unequivocally held fixed but false belief that isn‘t shared by others from the patient's locality. These could be related to topics such as feeling of self- importance, sexual or religious delusions. 5. Persecution— When mentally-ill persons falsely believe they are victims of some form of danger or are the main focus of a conspiracy 6. Passivity— When mentally-ill patients falsely think that their thoughts or activities are being controlled by an external force or individual. 7. Thought disorder—an inability to utilise language in a sensible and coherent way which usually shows as distorted or unreasonable speech. 8. Caregiver A person who has been living with the patient for over a year and has been closely involved in his/her activities that affect their daily living, healthcare, emotional and social dealings for more than a year, without receiving remuneration for their efforts. 9. Emotional Consequences: The presence of symptoms such as depression, anxiety, insomnia and excessive worry that impair an individuals‘s functioning University of Ghana http://ugspace.ug.edu.gh and could result in physical ill-health of the individual, due to taking care of a mentally-ill patient. 10. Economic consequences: The presence of problems, difficulties, challenges, loss of opportunities to earn an income or adverse effects due to taking care of a mentally-ill patient. 11. Social Consequences: All forms of discrimination and stigma associated with mental illnesses which result in situations such as loss of friends, spousal desertion, exclusion from family and withdrawal or refusal of admission into schools. 12. Mental health care- This refers to the resources, treatments and interventions available to mentally-ill patients in order to be fully integrated into society and live a life as normal as possible. University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 BACKGROUND The 4th edition of the DSM (Diagnostic and Statistical Manual) by the American Psychiatric Association describes mental illness as clinically significant change in forms of behavioural or emotional functioning that are linked with an observed level of agony, grief (pain, bereavement), or injury in one or more parts of functioning (e.g. work, societal and domestic relations); and the foundation of the impairment may be biological, or environmental factors, or a combination of them (DSM – IV, 1999). This area of health is very important as no one can function without an adequate state of mind. Mental illnesses include Bipolar Affective disorders, Schizophrenia, Depression, Mood disorders such as mania, personality disorders as well as intellectual disabilities. Schizophrenia is known to be a chronic and frequently a disabling mental disorder that accounts for about one(1) per cent of the world's population affected with mental illnesses. ( Insel, 2010). It is a mental illness that is among the world's top ten causes of long-term morbidity and in some cases, mortality. Symptoms associated with schizophrenia are apathy, psychosis, social withdrawal and cognitive impairment, which may lead to problems in social, personal and occupational functioning, and self-care. About one (1%) of the population is affected by schizophrenia, with similar rates across different countries, races, cultures and sexes. Schizophrenia may usually develop between the ages of sixteen (16) and thirty (30) years and would mostly persist throughout an affected individual‘s lifetime. Aetiological factors of schizophrenia are unknown, however, scientific evidence suggests genetic factors, early environmental influences (eg obstetric complications), and social 1 University of Ghana http://ugspace.ug.edu.gh factors like poverty as contributory factors. There are no known biological alterations that are pathognomonic of schizophrenia, although research has shown that many pathophysiological differences exist in several brain structures. Antipsychotic medications are the mainstay for treating schizophrenia, but not the cure. A number of psychological and social treatments are also helpful, but not curative. These include cognitive-behaviour therapy for psychosis, family interventions, supported employment, social skills training, assertive community treatment, teaching illness self-management skills and integrated treatment for co-morbidities such as substance misuse(Mueser & McGurk, 2004). Depression is known to cause significant distress and impairment in physical, social, occupational and other key areas of functioning. Women are estimated to be twice as likely as men to develop depression. (Stewart, Gucciardi, & Grace, 2004). According to the World Health Organisation (WHO), psychiatric disorders accounted for as much as twelve per cent (12%) of the total global disease burden in 2000. In the year 2020, it is estimated that this figure will rise to 15% , when unipolar depression is predicted to rise to second from the fourth most disabling health condition in the whole world(WHO, 2001). Using the World Health Organization formula for estimating the prevalence of psychiatric illness in any country, it is said that 10% of any given population experiences neuropsychiatric conditions and one per cent (1%) from severe mental illness at any particular time(WHO, 2001). It has been estimated that about 2.4million people suffer from mental illness in Ghana . Ghana reported 1,500 records of suicide cases annually and this is caused by depression(The Daily Graphic, 2015). Ghana lacks adequate social support and funding for mental health, resulting in caregivers having to bear the socio-economic consequences of the disease. A caregiver, defined here, is a person, typically a family member or friend, who helps a ill person with the physical care and management of a disease and doesn‘t receive remuneration for his or her services to the patient. The task of caregiving usually results in additional 2 University of Ghana http://ugspace.ug.edu.gh responsibilities on the caregiver's daily life. These responsibilities occupy the caregiver‘s energy, time and attention, which is demanding and complex. This burden associated with caregiving, when prolonged, might affect the physical health of caregivers, causing symptoms, such as anxiety and depression, hypertension and may lead to a negative impact on their for social life (Briggs, 2012). In Ghana, when the consequences of providing care was estimated using the WHO Impact of Caregiving Scale, Independent sample t-tests, correlations and analysis of variance were utilized. The relationship between background characteristics and the consequences of caregiving were found. A Linear regression used to look at determinants of the burden of providing care showed that: The mean age of caregivers was sixty-one years (standard deviation 14.5), the male:female ratio was almost equal. Averagely, about two adults per household required care. Under five percent of caregivers who took part in the research got monetary support as well as emotional, physical and personal care support. The residence, financial provison, health and physical help to recipients of care and receipt of financial, physical and health support were critical determinants of the results of providing care The research confirmed that the number of people who required care far out-weighed the number of people who provided care, thus demonstrating the high caregiver load in the nation. (Sanuade & Boatemaa, 2015). 1.2 PROBLEM STATEMENT Mental health remains one of the health areas of concern that has been neglected for several years in Ghana. The Mental Health Act 2012 passed by the parliament of Ghana in the month of March 2012 is a noteworthy point of reference in tending to psychiatric disorders as a matter of public health concern and furthermore in the insurance of the human rights of 3 University of Ghana http://ugspace.ug.edu.gh people living with psychiatric illnesses in Ghana. The last significant modification of the mental health law in the nation was in the late 1960s, bringing about the enactment of the Mental Health Decree, NRCD 30, in 1972(Forster, 1971). This act was passed mainly to address the problem of funding mental health, amongst other things. The Act seeks to promote de-institutionalization and promote homecare as well as to provide free treatment for affected persons. However, though home care is being promoted, funding is woefully inadequate resulting in family members having to bear the socio- economic consequences of the disease. The Mental Health Act proposes the setting up of a fund. Even though it is not clear how much funding would be required to run an effective and efficient mental health service, it is indeed clear that a lot is required. The health sector budgetary allocation for mental health is just over 2.2% versus the WHO-recommended 15%, a disproportionately small allocation even by the standards of a resource-constrained country. This shows how much mental health care is not regarded as a priority in this country (Omar et al., 2010). These patients are mostly mentally-incapacitated to work and so their relatives have to bear the cost of care as well as cater for their needs and this becomes a burden for both patient and caregiver. If the issue of funding mental health is not made a priority, these numbers will certainly go up as caregivers may even become patients themselves as a result of the social, emotional and economic burden they may encounter. 1.3 RESEARCH QUESTIONS: 1. What are the social consequences as caregivers take care of mentally ill relatives attending the OPD of the Accra Psychiatric hospital? 4 University of Ghana http://ugspace.ug.edu.gh 2. What are the economic consequences as caregivers take care of mentally ill relatives attending the OPD of the Accra Psychiatric hospital? 3. What are the emotional consequences as caregivers take care of mentally-ill relatives attending the OPD of the Accra Psychiatric hospital? 1.4 MAIN OBJECTIVE The main objective of this study is to examine the social, economic and emotional consequences on families as a result of taking care of mentally-ill relatives attending the OPD of the Accra Psychiatric hospital. Specific Objectives: a. To examine the social consequences on caregivers as a result of taking care of mentally-ill relatives attending the OPD of the Accra Psychiatric hospital b. To examine the economic consequences on caregivers as a result of taking care of mentally-ill relatives attending the OPD of the Accra Psychiatric hospital c. To determine the emotional consequences on caregivers as a result of taking care of mentally-ill relatives attending the OPD of the Accra Psychiatric hospital 5 University of Ghana http://ugspace.ug.edu.gh 1.5 CONCEPTUAL FRAMEWORK The public health burden arising from mental dis orders acr oss the w orld has been well d ocumented. Mental diseases have c onsiderable negative c onsequences  on the quality  of life  of patients and their caregivers. Caregiver burden has been described as the  overall physical, em oti onal, and financial c osts  of caring f or a relative suffering fr om a mental c onditi on. Caregivers‘ experiences enc ompass distress, stigma, w orry, shame, and guilt. M ost researchers and mental health pr ofessi onals have c oncentrated much time and eff orts  on pe ople living with Mental illnesses. There is n ow the need t o f ocus  on caregivers  of patients with Mental c onditi ons as well, especially in devel oping c ountries where health systems f or managing mental health patients and their caregivers are lacking. In Ghana and  other African c ountries, wide family netw orks including church s ocieties pr ovide supp ort t o individuals  or gr oups  of pe ople when s ocial pr oblems such as death  or disasters  occur. Pers ons suffering fr om mental illness and their caregivers are marginalized such that these s ocial supp ort systems are virtually n on-existent. Caregivers  of mentally ill health patients have n o ch oices but t o carry their physical, em oti onal, spiritual, and financial needs s olitarily. There is theref ore the need f or better understanding  of caregiver experiences in pr oviding care f or their relatives affected by Mental illnesses. This will help health service pr oviders and law- makers t o better understand the needs  of caregivers when targeted caregiver interventi ons are planned. 6 University of Ghana http://ugspace.ug.edu.gh ECONOMIC CONSEQUENCES: o Unemployment and poverty o Inadequate time and o resources for other Emotional activities Consequences Inappr opriate provision for mentally-ill patients SOCIAL CONSEQUENCES:  Stigma  Discrimination  Lack of support from Increased others consequences on  Emotional trauma caregive r  Depression Figure 1: A c onceptual framew ork f or em oti onal, s ocial and economic consequences  on caregivers  of mentally-ill patients. Source: Author’s original creation 7 University of Ghana http://ugspace.ug.edu.gh JUSTIFICATI ON  OF THE STUDY The trauma experienced fr om mental disorders cann ot be  over-emphasized. The economic burden and mental ag ony  on the family in particular are very significant. M ore imp ortantly, the prevalence  of mental dis orders in the c ommunity is still rising. Whereas kn owledge ab out  other major health pr oblems such as diabetes and Hypertensi on are c omm on, there is the lack  of the same degrees  of kn owledge ab out mental dis orders. Ghana lacks adequate s ocial supp ort f or mental health patients. The s ociety is such that the stigma  on mentally-ill patients is very high and s o getting empl oyment is difficult. If they d o find jobs, empl oyers terminate their app ointments when they find  out they have a mental illness, especially if they have an epis ode at w ork,  or, they bec ome a laughing st ock and get s o embarrassed that they even quit  on their  own. Most  of these patients end up staying at h ome and being highly dependent  on relatives (caregivers) as they are unable t o purchase their  own medicati ons. In additi on, they are unable t o pr ovide basic needs such as f o od, shelter, cl othing, transp ortati on and even s ometimes are unable t o attend regular reviews  on  out-patient basis  on their  own. Caregivers bec ome  obligated t o pr ovide all the ab ove as well as transp ortati on and time in  order t o impr ove the mental health status  of patients. They als o end up being stigmatized because  of all the inc onveniences the have t o g o thr ough f or their relatives and this may affect them em oti onally, s ocially and economically. This study will help t o bridge the kn owledge gap and als o impress  on the law-makers the imp ortance  of funding mental health. 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TW O LITERATURE REVIEW 2.0 Introduction This chapter presents a review  of literature ass ociated with the  objectives  of this study. It c omprises literature  on Gl obal mental health, mental health in Africa, Mental health in Ghana and Caregiver factors that affect consequences. It als o f ocuses  on the s ocial and ec on omic and emotional c onsequences  of caring f or mentally-ill patients. 2.1 Gl obal mental health W orld Health   Organisation (World Health Organisation, 1948) defines health as a state   of c  omplete physical, mental and s ocial well-being and n ot merely the absence   of diseases   or infirmity. American Psychiatric Ass ociati  on in Diagn ostic and Statistical Manual 4th edition (DSM – IV, 1999) describes mental illness as clinically significant patterns   of behavi oural   or em oti onal functioning that are ass ociated with some level   or distress, suffering (pain, death),   or impairment in   one   or m ore areas   of functioning (e.g. w  ork, s ocial and family interacti  ons); and the basis   of the impairment may be bi ol ogical,   or envir onmental fact ors, or a combination   of them. These references are classical in the field of psychiatry, and though old, cannot be overlooked in this study. The World Health   Organizati on approximates that 21 million people suffer fr om the illness worldwide which can als  o be implied t o mean that the same number   of families are equally affected by the dis order. Evidence has sh own that schiz ophrenia is the most severe mental health illness, representing the eighth(8th) cause   of disability in the w orld (Serretti et al, 2009). Schizophrenia is a severe mental illness which causes a significant disturbance in thinking, in percepti ons, in em  oti  ons and in c  conduct. It makes the patient perceive things which d  o not exist. Thus, it is very difficult t  o have any meaningful interacti on with the patient (Guo et al., 2007). 9 University of Ghana http://ugspace.ug.edu.gh The illness is characterized by the f ollowing sympt oms: Delusi ons, Hallucinati ons, Disorganized speech, Disorganized   or catat onic behaviour, and Negative symptoms such as alogia   or flattening   of affect. The patient must have experienced at least tw o   of the ab ove sympt oms and at least   one   of them sh  ould be delusi ons, hallucinati ons   or disorganized speech f  or a specified peri od. Continuous signs   of the disturbance must persist f  or at least 6 m onths, during which the patient must experience at least   one c ontinuous m onth   of active sympt oms.(American Psychiatric Association, 2013). Schiz ophrenia is   one   of the m ost seri ous and frightening   of all mental illnesses. There is n  o   other mental disorder that ar ouses as much anxiety in the general public, the media, and d  oct  ors as Schizophrenia. Even th  ough effective treatments are available, patients and their relatives   often find it hard t  o access good care. In the United Kingd om, as in many parts   of the w  orld, this is   often due t o po or service provision, but sometimes it is simply down t  o misinf ormation. In Ghana, it is as a result   of poor understanding and mis-prioritizati on   of mental health. (Picchioni & Murray, 2007). Alm ost half   of all schiz ophrenics als  o present with a lifetime hist ory   of substance use dis  orders (SUD), a rate that is much higher than in unaffected individuals (Volkow, 2009). Affected patients may als o have c  omplicati ons such as anxiety and depressi  on. Alth ough current treatments pr ovide c ontr ol rather than cure, l ong-term h  ospitalisati on is n ot required and pr ogn osis is better than traditi onally assumed,   once   on medication(Jim van Os & Kapur, 2009). Alth ough great advances in pharmacotherapy   of schiz ophrenia and related dis orders have been made, a large percentage   of persons with schizophrenia remain at least partially nonresp onsive t  o treatment some relapsing even   on medicati  ons, leading t  o increased morbidity and mortality, increased healthcare cost, and p o or quality   of life f  or affected 10 University of Ghana http://ugspace.ug.edu.gh individuals as well as their caregivers(Van Sant & Buckley, 2011). Antipsych otics are h owever still the mainstay in the pharmac ol ogic treatment   of schiz ophrenia and have pr oven t  o be much efficaci ous(Tandon, Nasrallah, & Keshavan, 2010). 2.2 Mental health in Africa Even though mental illnesses have rec  orded a high prevalence, they c ontinue t  o remain a low priority in Africa. There have been little   or no investigations   of the views   of stakeholders in Africa   on why this is and what can be done (  Omar et al, 2010). Stakeholders themselves simply have no interest. Primary and sec ondary data sources fr  om a situati onal analysis d  one   on mental health services in the three c ountries (Ghana, Uganda and S  outh Africa) were analysed. The findings indicated that significant challenges remain in integrating mental health care int  o primary health care. In Ghana, mental health care is n ot catered f or by the nati onal health insurance scheme. P o or implementati  on   of p olicy, lack access t  o essential drugs and inadequate number   of mental health specialists are s ome   of the reas ons f ound. (Bhana, Petersen, Baillie, Flisher, & The Mhapp Research Pr  ogramme C ons ortium, 2010). Maj ority (three-quarters )  of the gl  obal mental health burden exists in l  ow- and middle- inc  ome c  ountries (LMICs), yet the lack   of mental health services in these settings with p  o  or settings is striking (Mendenhall et al., 2014). Health p olicies in Africa just d o n ot give much c onsiderati on t  o mental health and thus the difference between mental health care in devel  oped c  ountries and the under-devel  oped   ones. It is time every c  ountry f  ormulates a mental health policy based   on its   own s  ocial and cultural and ec  on  omic realities. These p  olicies must take int  o acc  ount the sc  ope   of mental 11 University of Ghana http://ugspace.ug.edu.gh health pr  oblems, pr  ovide pr  oven and aff  ordable interventi  ons, safeguard patients' rights, and ensure equity (Gureje & Alem, 2000). In a study done in Malawi on mental illnesses, majority (63.3%)   of respondents   opini onated that they w ould be afraid t  o have a conversati on with a mentally-ill pers on. 68.5%   of participants said they w ould be able t  o maintain a friendship with a mentally-ill pers on. H owever, less than half: 8.1%, 18.6% and 40.6%   of the resp ondents said they w ould be ashamed if their relative was diagn osed   of a mental illness, marry an individual previ ously diagn osed   of a psychiatric dis  order and share a r o om with a mentally-ill pers on respectively. (Crabb et al., 2012) In Nigeria, Pe ople with mental dis orders were believed t  o be mentally retarded, a public nuisance and theref ore were danger ous. This is what theref ore inf ormed maj ority   of participants decisi on n ot t o have social interacti ons with patients diagn osed with mental dis orders (Gureje et al., 2005). Ab out 83% rep orted that they w  ould be afraid t  o have a c onversati on, 78% said that they w ould be upset   or disturbed about working   on the same job, 81% rep orted that they w ould n ot share a room, and 83% resp onded that they w ould feel ashamed if pe ople knew that s ome one in their family had been diagnosed with a mental illness.   only 17% reported that they could maintain friendship with a pers on with mental disorder (Gureje et al., 2005). Als o, a classical study which cannot be overlooked was   of attitudes t  owards 10 physical and mental illnesses in the Ethi opian p opulati on by Mulatu (1999) revealed a gap in attitude depending up  on the illness characteristics. Diagn oses with the str ongest stigma attached were leprosy, schizophrenia and tuberculosis, with less than 20%,   of the participants prepared t  o w  ork with, be friends with   or marry a pers  on with schiz ophrenia. Less than 25%   of the participants were prepared t  o w  ork with, be friends with   or marry a pers  on with 12 University of Ghana http://ugspace.ug.edu.gh lepr  osy and with less than 33%,   of the participants were prepared t  o work with, be friends with   or marry a person with tuberculosis. 2.3 Mental health in Ghana In Ghana, the   occurrence   of mental illness has been found t  o be about 13% (Addo & Aikins, 2013) The main burden   of ill-health, as in many sub-Saharan c  ountries, comprise communicable diseases, illnesses due t  o malnutrition and poor reproductive health. Even th ough these c onditi  ons are tackled,   other diseases, such as mental disorders and substance misuse dis orders, are als  o   on the rise and thus bec  oming the f  ocus   of devel  opment eff orts. In Ghana, it has been estimated that there are 2 166 000 individuals who have a mild t  o m oderate mental disorder, with a further 650 000 suffering from a severe mental disorder,   out   of a populati on   of 21.6 milli  on(WHO, 2010). As at 2003, the country's mental health workforce consisted   of   only 9 psychiatrists (  only 4   of whom w  orked in mental health services), 451 nurses and 160 c ommunity psychiatric nurses(The WHO World Mental Health Survey Consortium, 2004). At the moment, there are just 5 c  onsultant psychiatrists in active service in the public sect  or and 11 retired psychiatrists in the c  ountry. Appr  oximately 33 000 individuals are seen each year in Ghana by mental health services, there is an estimated treatment gap   of 98%(Ofori-Atta & Ohene, 2014). M ost mental healthcare is pr  ovided at the three large psychiatric hospitals, in the south   of the c  ountry. However, eff  orts have been made t  o decentralize this system   of care by providing community psychiatric units in every health facility. This is reflected in the ratio   of   out-patient attendance t  o admissi  on, which is 4.64 for mental health, c  ompared with 14.6 f  or all health c  onditions. In Ghana, it is estimated that about 32%   of all mental health conditi ons reported at the psychiatric h ospitals are diagnosed   of schizophrenia(Osei, Roberts, & Crabb, 2011). 13 University of Ghana http://ugspace.ug.edu.gh In Ghana, Ngissah (1975) c ompared the attitudes   of 564 American High Scho ol and C ollege students fr om Sacramento (Calif ornia) with 280 Ghanaian High Sch  o  ol and College Students fr  om Accra t  owards the mentally ill. Results   obtained sh  ow a m  ore negative and rejecting attitudes t owards mentally-ill pers  ons in the Ghanaian sample. 57.9%   of the Ghanaian resp ondents held the view that mental illness in the family brings shame   on the family name and 57.5% that it was wise t  o keep it a secret as much as p  ossible. 60.4%   of the Ghanaian participants felt that mental illness is n  ot an illness like   other illnesses, 78.9% agreed that patients in mental h ospital behaved like children and 71.8% subscribed t  o the   opinion that any  one h ospitalized f  or a mental illness should be banned from voting, thus taking away this basic human right. Sodzi-Tetteh (2007) c oncluded that the stigma towards mental illness is more seri ous than imaginable. He stressed that this stigma affects everything fr om the p olicy ad option stage thr  ough t  o c  ommitment and implementation   of the policy including c ommunity-based care. He argues that the plight   of the mentally-ill patients would have been better if n ot f  or the neglect by p oliticians and Ghanaians as a whole(Sodzi-Tetteh, 2007). 2.4 Caregiver Factors that affect c  onsequences The W orld Health   Organizati on estimates that ab  out 40-90%   of schizophrenic patients live with their families(World Health Organisation & Organization, 2008). A caregiver can be defined as a person being part   of the patient‘s family wh o takes responsibility f or the patient and dev otes his   or her time t  o take care   of the patient with out getting any financial remuneration(Gutiérrez-Maldonado & Caqueo-Urízar, 2007). Caregiving in Africa is mostly done by family members and close ass ociates like friends and relatives. Although, relatives are the most valued and the most dependable resources f  or the sick person and the family members play a significant role in helping their mentally impaired 14 University of Ghana http://ugspace.ug.edu.gh relatives, family caregivers are not appreciated for seeking the well-being   of their patients and relatives.(Glozman & Glozman, 2004). In health sciences, caregiver burden refers t  o the collective set   of stressful exposures   or ―stressors‖ that the caregiver faces(Friedemann-Sánchez & Griffin, 2011). Previous studies identified factors that may influence caregivers‘ burden. These included caregiver‘s characteristics, care recipient characteristics, caregiver‘s resources, and caregiver‘s support characteristics. Caregiver characteristics, such as gender, age, and kinship to the care recipient, have c  onsistently been associated with burden(Cumming, 2012). Caregivers play an important role in the management   of chronic mental illness in the c ommunity. Caring f  or patients with chronic mental illness like schizophrenia can cause deep emotional distress in the caregivers. H owever, the magnitude   of the pr oblem remains largely unknown in Sub-Saharan Africa and   other developing countries (Yusuf & Nuhu, 2011). A study in Iraq on mental health shows that the respondents have a fair knowledge   on the factors that cause mental illness.   Over half (51.32%)   or (61.5%)   of respondents agree that mental illness is caused by brain disease   or genetic inheritance respectively and nearly half (46.39%) belief that substance abuse is the cause   of mental illness and about two third (67.24%) believe mental illness is caused by something bad happening t  o you while less than a third (30.17%) thought mental illness is God‘s punishment and nearly two third (59.23%) view personal weakness as the cause(Sadik, Abdulrahman, Bradley, & Jenkins, 2011). A study   on Caregivers' knowledge   of etiology   of mental illness in a tertiary health institution in Nigeria revealed that Majority (244   or 61.9%)   of the respondents believed drug and alcohol misuse could cause mental illness, while the belief that it c  ould be due t  o 'curse' were rep  orted by   only 75 (19.0%) respondents. Male gender was significantly associated 15 University of Ghana http://ugspace.ug.edu.gh with belief that alcohol and drug misuse, stress, genetic inheritance, physical illness, and poverty were causes   of mental illnesses. Higher educational status was als  o ass  ociated with alcoh ol and drug, traumatic events, stress, genetic inheritance, and physical abuse as causes   of mental illness. Now, there is a better knowledge   of mental illness am  ong caregivers than the predominantly supernatural causes earlier attributed t  o mental illness by Nigerian c  ommunities. In   order t  o sustain this, there is need f  or c  ontinu  ous psycho-education (Issa, Parakoyi, Yussuf, & Musa, 2008). Another study in Nigeria revealed a remarkably p oor knowledge about mental illness. Not   only do they believe mental illness is due t  o p ossessi on by evil spirits   or divine punishment, but there is als  o a widespread belief that misuse   of drugs is the cause   of mental illness. This view is n ot c  ompletely wrong. However, since this is   only true f  or a very limited number   of individuals affected with mental disorders. Since the public   often views the misuse   of drugs as moral failing, this belief may be translated t  o a notion   of mental illness as being self- inflicted. Such a view is m ore likened t  o condemnation, where pe ople are blamed f  or their conditions, rather than understanding(Gureje & Alem, 2000). 2.5 S ocial consequences   of caring for mentally-ill patients. Mental illness alt ogether influences s oci o-economic status   of caregivers   of patients. As per a research conducted by Grad (2010), more than fifty (50) per cent   of the participants experienced deep and pr olonged peri ods   of intense worry t  o stressing   over the patient.   one   out   of every five   of them attributed s omatic symptoms like poor sleep, headaches, excessive irritability, and depression t  o their concern about their relative‘s conduct. The recreational and social exercises   of 33%   of the families had been c  onfined; alm ost a third had had their domestic r outine dis organized (h ousew ork, shopping etc); ab out a quarter had had their earnings reduced by at least 10%, and a tenth by m  ore than 50%. Inf ormation 16 University of Ghana http://ugspace.ug.edu.gh gathered indicated that in   one f ourth   of the families interviewed, s  ome  one had t  o quit their job   or absent themselves from w  ork in   order t  o look after their mentally-ill relative. M  ore than 33%   of the children in such families were disturbed and irritated. Individuals with psychiatric dis  orders experience the ill effects   of negative s ocial states   of mind which result fr om disgrace, stigma and misguided judgments   of psych ol ogical wellness issues(Patrick W. Corrigan & Penn, 1997). As indicated by Sodzi-Tetteh (2007), the vast majority do not want their relatives t  o specialize in mental health due t  o stigma attached t  o mental disorders. A few people decline t o g o f  or their relatives wh o have rec overed fr om the illness fr om the hospital. H owever,   others even give wrong addresses with the g oal that they w on't be f oll owed. Sh ockingly, some health professionals trust that a patient with dysfuncti onal behavior can never genuinely be fully well. A research on mental health investigated the delineation   of mental illness thr ough two primary government print media in Ghana from 2003 t  o 2012. Emphasis was placed   on   observing the daily papers‘ utilizati on   of dialect t  o describe individuals with psych ol ogical disorders. Data   obtained was analyzed with c  ontent analysis. Discoveries sh owed that in spite   of the m ove t  o change the unfav ourable and unacceptable disc  ourse   on mental illness, state-  owned media in Ghana c ontinue t  o use derogat ory language t  o depict this p opulace. Negative descriptor words such as ‗insane‘, ‗mad‘ and ‗mentally deranged‘   or ‗dumb‘ keep   on surfacing in print media. Shockingly, the use   of this language has the tendency t  o propagate the stigmatizati on   of mental disorders and undo some   of the strides made in curbing the situation. Notwithstanding, the study noticed that there were a few   occasi ons where the media tried t o teach people in general   on psychological illnesses in   order t  o get rid   of confusions and stigma and also t o advocate f  or enhanced services as well as personnel 17 University of Ghana http://ugspace.ug.edu.gh f  or that area. The study demonstrated how stigma keeps   on dominating the discussi  on   on mental disorders in Ghana(Mfoafo-M‘Carthy, Sottie, & Gyan, 2016). 2.6 Economic consequences   of caring for mentally-ill patients. In 2009, ab out 66 milli on Americans (three in 10 U.S. h ouseh olds) revealed n o less than   one individual giving free care as a family caregiver. M  ore adults with chr onic c  onditi  ons and disabilities find themselves at h  ome than ever bef  ore, and family caregivers have a considerably m  ore elevated am  ount   of   obligati  on. Looking after friends and family is related with a few advantages, including individual satisfacti  on. Be that as it may, pr  oviding care is likewise c  onnected with physical, mental, and financial c  onstraints. Essential care physicians can help in the identificati  on, supp  ort, and treatment   of caregivers by pr  oviding caregiver evaluati  ons and interviews directed at recognizing high levels   of burden as s  o  on as caregivers are identified(Collins & Swartz, 2011). Forty relatives   of patients wh  o were ch osen fr om the South Ver ona Psychiatric Case Register and had interviews conducted f  or them. A structured evaluati  on t o ol was used. This determined   objective burden, c  onduct   of patients, adapting techniques, satisfacti  on and requirements f  or services. Positive and negative aspects   of c  onsequences were apparent, 92%   of relatives were in t ouch with friends   or relatives, 72% had n  o change t  o their family earnings, and 52% c  ould deal with any family unit interrupti  ons amid an emergency. The main negative effects f  or relatives included decreased recreational activities (57%) and psych ological issues (67%). The main negative impacts were   on relatives   of patients wh  o were male (P = 0.016), unempl  oyed (P = 0.013) and determined t  o have psych osis(Samele & Manning, 2000). Caregiver burden may come about as a result   of providing care f  or patients with chronic illness. It can happen in any   of the 43.5 milli  on pe ople   offering help t  o midlife and   older 18 University of Ghana http://ugspace.ug.edu.gh gr own-ups. The strain experienced by caregivers goes unnoticed by prescribers and   other health workers. It was discovered that risk factors f  or caregiver burden included female sex, low educati onal attainment, living with the patient, longer number   of hours spent giving care, depression, is olation from the society, financial constraints, and lack   of choice in being a caregiver (Adelman, Tmanova, Delgado, Dion, & Lachs, 2014). Caregivers sh ould be directed t o appropriate resources for support, including national caregiving   organizations, local area agencies   on aging, Web sites, and respite care. Psych  oeducati  onal, skills-training, and therapeutic c ounseling interventi ons f  or caregivers   of patients with chr onic c  onditi  ons such as dementia, cancer, stroke, and heart failure have shown small t  o m oderate success in decreasing caregiver burden and increasing caregiver quality   of life. Further research is needed t  o further identify strategies t  o   offset caregiver stress, depression, and p o or health   outcomes. Additional support and anticipatory guidance f  or the care recipient and caregiver are particularly helpful during care transiti ons and at the care recipient's end   of life (Collins & Swartz, 2011). A study d  one in Australia attests t  o the fact that schiz  ophrenia is a very expensive illness t  o treat. According t  o the study schiz  ophrenia affects n  ot m  ore than 10%   of the number   of patients suffering fr  om my  ocardial infecti  on, h  owever, the c ost   of treating schizophrenia is 75% the estimated c  ost   of treating my  ocardial infecti  on (Davies et al., 1990). In a study done by Rymer et al. ( 2002), dementia severity, functional impairment, awareness   of mem ory deficit, and behavi oral disturbance were measured and examined in relation t  o caregiver burden. P ositive correlati  ons were f  ound between caregiver burden and both impaired awareness   of mem ory deficit and behavioral disturbance. Regressi on analysis dem onstrated that b oth impaired patient awareness   of mem ory deficit and behavi oural disturbance c ontributed t  o caregiver burden   over and above dementia severity and functional impairment. However, when both were entered t ogether int o regressi on equati ons,   only 19 University of Ghana http://ugspace.ug.edu.gh behavi  oral disturbance c  ontributed to caregiver burden. It was concluded that b oth patient awareness   of mem ory deficit and behavi oural disturbance impact caregiver burden, with behavi oral disturbance making the greater c  ontribution(Rymer et al., 2002). In Nigeria, a study done sh owed that care giving is ass ociated with em oti onal and cognitive transf ormati ons. The m ost imp ortant predict ors   of burden are pr oblematical behaviour, disability and the severity   of symptoms. Effective treatment is thus the first step t  o reduce burden. High expressed em oti on may indicate the family's attempts t  o help the patient; and is mediated by c  ontr  olling behavi  our, stigma, burden, and caregiver percepti  ons   of the patient's c ontr  ol   over their   own behavi our. Psych  o-educati  on is the m  ost p  opular family interventi on treatment (  Ohaeri, 2003). In Ghana, the burden   of caregiving was measured using the WHO Impact   of Caregiving Scale. Independent sample t-tests, correlati  ons and analysis   of variance were used t  o investigate ass  ociati  ons between backgr ound characteristics and the burden   of caregiving. Linear regressi  on was used t  o examine determinants   of the burden   of caregiving. Results: The mean age   of caregivers was 61 years (standard deviati on 14.5), and the male:female rati  o was appr  oximately equal.   on average, appr  oximately tw  o adults per h  ouseh  old required care. Less than five percent   of caregivers received financial, em  oti  onal, health, physical and pers  onal care supp  ort. Place   of residence, pr ovision   of financial, health and physical supp  ort t  o care recipients, and receipt   of financial, physical and health supp  ort were significant determinants   of the burden   of caregiving. Conclusions: This study f  ound a mismatch between the number   of pe  ople needing care and the number   of people pr oviding care (Sanuade & Boatemaa, 2015). 20 University of Ghana http://ugspace.ug.edu.gh 2.7 Emotional c onsequences   of caring for mentally-ill patients. Caregivers   of mental patients exhibit less satisfacti on with quality   of life largely due t o s ome maj or em oti onal c  onsequences. A review   of literature revealed that care-giving is ass  ociated with em  oti  onal and c  ognitive transf  ormati  ons. They are frequently stressed and experience a l ot   of em oti onal burden (Fieldhouse &   onyett, 2012). The m ost important predict ors   of such burden are pr oblematical behavi  our, disability and the severity   of such sympt oms. According t o a previ ous study by Grad and c olleagues, more than half   of caregivers in their study felt excessive anxiety due t o worrying ab  out the patient. A fifth   of them attributed neur otic symptoms (ins omnia, headaches, excessive irritability, and depressi on) t  o their concern ab  out the patient‘s behaviour (Grad et al, 2010). Caregivers like family members   or   other relatives are central and pr  ovide n  ot   only practical help and pers  onal care but als o give emotional support, and they are suffering fr  om plenty   of challengeable tasks. These, eventually, cast   out family caregivers int  o multidimensi onal problems prominently f  or mental distress like depression, anxiety, sleep pr oblem and s omatic dis  order which are f oll owed by physiologic changes and impaired health habits that ultimately lead t  o illness and possibly t o death(Sintayehu, Mulat, Yohannis, Adera, & Fekade, 2015). Effective treatment is thus the first step t  o reduce burden. High expressed em  oti  on may indicate the family's attempts t  o help the patient; and is mediated by c  ontr olling behaviour, stigma, burden, and caregiver percepti ons   of the patient's c ontrol   over their   own behavi  our. Psych o-educati on is the m ost p opular family interventi on treatment (  Ohaeri, 2003). The study findings identified an array   of coping strategies used by the family caregivers, including religi ous coping, emoti onal coping, acceptance, becoming engaged in leisure activities, and the use   of traditi onal healing t  o help them cope with their mentally ill members. 21 University of Ghana http://ugspace.ug.edu.gh In health sciences, caregiver burden refers t  o the c  ollective set  of stressful exposures   or ―stressors‖ that the caregiver faces(Friedemann-Sánchez & Griffin, 2011). Changes in the degree   of depression experienced by caregivers have also been associated with the changes in disability and health status   of their patients. As a chr onic conditi on where episodes are frequent, these changes in patients‘ well-being em  otionally affect caregivers. Improvement in health, characterized by less visits t  o the h  ospital, bring j oy and hope t  o caregivers. In a study exploring the experiences   of informal family caregivers   of persons with mental illness in a rural area in South Africa, data were c  ollected through eight individual semistructured interviews   of inf ormal caregivers wh o cared f  or relatives with mental illness and c  ollect medicati ons monthly at a community clinic in the Makhuduthamaga local municipality in Limpop o. A qualitative research design was used, which was explorative, descriptive, and contextual. The data analysis revealed four major themes: (i) experiences   of pr oviding f  or physiological/physical needs; (ii) experiences   of pr oviding f or emotional needs; (iii) experiences   of providing f  or security needs; and (iv) experiences associated with the medical health-care pr ogramme. The study revealed that the experiences   of family caregivers were conceptualized negatively, alt hough the interview questi ons were intentionally neutral. This is believed t  o be due t  o the cultural explanatory models   of mental illness prevalent in this region   of South Africa. It is suggested that t  o increase compliance with medicati  on, reduce relapse, and mitigate stigma ass  ociated mental illness, medical pr  ofessi  onals need t  o inc  orp  orate aspects   of cultural explanat  ory m odels int  o their explanati  ons   of the causes   of illness.(Mavundla, Toth, & Mphelane, 2009). In a study   on Caregiver pr ofiles and determinants   of caregiving burden in Ghana by Sanuade et al (2015), it was f  ound that less than five percent   of caregivers received financial, emotional, health, physical and pers  onal care support. Place   of residence, pr  ovisi  on   of 22 University of Ghana http://ugspace.ug.edu.gh financial, health and physical support t  o care recipients, and receipt   of financial, physical and health support were significant determinants   of the burden   of caregiving. Caregivers lack support and this has great impact   on their em oti ons. 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METH OD OLOGY 3.0 INTRODUCTION This chapter briefly presents some information about the study area, the design of the study, population and sampling technique. It also highlights data collection and anlysing methods as well as ethical issues regarding the study. 3.1 STUDY AREA This study was carried   out at the   out-patient department   of the Accra Psychiatric h ospital in Asylum d own near Adabraka, ab out 500metres fr  om the Greater Accra Regi onal h ospital,   Osu-Kl ottey district, Greater Accra regi on. The H ospital was established as a Lunatic Asylum commissioned in 1906 f  or 200 inmates. It has underg one m odificati ons t  o a H ospital with a bed capacity   of 600. It used t o have inpatients t  otalling 2,300 s  ome time ag o then later 1,200 (Annual perf  ormance review, Accra Psychiatric h ospital, 2016). It functi  ons under the Mental Health Auth ority which is semi-aut  on  omus, as stipulated by the mental health act   of 2012. The H  ospital now   operates within the wh  ole catchment area   of Accra Metropolitan, with a p opulati on   of ab  out 4.8 million extending t  o Tema, and some parts   of Central, Eastern, Volta regi  ons and the rest   of the country. The University   of Ghana Medical School has a faculty established in the h ospital f  or undergraduate training in psychiatry and p ostgraduate training under the West African C ollege   of Physicians(WACP). 24 University of Ghana http://ugspace.ug.edu.gh Nurses fr om all   over the country are affiliated t  o this h ospital f  or 6-month pr oficiency training in psychiatry. It als  o has facilities which are accredited f  or p ostgraduate training in psychiatry. As at the 31st December,2016, inpatients were 382 as a result   of repatriation and closure   of admissi ons. There are a t otal   of 18   operati onal departments in the h ospital. These include: • S ocial Welfare Department • Pharmacy Department •   Occupati onal Therapy Department and •   Out Patients Department (C onsulting R o oms, Injecti on R o om) In 2016 a t  otal   OPD attendance   of 33, 030 t  o the h  ospital recorded, c omprising 1754 females and 15, 175 females.   out   of 1764 cases seen in 2016, 511 were diagnosed as schiz ophrenia and 328 as depressi on. Other cases seen included Dementia, Bipolar affective disorder, substance abuse and epilepsy. Fig 3.1: The   out-patient department   of the Accra Psychiatric hospital 25 University of Ghana http://ugspace.ug.edu.gh 3.2 DESIGN A qualitative research design was employed t  o conduct the study amongst caregivers   of patients visiting the Accra Psychiatric hospital f  or reviews at the   OPD. This method was used because it was effective in   obtaining specific inf  ormation and   opinions ab out caregivers of mentally-ill patients experiences during their care pr ocesses. It was also interpretive, gave clear reas ons and understanding   of the reality   of the subject   of burden   on families (P olit & Beck, 2004). This study empl  oyed the narrative inquiry appr oach t  o describe the consequences. This pr ovided individual st  ories t  o devel  op expl  ore the problems by using inductive data analysis t o learn ab out the meaning that participants h old ab out them through the identificati on   of patterns   or themes (Creswell, 2007). 3.3 P OPULATI  ON AND SAMPLE A caregiver was defined as a family member   of the patient wh o supp orted m ost, if n ot wholly, the patient‘s daily care needs physically, em oti onally and financially. In the c onsulting r o om, f olders   of patients diagn osed with mental illness f or at least 6 m onths were selected and caregivers wh  o attended the h  ospital with the patients were identified. They were then asked t  o confirm if they were the main caregivers bef ore the interview c ould pr oceed 3.4 SAMPLING TECHNIQUE A purp osive sampling method was used t  o select the 10 caregivers. T  o ensure adequate representati  on   of all gr  oups and t  o eliminate bias, caregivers were purp osively selected based   on their gender, age and s oci o-ec on omic backgr ounds. This was done by conducting a brief interview with them and asking them ab  out their dem ographic inf ormati on and their   occupati on as a pr oxy t  o determine their s oci o-econ omic backgr ound. . The interview was then conducted until at a certain point no new information was obtained and thus saturation attained. At This point, enough information had been obtained to answer the research 26 University of Ghana http://ugspace.ug.edu.gh questions. In using purp osive sampling, establishing rapport with participants t  o pr ovide study access and yield valid data including the imp ortance and elements   of a good consent (Etikan, 2016). This is als o needed t  o kn ow the culture bef  ore   one samples the p opulati on in   order t  o find kn owledgeable and reliable inf ormants m ost efficiently. 3.5 INCLUSI  ON AND EXCLUSI  ON CRITERIA Caregivers wh  o had lived with the patient f  or greater than a year were included and th ose who refused t  o give written c  onsent were excluded. Caregivers bel ow age 18 were excluded in this study. It was ensured that every caregiver wh  o participated in the study was n ot being paid f  or taking care   of the patient. 3.6 DATA C  OLLECTI  ON TOOLS An interview guide was used to collect data relating t  o patient‘s illness and family income and empl  oyment; s  ocial and leisure activities   of the family; domestic r  outine; health   of primary caregiver; and relations with neighbours. 3.7 ETHICAL ISSUES Ethics was sought fr  om the Ghana Health Service Ethics Review Board (Ref number GHS- ERC067/01/18). Permissi on was also sought fr  om authorities   of the facility with a f  ormal intr oductory letter   obtained from the Sch ool   of Public Health thr ough the Social and Behavi oural Science department. Inf ormed consent was als  o sought from the care givers/relatives bef ore the interviews were c  onducted. Inf  ormed consent Participati  on in this study was voluntary. Written consent was sought from each participant before taking inf ormation from them and they were all owed to   opt   out at any time during the course   of the study. 27 University of Ghana http://ugspace.ug.edu.gh Confidentiality and Anonymity Interviews were c  onducted in an enclosed setting t  o guarantee privacy. Names   of caregivers were not used   or re orded   on the recorder in   order t  o minimize the p  ossibility   of tracing inf ormati  on t o respondent (caregiver). This was d  one t  o sure c  onfidentiality   of inf  ormation received from the participants. Compensation Each respondent was given an am  ount   of GHS 5 f  or refreshment. This was done after the interview had been c onducted using the interview guide. Data storage and use The recordings were transcribed and coded within 24 h ours and subsequently kept in a safe cardboard   of the staff   office  of the h ospital on a password-protected laptop which was kn own  only to the researcher. All informati on received from respondents by the principal researcher and  copies were als o saved   on an external hard drive and   on a CD-R OM. The data collected will be kept by the principal researcher f  or 3-4 years t  o all  ow f  or publicati  on   of research after which data   on both the hard drive and CD-R OM will be deleted. 3.7 DATA ANALYSIS The participants who were selected purposively were interviewd until saturation was attained by the 10th interview. At this point, answers from the caregivers had become repetitive and no new information was obtained. Thus, no one was interviewed beyond the tenth person. They were all successfully interviewed and they all c ompleted their interviews. The interviews were however conducted   on different days f  or some   of the caregivers. Interviews were done in the m onth   of June 2018 and were all conducted by the researcher t  o ensure uniformity   of inf ormation   obtained. After caregivers   of patients had signed the inf ormed 28 University of Ghana http://ugspace.ug.edu.gh consent, and permissi on s ought, interviews were audi o-recorded. The vari ous resp onses were cleaned and errors c orrected. During the interview, questi ons were adequately explained t  o the resp ondents s o as t  o avoid receiving vague   or irrelevant answers. Respondents als  o had   opp ortunity t  o clarify   or adjust their responses f  or accuracy. The   one   on   one interview data were then transcribed by the researcher. Cr oss-checking   of transcript with n otes taken during the interviews contributed t  o the trustworthiness   of the data. Transcripts were analysed using thematic analysis guided by the f ollowing research questions: What are the emoti onal, economic and social consequences for caregivers   of mentally-ill patients attending the   OPD   of the Accra Psychiatric h  ospital. Data analysis were done by the researcher. All the transcripts were read thr  ough several times by the researcher, data were then coded and grouped into themes t  o enable abstracti  on and analysis. During the interviews, caregivers were given pseud onyms in   order t  o further pr  otect their true identity and t  o prevent tracing the inf  ormation given back t  o them. They were also represented with c odes that were serialized and each caregiver was represented by a figure ranging from 1-10. Qualitative research studies involve a c  ontinuous interplay between data collecti on and data analysis (Corbin & Strauss, 1994). For this reason, data analysis started from the first interview t o begin identifying patterns, and t o facilitate subsequent data collection. The first step in the data analysis process was transferring audi o files t  o a password-pr otected laptop. Thematic analysis with NViv  o 11 was used t o   organise the data and emerging themes were identified. Specific themes   of interest    included emoti onal, s ocial and economic consequences   of having a family member with mental health pr oblems t  o families. In assigning   codes f  or the primary d  ocuments, the research questi ons were referred t o s o that the codes c ould be related t o the research questions. The transcribed data were then gr ouped 29 University of Ghana http://ugspace.ug.edu.gh according to the themes devel oped from   the subsequent familiarization with the data and participants‘ responses. 30 University of Ghana http://ugspace.ug.edu.gh CHAPTER F OUR RESULTS 4.1 Introducti on This chapter presents the findings   of the study. The findings are described under f our maj  or themes which are in accordance with the study   objectives. The chapter highlights the dem ographic characteristics   of the participants and then the presentati on   of the themes identified. 4.2 Characteristics   of participants Ten participants c omprising seven males and three females aged between 29 and 69 years participated in this study. Tw o   out   of the ten participants were aged bel  ow 40 years and the   others m ore than 40 years. Seven   out   of the ten interviewees were married and were living with their spouses whiles two were single and an other was separated fr  om her husband. Most caregivers were very close relatives, that is, belonging t  o the nuclear families.   One   out   of the ten caregivers belonged t  o the extended family   of the patient. All caregivers had lived with the patients for between a period   of   one (1) year t  o thirty-three (33) years. Some had lived with the patients before the   onset   of the illness and   others had t  o step in and take care   of them after the illness started.   One patient had been ill f  or six (6) months but the   others ranged from   one year t  o thirty-f  our (34) years, as duration   of illness  of the patients. Most   of the participants lived in some part   of Accra with the excepti  on two who lived in Ho and H  oh oe. Majority   of the participants were gainfully employed   or engaged in trading. S ome were running their   own businesses. The estimated monthly income   of the caregivers had the l  owest being two hundred Ghana cedis (Ghc 200) and the highest being two thousand five hundred Ghana cedis (Ghc 2,500). 31 University of Ghana http://ugspace.ug.edu.gh The highest earner was the Chief executive   officer   of his company whiles the least earner was an evangelist. H  owever,   one petty trader c ould not pr  ovide an estimate of the income generated from her selling   of l ocally prepared drinks. Details   of the dem ographic characteristics   of participants are presented in Table 1. 32 University of Ghana http://ugspace.ug.edu.gh Table 1: Details of caregivers(N=10) Pseud onym Interview Gender Age Relati onship Marital Place  of Length Number  Occupati on Average date (yrs) T o Status Residence  of  of years m onthly Patient stay with with inc ome(Ghc) patient illness Mark 25/6/18 Male 54 Father Married H oh oe 21years 6 m onths Trader 500 J ohn 25/6/18 Male 49 Husband Married Kas oa 11years 6years Evangelist 200 Tim 26/6/18 Male 54 Br other Single Kas oa 30years 30years Public servant Bel ow 2000 (acc ountant) Daniel 26/6/18 Male 56 Br other Married Lab one 5years 10years Building 1000 c ontract or/ Secretary t o chief Vivian 27/6/18 Female 58 M other Married Achim ota 10years 10years Teacher 1200 Jerry 28/6/18 Male 69 Husband Married K ot obaabi 33years 5 years CE O/ Owner  of 2500 Electrical Engineering c ompany Ruth 28/6/18 Female Wife Married  Osu 20years 1 year Petty trader N ot sure Ken 28/6/18 Male 29 S on Single Ab ossey 1 year 12 years Graphic designer 1000-2000  Okai Philip 29/6/18 Male 34 Nephew Married B ortian or 25years 34years Pr ocurement 1000  officer Mary 29/6/18 female 50 M other Separated H o 10years 31years Caterer 1500 33 University of Ghana http://ugspace.ug.edu.gh 4.3 Summary  of themes All the data presented were   obtained from interviews with these caregivers wh  o attended the hospitals with their patients. The various themes were drawn fr  om their statements made t  o questions p osed by the researcher which were guided by an interview guide. These themes were emotional, social and econ omic consequences. Under emotional consequences, sub themes generated include Depressi on, Anxiety, Strained marital relationships, psychological distress and physical ill-health. Sub-themes generated under s  ocial c  onsequences are family effects, risk   of is olation, stigmatizati on, change in domestic routines, reducti on in physical activity and reduced leisure Sub-themes that were f  ound under economic consequences are Loss   of productive time, Loss of economic value and reduced quality   of life. 4.3.1 Emotional consequences   of caring f  or mentally-ill relatives Caregivers in this study expressed marked em otional c  onsequences experienced in their daily lives as they lived and cared f  or their mentally-ill relatives. S ome   of the em oti onal effects were worrying and frequently caused pr  oblems. Few relatives, however, could deal with such consequences though majority wh o c ouldn‘t deal with their em oti onal pr  oblems remained committed t  o caring f  or the patients. Caregivers mostly said they mainly endured without c omplaint but some wondered how l ong they could cope. There were f  our sub-themes discovered. These were depressi on, anxiety, strained marital relati onships and psych ol ogical distress and ill-health. 34 University of Ghana http://ugspace.ug.edu.gh Depression Participants expressed deep w orry ab out caring f or relatives wh o were functi onally impaired as a result   of their mental illness and mentioned that they have experienced depressi on. S ome said that this has been s o especially because   of the lack   of understanding and the label that has been ass ociated with the c onditi on. Bel ow are s ome   of the excerpts   of what some caregivers complained ab out: “….First my mother did n  ot all  ow me t  o c  ome because   of his behavi  or but I f  orced t  o c  ome and it reached a certain stage I was n  ot happy. I realized I was feeling t  o  o l  ow and deeply sad anytime I am with him. It is extremely frustrating….S ometimes I feel very depressed. I mean, eerrm!!! Badly l  ow in spirit…Do y  ou get what I mean? When the illness comes…….he has t  o be f  orcibly br  ought home.” (Daniel) “H  ow can y  ou live in a h  ouse with him and n  ot feel depressed?‖ (J  ohn) Another lamented; ―… ..In actual fact, I will say that ….what I’ve seen about the past 2 and half years, y  ou have n  o idea. S  ometimes,…… I get s  o  o s  o d  own in me, like, s  ome depressi  on …   or what? S  ometimes she refuses t  o take her medicati  on and I have t  o g  o the h  ospital.” (Jerry) For a caregiver wh o t o ok a deep breath when asked about how she has been affected, she simply responded as such: “..Depressed? Yes a l  ot” (Ruth) 35 University of Ghana http://ugspace.ug.edu.gh Relatives   of mentally-ill patients menti  oned the detrimental psych ological effects they experienced. S  ome menti oned even neglecting their   own health and eating poor-quality diet because   of their depressed state.   one caregiver said this: “…I get s  o depressed that I cann  ot eat f  or l  ong peri  ods and take just b  ottle   or tw  o   of beer” (Mary)   one participant intimated that caring f  or the mentally ill patient was more challenging than caring f  or a patient with physical disabilities. They will typically require more supervision and are less likely t  o express gratitude f  or the help they receive. This is an excerpt   of the speech: “It is even m  ore depressing when y  ou d  on’t even receive thank y  ou and she calls y  ou names. F  or caring f  or accident victims, at least y  our thank y  ou will n  ot …. Y  ou w  on’t miss that..”(Tim) Strained marital relati  onships Spouses had a l  ot   of complains ab  out the way their relationships have been affected. Marriage is t o be enjoyed but some   of the behaviour sh own by patients was hard t  o bear, and ‗negative‘ symptoms such as misery, withdrawal, and worrying c ommonly caused problems. Interviewees mentioned that because they were the closest relatives to the patients, they experienced direct effects and their relati  onships were duly affected. Some participants felt that it was   overwhelmingly affecting their sexual relationships with their partners and it was difficult t  o appreciate when a sp ouse was acting sad, angry, anxi  ous   or generally unpleasant and t  o attribute these t  o the illness.   One has t  o exercise extreme cauti on and self-awareness when with the patient s  o as n  ot t  o trigger unnecessary quarrels. They mentioned that it was difficult though imp ortant t  o separate   one‘s sp ouse fr  om their illness 36 University of Ghana http://ugspace.ug.edu.gh and it was very natural t  o want t  o em oti onally disc  onnect and safeguard   one‘s self when   one‘s sp ouse was exhibiting behavi  our that seemed f oreign fr om the pers on already kn own. A caregiver said: “When she is ill h  owever she doesn’t like me t  o c ome close…” (J  ohn) An  other added that: “ it affects me sleeping with her. Sometimes she used … t  o just accuse me..Yes, the   only way it affects me and if I am n ot careful we will just be fighting unnecessarily..” (Jerry) Th ough a participant alluded t  o the pride in fulfilling spousal responsibilities and enhanced closeness with a sp ouse receiver, the strain   on their marriage could not be   overemphasised. “…my problem is that I expect a l  ot   of impr  ovement in his c  onditi  on but I am n  ot seeing that all..if he is asleep fine but…when he is awake and inside I call him   out t  o meet   our visit  ors. He is always sleeping, as a husband and I am his wife, I will c  oncentrate   on   other things than us…”(Ruth) Anxiety, Psychological Distress and Physical ill-health Caregivers menti  oned they experience psych  ol  ogical distress which c  ould result in physical ill-health s  ometimes. S  ome menti  oned that being a caregiver raised difficult pers  onal issues ab  out duty, resp  onsibility, adequacy and guilt. Caring f  or a relative with a mental health pr  oblem was n  ot a static pr  ocess since the needs   of the caregiver and recipient change as their condition changes. They said this c ould result in a l  ot   of distress. They mentioned particularly adjusting t  o change, daily hassles and r  ole strains. Carers have w  orried ab out whether their patients‘ basic needs have been met, which caused them a great deal   of distress and s ometimes anger towards self. Due t  o high burden and responsibilities, caregivers 37 University of Ghana http://ugspace.ug.edu.gh experienced l ower life satisfacti  on. It was mentioned that families wh  o are caring f  or a mentally-ill relative are likely t o experience high rates   of physical ill health. there are some ass ociated effects   on the physical health   of caregivers   of mentally ill patients. Some relatives have suffered diseases such as migraines, diabetes and hypertension as a result   of the stress they g  o though fr  om caring f  or their patients. Sometimes, the strenuous nature   of the care gets the better part   of carers and their health gets affected. They said that they pay regular visits t o the h ospital f  or review and refill   of their prescripti ons. They had t  o keep t  o these tight schedules t  o ensure continuity   of care f  or the patients. Some caregivers c omplained   of frequent headaches resulting fr  om poor sleep which they attributed largely t  o the taking care   of their mentally-ill relatives. S  ome participants said they c  ould n  ot sleep well since their relatives were under their care and have had t  o get treatment themselves.   one participant said: “….Yes, it affects my sleep. S  ometimes she used t  o talk whiles we are sleeping, accusing me that I have d  one a l  ot things…” (Jerry) Another added that: “ I d  on’t feel well at all, I cann  ot sleep…l  o  oking after him has been difficult. It’s affecting my health” (Mark)   one participant said he had t  o adapt several times t  o the c  onditi  on and this affected him: “He changes a l  ot every time and I have t  o adjust…at first, it was bad but n  ow it is much better.this is stressful because y  ou have t  o change   or adapt..” (Philip) Some participant expressed his frustrati  on this way: 38 University of Ghana http://ugspace.ug.edu.gh “…it was n  ot until she refused t  o take medicati  on….. Y  ou have c  ome t  o the h  ospital as s  o  on as, y  ou c  ome and g  o many times. Transp  ortati  on fr  om the h  ouse t  o this place and we spend h  ours anytime. It takes us ab  out 4h  ours in all t  o see the d  oct  or and g  o h  ome” (Jerry) Another caregiver added that: “…by the grace   of G  od, I d  on’t think much and pe  ople have been advising me n  ot t  o. Its terrible as y  ou d  on’t kn  ow whether y  ou are d  oing the best f  or him. I can’t d  o what I want t  o d  o. It’s a resp  onsibility...” (Vivian) 4.3.2 Social consequences   of taking care   of mentally ill relatives Acc  ording t  o the caregivers interviewed, they suffer social consequences as they care f  or their mentally ill patients. F  or many   of them, despite the willingness t  o support their   own family members, the s  ocial impact   of their service was worrying. Negative Family effects The study revealed that there were consequences   on the family as a result   of living with a mentally-ill family member. M ore over, the study revealed that living with a mentally ill family member generated vari  ous s ocietal resp onses.   one   of the resp onses was that s  ociety was callous with the families   of mentally-ill. The c ommunity was unsympathetic, heartless, pitiless,   or insensitive t  o families with a mentally ill family member. Am ong   other c onsequences family members described the l  oss   of freed om t  o s ocialize and participate in activities   outside the home. C  onsequences highlighted were that caring f  or the mentally ill was a c  ontractual   obligati  on that left certain members in the family as their sole responsibility, duty, job, task, function,   or liability.   One m other said: 39 University of Ghana http://ugspace.ug.edu.gh “F  ormerly   one   other family member was supp  orting but n  ow they’ ve all left everything f  or me. He is my s  on, my j  ob..” (Vivian) A man wh o was l ooking after his m  other said: “There is n  o…n  o   other supp  ort. She lives with me” (Ken) An  other man wh  o was l  o  oking after his sister als  o had this t  o say: “Hmm like I said, we live al  one. I l  ock her up in the h  ouse, give her breakfast, lunch and supper t  ogether with instructi  ons and then g  o t  o w  ork. I am always w  orried ab  out what may happen t  o her s  o I always rush h  ome.” (Tim) The family members interviewed als  o revealed an  other c  onsequence that, it was unpleasant living with a mentally-ill family member. Family members used w  ords like, ‗terrible, disgusting and h  orrible as they expressed feeling resulting fr  om living with a mentally ill family member. A caregiver said: “S  ometimes he used t  o r  oam ab  out and was very dirty and pe  ople w  ould find him and him and bring him h  ome…this is terrible” (Mary) The   other c  onsequence t  o families was that mental illness became the prime f  ocus and problem. Family members described living with a mentally ill family member as the biggest   or largest pr oblem the family had. Risk   of isolation The study revealed that caregivers were at the risk   of is  olati  on fr  om their c  ommunities. They had no friends from their immediate dwellings and pe  ople refused t  o freely ass ociate with them. An interviewee explained as such: 40 University of Ghana http://ugspace.ug.edu.gh “I am always w  orried about what may happen t  o her if I am n  o m  ore. I d  on’t even have friends.” (J  ohn)   one 54year man menti  oned that he c  ould n ot keep a stable relati onship because   of caring f  or her sister. He had this t  o say: “N  o, I am n  ot married. It’s because   of her. I dedicated my wh  ole life t  o taking care   of her because everyb  ody gave up. I c  ouldn’t marry because   of her. She has been living with me f  or alm  ost 30 years. The illness started   over 30 years ag  o, when she was ab  out t  o enter sec  ondary sch  o  ol. I am n  ow al  one” (Tim) Stigmatisation The study revealed they experienced negative view, attitude, belief   or acti ons placed   on them which had negative effect. Usually, these behavi  ours were demeaning t  o them. They were   often blamed wr ong acts. At certain instances, the c  ommunity blamed them f  or the   occurrence   of mental illness in their family member. When neighb  ours realised, they needed help with their patient, n  o   one came t  o their aid. In a sad t  one,   one caregiver narrated: “S  o every m  onth we travel all the way here…we prefer here. Usually, we c  ome the day bef  ore his review date and stay with my sister…and g  o back the f  oll  owing day. The neighb  ours behave s  omeway, they l  o  ok at y  ou s  omeway that is demeaning and distasteful…” (Mary) Another added that: “We have been ejected fr  om previ  ous rented h  ouses…several time….. I am w  orried ab  out the pe  ople in the area.. their attitude is n  ot fine at all..as if we br  ought the disease   on my sister. ” (Tim) 41 University of Ghana http://ugspace.ug.edu.gh Some caregivers described s  ocietal resp  onse as discriminat  ory. A caregiver realised that people avoided them in the c  ommunity. There was a misc  oncepti  on ab  out the causes   of mental illness and pe  ople held false impressions. He had this t  o say: “..They said I am als  o sick…I mean, mad…” (Tim) Reducti on in physical activity The study revealed that caregivers were socially restrained and could not be physically active as a result. During the interview, caregivers expressed concerns about some effects   on their physical activities as they cared f  or their loved   ones who happened t  o have psychiatric illness. They mentioned the effects   on their physical activities. They usually have t o keep an eye   on these patients when they are around them s  o that, they can be adequately m onit ored. Some explained that, that is necessary because   of past experience they have had where the mentally-ill patient had experienced sudden episodes and have led t  o serious c  onsequences f  or them. This is m  ore the case when the patient inv olved is a child. Some participants expressed their views in the f oll owing ways: “……. actually, we are w  orried and y  ou can’t d  o anything but t  o sit around him…… we d on’t kn  ow how things will end” (Daniel) An evangelist described h  ow he has t  o h  old   on with all activities and just remain at home whenever his wife had a relapse: “….when she is ill,….The   only thing I am unable t  o d  o is t  o   organize a church programme, I will have t  o stay with her till she is well bef  ore I d  o any physical activity… (J  ohn) A m other narrates her frustration when asked ab  out h  ow this affected her movement: 42 University of Ghana http://ugspace.ug.edu.gh “….Y  ou see….he was   on admissi  on f  or s  ometime, …ab  out a year. Hmm! During these times, it was difficult, y  ou cann  ot d  o anything….m  ovement…y  ou are stuck” (Vivian) A 69 year   old caregiver wh  o had been taking care   of his wife f  or five years said: “Yes, the way it affects me is that I can’t m  ove   out. When y  ou want t  o m  ove   out she’ll ask y  ou several questi  ons…” (Jerry) Reduced leisure T  o explore s ome specific effects   of the s ocial activities, s ome   of the interviewees experienced s  ome effects   on leisure. They menti oned that the burdens   of caring f  or a mentally-ill patient at h  ome are c  onsiderable. They   often affect the caring relative's leisure activities. It was difficult t  o engage in a l ot   of leisure activities when caring f  or them as a l  ot   of dedicati  on is required. It was explained that caring f  or such patients t  o  ok a l  ot   of time and leisure times are m  ostly spent with such patients. A l ot   of leisure time has t  o be sacrificed f  or caring f  or these patients. Caregivers have t  o pri oritise f  or example taking their ill relatives t  o the h  ospital, supervising medicati  on administrati  on etc t  o engaging in leisure activities. It was practically imp  ossible f  or carers t  o travel   on vacati  on either al  one   or with their ill relatives since they were n  ot sure   of what w  ould befall them. Excerpts   of their c oncerns are provided bel  ow: “….I can’t travel, either alone   or with him. I have t  o cut sh  ort my trips, I can’t just d  o what I want t o d  o.” ( Vivian) A y  oung man expressed his frustration this way: 43 University of Ghana http://ugspace.ug.edu.gh “ …She is n ot making any eff  ort t  o get   on her feet. That is what w  orries me ab  out her all the time and I can’t even leave her t  o engage in any activities. She is m  ore imp  ortant t  o me s  o I just stay with her…” (Ken) Routine domestic effects There were c  omplains from some   of the caregivers ab  out the effect caring f  or mentally-ill individuals have had   on d  omestic activities. Marriage is an instituti  on in which pe  ople ch  o  ose t  o live t  ogether because they can increase their utility by sharing and rearranging tasks, resp  onsibilities and caring f  or children. Sp  ouses in the study c  omplained that they did n  ot receive the required assistance required in the functi  oning   of family life. They said they did n  ot get en  ough time t  o c  ontribute t  o h ouseh old chores. A participant wh  o was preparing t  o get married retorted: “ …. Yes, It has affected my life, my wife t  o-be (fiancée) has a kid and even th  ough I have rented a place f  or her, I can’t sleep there. It affects my c  ontributi  on t  o his upbringing especially and it b  others me a l  ot” (Ken) A caregiver revealed an  other burden caring f  or the mental ill brings. Relatives have difficulties in understanding and c  oming t  o terms with illness-related behaviour at h  ome. There has theref  ore been the need t  o   obtain s  ome f  orm   of training t  o adequately care f  or such relatives. It has bec  ome a part   of domestic r  outines that requires mastery A caregiver described his experience as below: “With my uncle….. At first, it was bad but n  ow it is much better….experience, I guess. After it became part   of the d  omestic r  outines.” (Philip) 44 University of Ghana http://ugspace.ug.edu.gh 4.3.3 Economic consequences   of taking care   of mentally-ill relatives The financial burdens   of caring f  or a patient at h ome were c  onsiderable and resulted from mainly  oss   of productive time, and l  oss   of economic value   of caregivers. They had to meet the financial needs   of the ill member besides meeting the treatment costs. Caregivers incurred regular cost   on transportation, medicines, and living expenses. They mentioned that their mentally ill members did n  ot engage in productive ventures and hence were huge financial burden   on them. M  ost   of them did not receive any supp  ort fr  om elsewhere and had t  o bear their t otal cost. M  ost   of the interviewees were self-employed and did not have regular incomes. They had t  o battle with bearing all the c  ost associated with caring f  or their relatives. M ore over, there have been economic distractions   of their families as n o pr oper financial planning can be made. Caring f  or these individuals als o demands a lot   of time and some interviewees menti oned the vari ous effects it has had   on their jobs. Some could n ot give their best t  o their trade as they cared f  or their l  oved   ones. Bel ow is an excerpt from a caregiver: “….. Last medicati  ons c  ost us ab  out 80 cedis. In all its ab  out 100 cedis f  or a review because we pay twenty cedis f  or c  onsultati  on…. Transp  ortati  on c  osts 70 cedis in, 70   out. If y  ou include taxi its 146 f  or us b  oth…..Business is n  ot g ood n  ow s  o I make ab  out 500 cedis profit a m onth. The wh  ole m  onth   o!(Mark) Loss   of pr oductive time Three (3)   out   of the ten (10) interviewed w  orried ab  out l  oss   of w  orking time because   of caring f  or their ill relatives. Two m ore interviewees als  o menti oned that they could have engaged in m  ore productive ventures if they were n  ot caring f  or their mentally ill patients. They   often have t  o sacrifice their ec  on  omic activities t  o care   of these patients. A caregiver narrated his experience: 45 University of Ghana http://ugspace.ug.edu.gh “N  ormally we leave the h  ouse at 6am and get h  ome 12pm, that’s ab  out 6 h  ours. I c  ould have been at w  ork. And this is very regular It takes my time, the   other time I had t  o leave because   of time. It affects my w  ork greatly..” (Daniel) An other added that: “We c  ome here m  onthly but als  o see the psych  ol  ogist in between but n  ot all the time. I spend r  oughly 2 h  ours in and 2 h  ours   out when c  oming t  o the h  ospital here. When she gets admitted that we spend 500 cedis   on admissi  on fee and even spend m  ore   on medicati  ons etc. during th  ose peri  ods, I have t  o even f  or g  o m  ore time with my j  ob.” (J  ohn) Angrily, this caregiver said: ―I am currently writing s ome exams but she d  oesn’t even all  ow me t  o study. She is n  ot as calm as y  ou see her t  o be. When she sees the d  oct  or’s she is very well- behaved. She burnt my f  o  od yesterday.” (Tim) Loss   of Economic value Caregivers menti oned that they had t  o spend   out   of their incomes t  o cater f  or their care recipients. These have s ometimes resulted in financial pr oblems. They secured treatment, buy medicines, pr ovide f o od and shelter and   other living expenses. Some feared it w  ould intr oduce economic hardships int  o their families. Despite the l  ow cost   of treatment t  o the mentally ill patients in the c  ountry, there were   other indirect costs associated with their care that should be borne by the caregivers. Usually, interviewees have had t  o suspend meeting their needs t  o provide res  ources f  or their ill members. Caregivers c  ould not keep their j  obs f  or a l  ong time due t  o c  onstant interrupti  ons that result fr  om spending m  ore time caring f  or their relatives. A caregiver wh  o had previ ously lost his j  ob had this t  o say: 46 University of Ghana http://ugspace.ug.edu.gh “I am an acc  ountant with the audit  or general’s department. It’s a new j  ob I g  ot. I l  ost my f  ormer j  ob because   of her. I was always asking f  or permissi  on t  o bring her t  o the h  ospital   or t  o take care   of her. They even said I was als  o sick.” (Tim) Participants lamented also   on the huge expenses inv  olved in taking care   of their relatives.   One caregiver had this t  o say about that: “The c  ost   of the medicati  ons was ab  out tw  o hundred cedis, at first it was 134 and n  ow its 220 cedis and then everyday I attend the h  ospital, there is transp  ortati  on c  ost…and I am paid   only 1000 cedis a m  onth. H  ow d  o I survive?” (Philip) A middle-aged petty trader who was taking care   of her husband said: “…its just me and my children. I spend ten cedis, in and   out… when we are c  oming, I take dr  opping (hired taxi) and then 200 cedis every m  onth   on drugs. And I sell s  ob  ol  o.. I can’t say h  ow much be because it varies fr  om day t  o day. S  ometimes by 3pm its all finished, s  ometimes even by 10 pm its n  ot finished. It is very draining taking care   of him..” (Ruth) When asked if taking care   of his mom was affordable, This caregiver said this in a disgruntled tone: “Errrm! In terms   of c  ost, I spend   over 700 cedis every m  onth t  o see the physician and then 100 f  or a dietician. The drugs al  one are expensive…ab  out 200 cedis here and there and what is w  orrying is she is n  ot making any eff  ort t  o get   on her feet. That is what w  orries me ab  out her all the time. Th  ough I am d  oing my   own j  ob, I am a graphic designer and my inc  ome is n  ot c  onstant. S  ometimes I   only earn 1000 cedis in a m  onth” (Ken) Another caregiver said: 47 University of Ghana http://ugspace.ug.edu.gh “I take 30 cedis daily f  or taxi and then drugs. I spend all by myself. F  ormerly my br  other was supp  orting but he went   on retirement s  o d  oesn’t supp  ort anym  ore. Its his sister wh  o supp  ort me n  ow, n  ot really financially but in   other ways.” (Vivian) Reduced quality   of life Participants intimated that they c  ould have better quality   of life if they did not have t  o care f or their mentally-ill relatives but because they spent a l  ot   of money   on their relatives, their   own standard   of living had t  o be compromised. A y  oung man wh  o was l ooking after his mother said: “……Yes, It has affected my life, my wife t o-be has a kid ………. It affects my c ontributi on t o his upbringing especially and it b others me a l ot” (Ken) 48 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Intr oducti on This chapter discusses the findings generated fr om the data c ollected which were in relati on t o the existing literature reviewed in the study area. The study was designed t o examine the em oti onal, s ocial and ec on omic c onsequences  on families as a result  of taking care  of mentally-ill relatives. The study was limited t o caregivers wh o were relatives that attended clinic with their patients and shared their pers onal experiences. The study f ound that the burden  of care was m ore defined by their impacts and c onsequences  on caregivers and they included the em oti onal, ec on omic and s ocial impact. There were embedded in these, subtle but distressing n oti ons like shame, embarrassment, feelings  of guilt, self-blame and self-pity (Awad & V oruganti 2008; Singh & Prajapati, 2013). The c onsequences  of caring f or the mentally-ill relative is a c omplex c onstruct that auth ors agree challenges simple definiti on. S ome researchers have categ orized it as either subjective  or  objective (Awad & V oruganti, 2008). In this study, the  objective burden  of care included effects  on h ouseh old such as taking care  of daily tasks whereas the subjective burden  of care indicates the extent t o which the caregivers perceived the burden  of care. There are h owever expl ored imp ortant determinants and fact ors that likely c ontribute the caregiver‘s percepti on  of the burden  of care. In  our study, th ough they were burdened, their cultural c onstruct held them b ound t o accepting caring f or their relatives as a resp onsibility. H owever, investigat ors have f ound  other fact ors like male gender and ethnicity issues as subjective c ontribut ors t o burden  of care ( Ozlu et al, 2015). 49 University of Ghana http://ugspace.ug.edu.gh 5.3 Emoti onal c onsequences  of caring f or mentally-ill relatives Fr om the study, it was revealed that caring f or mentally-ill relatives was em oti onally draining. This caused strained marital relati onships, psych ol ogical distress, anxiety, excessive w orry and in s ome cases, depression. Acc ording t o a previ ous study, m ore than half  of the inf ormants felt excessive anxiety due, they said, t o w orrying ab out the patient. A fifth  of them attributed neurotic sympt oms (ins omnia, headaches, excessive irritability, and depressi on) t o their c oncern ab out the patient‘s behavi or (Grad et al, 2010). In Nigeria, a study d one  on The burden  of caregiving in families with a mental illness: a review  of 2002, Current  Opinion in Psychiatry, sh owed that care-giving is ass ociated with em oti onal and c ognitive transf ormati ons. The m ost imp ortant predict ors  of burden are pr oblematical behavi our, disability and the severity  of sympt oms. Effective treatment is thus the first step t o reduce burden. High expressed em oti on may indicate the family's attempts t o help the patient; and is mediated by c ontr olling behavi our, stigma, burden, and caregiver percepti ons  of the patient's c ontr ol  over their  own behavi our. Psych o-educati on is the m ost p opular family interventi on treatment ( Ohaeri, 2003). In health sciences, caregiver burden refers t o the c ollective set  of stressful exp osures  or ―stressors‖ that the caregiver faces(Friedemann-Sánchez & Griffin, 2011). Previous studies have identified fact ors that may influence caregivers‘ burden. These include; caregiver‘s characteristics, care recipient characteristics, caregiver‘s res ources, and caregiver‘s supp ort characteristics. (Chang, Chiou, & Chen, 2010) Caregiver characteristics, such as gender, age, and kinship t o the care recipient, have c onsistently been ass ociated with strain(Sanuade & Boatemaa, 2015). The study showed that nine  out  of ten caregivers were first relatives wh o were part  of the nuclear family an  one was part  of the extended family. The cl oser relati ons experienced m ore burden as c ompared t o the m ore distant  ones. 50 University of Ghana http://ugspace.ug.edu.gh Caregivers play an imp ortant r ole in the management  of chr onic mental illness in the c ommunity. Caring f or patients with chr onic mental illness like schiz ophrenia can cause em oti onal distress in the caregivers. H owever, the magnitude  of the pr oblem remains largely unkn own in Sub-Saharan Africa and  other devel oping c ountries (Yusuf & Nuhu, 2011). 5.4 Economic consequences  of caring f or mentally-ill relatives The W orld Mental Health has stated that mental dis orders  occur c omm only acr oss the w orld and  often impairs many c ountries financially (Kessler et al, 2011). In the United States f or example, it is estimated t o c ontribute 6.2%  of the nati on‘s health care c ost (Insel, 2008). This study sh owed that treating and caring f or patients with mental illnesses were expensive and a chr onic venture, thus putting unnecessary strain  on families. M ost caregivers were n ot f ormally empl oyed, had little disp osable inc omes with n o external financial supp ort especially fr om family members and s o had t o bear the financial burden al one. A study d one in Australia attests t o the fact that mental illness is a very expensive illness t o treat (B osanac & Castle, 2012). According t o their study schiz ophrenia affects n ot m ore than 10%  of the number  of patients suffering fr om my ocardial infection, h owever, the c ost  of treating schiz ophrenia was 75% the estimated c ost  of treating my ocardial infecti on. This study f ound that the main financial effects  of caregivers included l oss  of pr oductive time as it t o ok them at least f our h ours  once a m onth t o see the d oct or, in addition t o the emergency visit. This led t o disrupti ons in their w ork and business resulting in l oss  of inc ome. Being a caregiver in s ome cases required full attenti on and theref ore s ome c ould just n ot w ork and had t o rely  on their family members t o supp ort financially. The s ocial and leisure activities  of a third  of the families had been restricted; nearly a third have had their d omestic r outine upset (h ousew ork, sh opping and s o  on); ab out a quarter have had their income reduced by at least 10%, and a tenth by m ore than half. 51 University of Ghana http://ugspace.ug.edu.gh Alth ough the c ost  of caregiving was c onsidered t o be a significant part  of inc omes, there varied widely am ong families and there were n o reliable estimates  of the c osts associated with such care. The financial burden  of care is kn own t o be a c omplex construct and w ould require appr opriate meth odology f or its costing. Unlike  other medical disorders, the costs  of mental disorders are m ore ‗indirect‘ than direct. The study revealed the direct c osts as including medicati on, clinic visits  or h ospitalizati on. The indirect costs are th ose incurred thr ough reduced pr oducti on time, reduced educati onal attainment and c ost ass ociated with  other c onsequences such seri ous mental illness leading t o admissi ons (Inselet al, 2008). In the study, caregivers had t o prepare t o f oreg o their ec on omic activities t o attend t o epis odes  of severe ill health  of their relatives. Such c ost  on the relatives were huge and investigat ors fear it c ould increase but there is an urgent need t o devel op reliable appr oaches t o generate data that can inf orm in p olicy making and  organizati on  of care services. An other important cost incurred related t o the personal upkeep  of the mentally ill patients. Usually, these patients d o n ot generate inc omes and hence caregivers are s olely pr oviders  of feeding, cl othing, shelter and  other pers onal items. In Ghana, the burden  of caregiving was measured using the WH O Impact  of Caregiving Scale.  On average, appr oximately tw o adults per h ouseh old required care. Less than five percent  of caregivers received financial, em oti onal, health, physical and pers onal care supp ort. Place  of residence, pr ovisi on  of financial, health and physical supp ort t o care recipients, and receipt  of financial, physical and health support were significant determinants  of the burden  of caregiving. Conclusi ons: This study f ound a mismatch between the number  of pe ople needing care and the number  of pe ople pr oviding care.(Sanuade & B oatemaa, 2015). This study theref ore confirms that caregivers are  over-burdened and haven‘t g ot the necessary em oti onal, physical and ec on omic supp ort. 52 University of Ghana http://ugspace.ug.edu.gh 5.5 S ocial c onsequences  of caring f or mentally-ill relatives. The study revealed that caregivers suffered numer ous s ocial c onsequences. These include negative s ocial effects  on the family, risk  of is olati on  of the family and stigmatizati on. In Ghana, Ngissah (1975) c ompared the attitudes  of 564 American High Sch o ol and C ollege students fr om Sacrament o (Calif ornia) with 280 Ghanaian High Sch o ol and C ollege Students fr om Accra t owards the mentally ill. Result sh ows a m ore negative and rejecting attitudes t owards mentally ill pers ons in the Ghanaian sample. 57.9%  of the Ghanaian resp ondents held the view that mental illness in the family brings shame  on the family name and 57.5% that it is wise t o keep it a secret as much as p ossible, 60.4%  of the Ghanaian participants felt that mental illness is n ot an illness like  other illnesses, 78.9% agreed that patients in mental h ospital are like children and 71.8% subscribed t o the  opini on that any one h ospitalized f or a mental illness sh ould be banned fr om v oting. Pe ople with mental illnesses suffer fr om negative s ocial attitudes which result fr om stigma and misc oncepti ons  of mental health pr oblems(P W Corrigan & Penn, 1999). This study sh owed that attitude t owards mental health hasn‘t changed and caregivers burden is increased as a result  of s ocial c onsequences especially stigma. Stigma is described as c onsisting  of difficulties in kn owledge (ignorance and misinf ormati on), attitudes (prejudice) and behavi or (discriminati on) (CA et al, 2009). The findings in this study is als o supp orted by the rec ogniti on  of the attribute assigned t o stigmatized pers on t o be ‗reduce fr om a wh ole and usual pers on t o a tainted  or discounted  one‘ (Brohan et al, 2010). This phen omenon even  originates fr om pe ople wh o are supp osed t o kn ow better. In a study  of nurses with mental illness, it was disc overed that nursing peers wh o generally c onsidered the disease acceptable within the c ontext  of nursing culture, sh owed negative stereotyping(Peters on, 2017). Supervisi on and  other  opp ortunities f or pr ofessi onal devel opment  of the participants in this study were c onnected with particular labels t o negative characteristics that was based mainly 53 University of Ghana http://ugspace.ug.edu.gh  on cultural reacti ons t o the c onditi ons. Unf ortunately, stigma has pernici ous effects  on the lives  of pe ople with seri ous mental illnesses  of pe ople with seri ous mental illnesses and may even interfere with mental health service use. Like an auth or wr ote: Stigma  of mental illness is an attribute that is deeply discrediting (Br ohan et al.,2010). Acc ordingly, stigma is als o kn own as a f orm  of s ocial deviance that leads  others t o judge an individual as illegitimate f or participati on in any s ocial interacti on (Elli ott, Ziegler, Altman, & Sc ott, 1982). With the attendant huge demands and challenges ass ociated with caring f or the mentally ill patient, it has been f ound  out that family caregivers with greater family demands but less s ocial supp ort experienced higher degrees  of caregiver burden (Hsiao, 2010). In  our study, very little s ocial supp ort was  obtained by the caregivers unlike in  other studies (Chadda 2014; Turner & Br own 2010; Kilbourne et al., 2007) The study revealed that caregivers  of mentally-ill patients als o experiences different physical effects. These includes physical ill health, reducti on in physical activity, reduced leisure and s ome effects  on ability t o undertake r outine d omestic activities. In a study by Schulz et al (2008) which studied the physical and mental health effects  on families  of mentally ill patients, they als o f ound evidence  of health effects  of caregiving. They n oted that data gathered  over tw o decades sh owed that it was a maj or public health issue that needed p olicymakers‘ interventi ons. Clinical  observati on and early empirical research further sh owed that assuming a caregiving r ole resulted in all the features  of s ome f orm  of mental illness (Tracy & Biegel, 1994). An other study als o sh owed the imp ortant influence  of mental health  on caregiver‘s physical health and rec ommended the need f or interventi ons f or caregivers t o target health in a h olistic way (Chang, Chi ou, & Chen, 2010). 54 University of Ghana http://ugspace.ug.edu.gh LIMITATI ONS  OF THE STUDY Th ough the study was generally insightful, s ome challenges were enc ountered which c ould be impr oved up on in further studies. By the time a sample size of ten was attained, no new information was obtained and thus saturation was reached quite early. Als o, caregivers were mainly fr om Accra except tw o wh o were fr om the V olta regi on. This study cann ot be generalized as pe ople fr om all regi ons were n ot equally represented, especially th ose in the three n orthern regi ons that experience extreme p overty and lack  of health pers onnel and facilities. S ome transcripts had t o be translated fr om Twi t o English bef ore they were transcribed. As a result, some inf ormation may have been l ost in the pr ocess. 55 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY  OF FINDINGS, C ONCLUSI ONS AND REC OMMENDATI ON 6.1 Intr oducti on This is the final chapter, which c omprises an  overview  of the study, emphasising the maj or findings t o draw c onclusi ons. This chapter will als o make rec ommendati ons  of the study and suggest areas f or further research. 6.2 Summary  Of Findings Many caregivers were very cl ose relatives  of patients and they experienced numer ous em oti onal, s ocial and ec on omic c onsequences that affected their lives. M ore over, there were  other physical effects such as physical ill health as a result  of caring f or such relatives. The em oti onal c onsequences f or caregivers included depressi on, anxiety, strained marital relati ons and psych ol ogical distress that resulted in physical ill-health. The ec on omic c onsequences f or caring mentally ill relatives included experiencing financial burden thr ough the l oss  of pr oductive time and l oss  of ec on omic value t o the family. Caregivers had t o sacrifice ec on omic activities t o spend time t o stay, m onit or cl osely, send them treatment and regular reviews and generally care f or the mentally-ill relatives. This resulted in reduced quality  of life f or b oth the caregivers and  other members  of the family, especially dependents  of the caregiver. The s ocial c onsequences t o caregivers included l oss  of freed om t o s ocialize and risk  of is olati on where caregivers are neglected by  other members  of the family and c ommunity and perceived it as an  obligati on. They experienced stigmatizati on which was exhibited as negative attitudes and were  often blamed by the c ommunity f or s ocietal ills. They als o 56 University of Ghana http://ugspace.ug.edu.gh experienced reducti on in leisure as well as physical activity which was detrimental t o their health. Despite the numer ous c onsequences  of caring f or mentally ill relatives, caregivers were c ommitted and determined t o c ontinue t o stay and care f or their patients. They h owever w ould be happy t o receive s ome f orm  of supp ort in  order t o lessen the c onsequences., 6.3 C onclusi ons Emotional C onsequences  of taking care  of mentally-ill relatives Fr om the study, it was f ound that caring f or mentally-ill relatives had dire em oti onal c onsequences. These c onsequences were f ound t o include depressi on, strained marital relati on‘s, anxiety and psych ol ogical distress that c ould result in physical ill-health. Caregivers expressed that they f ound it difficult t o sleep, had l ost appetite and were extremely sad, especially when their patients had a relapse  or there was n o impr ovement in their c onditi on. These c onsequences w orsened with increasing durati on  of illness and length  of stay with patient. S ocial C onsequences  of taking care  of mentally-ill relatives Mental illness is kn own t o be debilitating affecting b oth the patient, caregiver and the s ociety in general. It c ould be chr onic and may incapacitate affected individuals f or life. C onsequently, it  often affects the caregiver‘s s ocial life. It increases the risk  of is olati on fr om s ociety as pe ople shun the family, stigmatizati on is high and this results in reduced leisure activities. It als o pr om otes physical inactivity and causes a change in d omestic r outines  of families, as adjustments have t o be made t o acc omm odate the patient and his needs. 57 University of Ghana http://ugspace.ug.edu.gh Economic Consequences  of taking care  of mentally-ill relatives Financial pr oblems arise frequently as a result  of taking care  of mentally-ill relatives. This includes l oss  of pr oductive time, l oss  of ec on omic value and reduced quality  of life  of caregivers and their families, especially dependents. This is because m ost caregivers spent m ost  of their day taking care  of their mentally-ill relatives and s o d o n ot have en ough time t o w ork and make sufficient funds. When they d o, they spend m ost  of their earnings attending t o health needs  of the patients, reducing the am ount  of m oney available t o the rest  of the family. 6.4 Recommendati ons These include suggesti ons based  on em oti onal, s ocial and ec on omic c onsequences that were  observed in the study. Recommendati ons t o reduce emoti onal consequences The Mental Health Authority has been established as the main body responsible for mental health in Ghana. The onus lies on the authority to improve upon mental health in Ghana. It is imperative that clinicians and mental healthcare providers who come into direct contact with caregivers try to ease the burden. Caregiver burden sh ould n ot be  overl o oked by clinicians and health care managers.  Once a patient has a c onstant caregiver, clinicians must establish a relati onship with the caregiver such that the caregiver can at any p oint v oice  out their em oti ons. Mental health care providers should make it a point to ask about the welfare of the caregivers accompanying patients and make an attempt to find out about their social circumstances. The Mental health Authority in collaboration with Medical Direct ors and heads  of h ospitals especially psychiatric h ospitals sh ould c onsider the creati on  of supp ort gr oups and 58 University of Ghana http://ugspace.ug.edu.gh ass ociati ons f or caregivers, ass ociati ons that c ould meet quarterly when they take their patients f or review at the h ospital. At these meetings, they can share their pr oblems and may find s oluti ons fr om  others, especially the m ore experienced caregivers. This w ould als o be a f orm  of s ocialisati on f or s ome caregivers wh o hardly get the chance t o d o s o. At these meetings, psych ol ogists can als o be invited t o c ounsel caregivers  on h ow t o manage the stress ass ociated with care-giving. Psych oeducati onal, skills-training, and therapeutic c ounseling interventi ons f or caregivers  of patients with chr onic c onditi ons such as schiz ophrenia will help t o reduce the stress. Medical Direct ors and heads  of h ospitals sh ould  organise psych ol ogists and nurses t o give  open talks and educate the caregivers as they sit at the waiting area  of the  out-patient department  of the h ospital, waiting t o be seen by a d oct or. Churches and religi ous  organisati ons sh ould rec ognise the impact  of caregiving  on the caregivers and supp ort them. This c ould be thr ough f orming gr oups c oncerned with the welfare  of such caregivers. The em oti onal, s ocial and ec on omic needs if subsidised by the church will help t o lessen the c onsequences these caregivers experience in taking care  of mentally-ill patients. Recommendati ons to reduce social consequences Educati on by vari ous agencies including the ministry  of health, mental health auth ority and the vari ous psychiatric h ospitals sh ould be d one  on mental health issues. This can be d one in h ospitals,  on televisi on and radi o, s ocial media, web sites, market places and at health pr ogrammes. Educati on c ould be in the f orm  of sh ort sketches, messages, talks and p osters. The focus  of the educati on sh ould be making m ore pe ople aware ab out mental illnesses, causes and treatments available. This will g o a l ong way t o reduce stigma in the s ociety. 59 University of Ghana http://ugspace.ug.edu.gh Recommendati ons t o reduce economic consequences The Mental Health Authority should impress on the government the need to pass the mental health bill which from the mental health act  of 2012, will make mental health c ompletely free as a result  of levies that will be taken fr om w orkers‘ salaries and the c ons olidated fund. This will increase accessibility t o mental health care and pr om ote the well-being  of patients and thus enc ourage g o od pr ogn osis, eventually decreasing the burden  on caregivers. This is imperative as most patients are in no position to earn an income and so depend solely on others for financial support. Again, the G overnment needs t o put Mental Health care  on the National Health insurance system (NHIS). This will g o a l ong way t o reduce the c onsequences, especially the economic consequences  of taking care  of mentally-ill relatives. G overnment, NG O‘S and the Mental Health Auth ority sh ould pr ovide research grants f or deeper research t o be d one  on burden  of caregivers 60 University of Ghana http://ugspace.ug.edu.gh REFERENCES Addo, R., & Aikins, M. (2013). Household cost of mental health care of patients attending Ho Municipal Hospital. Journal of Mental Health Policy and Economics, 1), S1. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=e med15&AN=71383699 Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S. (2014). Caregiver burden: a clinical review. JAMA : The Journal of the American Medical Association, 311(10), 1052–1060. https://doi.org/10.1001/jama.2014.304 American Psychiatric Association. (2013). DSM-V : Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric, 947 (87-110). Awad, A. G., & Voruganti, L. N. P. (2008). The burden of schizophrenia on caregivers: A review. PharmacoEconomics. https://doi.org/10.2165/00019053-200826020-00005 Bhana, A., Petersen, I., Baillie, K. L., Flisher, A. J., & The Mhapp Research Programme Consortium. (2010). Implementing the World Health Report 2001 recommendations for integrating mental health into primary health care: a situation analysis of three African countries: Ghana, South Africa and Uganda. International Review of Psychiatry (Abingdon, England), 22(6), 599–610. https://doi.org/10.3109/09540261.2010.536152 Bosanac, P., & Castle, D. J. (2012). Schizophrenia and depression. Medical Journal of Australia, 1, 36–39. https://doi.org/10.5694/mjao12.10516 Briggs, J. (2012). Caregiver burden of terminally-ill adults in the home setting. Nursing and Health Sciences, 14(4), 435–437. https://doi.org/10.1111/nhs.12013 Brohan, E., Slade, M., Clement, S., & Thornicroft, G. (2010). Experiences of mental illness stigma, prejudice and discrimination: A review of measures. BMC Health Services Research. https://doi.org/10.1186/1472-6963-10-80 CA, R., & EM, G. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. Journal of Psychiatric & Mental Health Nursing, 16(6), 558–567. https://doi.org/10.1111/j.1365- 2850.2009.01399.x Chadda, R. K. (2014). Caring for the family caregivers of the persons with mental illness. Indian Journal of Psychiatry, 56(3), S2. https://doi.org/10.4103/0019-5545.140616 Chang, H. Y., Chiou, C. J., & Chen, N. S. (2010). Impact of mental health and caregiver burden on family caregivers‘ physical health. Archives of Gerontology and Geriatrics, 50(3), 267–271. https://doi.org/10.1016/j.archger.2009.04.006 Collins, L. G., & Swartz, K. (2011). Caregiver care. American Family Physician, 83(11), 1309–1317. Corbin, J., & Strauss, A. (1994). Grounded theory methodology. Handbook of Qualitative Research, 0, 273–285. https://doi.org/10.1007/BF00988593 Corrigan, P. W., & Penn, D. (1997). Disease and discrimination: Two paradigms that describe severe mental illness. Journal of Mental Health, 6(4), 355–366. https://doi.org/10.1080/09638239718680 61 University of Ghana http://ugspace.ug.edu.gh Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric\nstigma. Am. Psychol., 54(9), 765–776. Crabb, J., Stewart, R. C., Kokota, D., Masson, N., Chabunya, S., & Krishnadas, R. (2012). Attitudes towards mental illness in Malawi: a cross-sectional survey. Bmc Public Health, 12. https://doi.org/10.1186/1471-2458-12-541 Creswell, J. W. (2007). Research Design: Qualitative, Quantitative and Mixed Method Aproaches. SAGE Publications, 203–223. https://doi.org/10.4135/9781849208956 Cumming, J. M. (2012). Statistical modeling of caregiver burden and distress among informal caregivers of individuals with Amyotrophic Lateral Sclerosis, Alzheimer‘s disease, and cancer. Dissertation Abstracts International: Section B: The Sciences and Engineering. Retrieved from http://gateway.proquest.com/openurl?url_ver=Z39.88- 2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&res_dat=xri:pqdiss&rft_dat=xri:pq diss:3468761 Elliott, G. C., Ziegler, H. L., Altman, B. M., & Scott, D. R. (1982). Understanding stigma: Dimensions of deviance and coping. Deviant Behavior, 3(3), 275–300. https://doi.org/10.1080/01639625.1982.9967590 Etikan, I. (2016). Comparison of Convenience Sampling and Purposive Sampling. American Journal of Theoretical and Applied Statistics, 5(1), 1. https://doi.org/10.11648/j.ajtas.20160501.11 Fieldhouse, J., & Onyett, S. (2012). Community mental health and social exclusion: Working appreciatively towards inclusion. Action Research, 10(4), 356–372. https://doi.org/10.1177/1476750312451761 Forster, E. B. (1971). Forensic attitudes in the delivery of mental health care in Ghana. Ghana Medical Journal, 10, 52–55. Friedemann-Sánchez, G., & Griffin, J. M. (2011). Defining the boundaries between unpaid labor and unpaid caregiving: Review of the social and health sciences literature. Journal of Human Development and Capabilities, 12(4), 511–534. https://doi.org/10.1080/19452829.2011.613370 Glozman, J. M., & Glozman, J. M. (2004). Quality of life of caregivers. Neuropsychology Review, 14(4), 183–196. Guo, X., Zhao, J., Liu, Z., Zhai, J., Xue, Z., & Chen, J. (2007). Antipsychotic combination with psychosocial intervention on outcome of schizophrenia (acpios): Rationale and design of the clinical trial. Clinical Schizophrenia and Related Psychoses, 1(2), 185– 192. https://doi.org/10.3371/CSRP.1.2.9 Gureje, O., & Alem, A. (2000). Mental health policy development in Africa. Bulletin of the World Health Organization, 78(4), 475–482. https://doi.org/10.1590/S0042- 96862000000400009 Gutiérrez-Maldonado, J., & Caqueo-Urízar, A. (2007). Effectiveness of a psycho-educational intervention for reducing burden in Latin American families of patients with schizophrenia. Quality of Life Research : An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 16(5), 739–47. https://doi.org/10.1007/s11136-007-9173-9 Hsiao, C. Y. (2010). Family demands, social support and caregiver burden in Taiwanese 62 University of Ghana http://ugspace.ug.edu.gh family caregivers living with mental illness: The role of family caregiver gender. Journal of Clinical Nursing, 19(23–24), 3494–3503. https://doi.org/10.1111/j.1365- 2702.2010.03315.x Insel, T. R. (2010). Rethinking schizophrenia. Nature, 468(7321), 187–193. https://doi.org/10.1038/nature09552 Insel T. (2008). Assessing the Economic Costs of Serious Mental Illness. American Journal of Psychiatry, 165(6), 663–665. https://doi.org/10.1176/appi.ajp.2008.08030366 Issa, B. A., Parakoyi, D. B., Yussuf, A. D., & Musa, I. O. (2008). Caregivers‘ knowledge of etiology of mental illness in a tertiary health institution in Nigeria. Iranian Journal of Psychiatry and Behavioral Sciences, 2(1), 43–49. Jim van Os, S., & Kapur, S. (2009). Schizophrenia. The Lancet, 374(22), 635–645. https://doi.org/10.1016/S0140-6736(09)60995-8 Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., … Wang, P. S. (2011). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiologia E Psichiatria Sociale, 18(1), 23–33. https://doi.org/10.1017/S1121189X00001421 Kilbourne, A. M., McCarthy, J. F., Post, E. P., Welsh, D., & Blow, F. C. (2007). Social support among veterans with serious mental illness. Social Psychiatry and Psychiatric Epidemiology, 42(8), 639–646. https://doi.org/10.1007/s00127-007-0212-1 Mavundla, T. R., Toth, F., & Mphelane, M. L. (2009). Caregiver experience in mental illness: A perspective from a rural community in South Africa. International Journal of Mental Health Nursing, 18(5), 357–367. https://doi.org/10.1111/j.1447-0349.2009.00624.x Mendenhall, E., De Silva, M. J., Hanlon, C., Petersen, I., Shidhaye, R., Jordans, M., … Lund, C. (2014). Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science and Medicine, 118(C), 33–42. https://doi.org/10.1016/j.socscimed.2014.07.057 Mfoafo-M‘Carthy, M., Sottie, C. A., & Gyan, C. (2016). Mental illness and stigma: a 10-year review of portrayal through print media in Ghana (2003–2012). International Journal of Culture and Mental Health, 9(2), 197–207. https://doi.org/10.1080/17542863.2016.1165271 Mueser, K. T., & McGurk, S. R. (2004). Schizophrenia. In Lancet (Vol. 363, pp. 2063–2072). https://doi.org/10.1016/S0140-6736(04)16458-1 Ofori-Atta, A., & Ohene, S. (2014). Changing trends in mental health care and research in Ghana. Changing Trends in Mental Health Care and Research in Ghana. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 84951045857&partnerID=40&md5=63152e83df82ef96909c458a32fd44f1 Ohaeri, J. U. (2003). The burden of caregiving in families with a mental illness: a review of 2002. Current Opinion in Psychiatry, 16(4), 457–465. https://doi.org/10.1097/01.yco.0000079212.36371.c0 Omar, M. a, Green, A. T., Bird, P. K., Mirzoev, T., Flisher, A. J., Kigozi, F., … MHaPP Research Programme Consortium. (2010). Mental health policy process: a comparative study of Ghana, South Africa, Uganda and Zambia. International Journal of Mental 63 University of Ghana http://ugspace.ug.edu.gh Health Systems, 4, 24–34. https://doi.org/10.1186/1752-4458-4-24 Osei, A. O., Roberts, M., & Crabb, J. (2011). The new Ghana mental health bill. International Psychiatry, 8(1), 8–9. Retrieved from http://search.proquest.com/docview/1417548300?accountid=13042%5Cnhttp://oxfordsf x.hosted.exlibrisgroup.com/oxford?url_ver=Z39.88- 2004&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&genre=article&sid=ProQ:ProQ:assiash ell&atitle=The+new+Ghana+mental+health+bill&t Ozlu, A., Yildiz, M., & Aker, T. (2015). Burden and burden-related features in caregivers of schizophrenia patients. Dusunen Adam, 28(2), 147–153. https://doi.org/10.5350/DAJPN2015280207 Peterson, A. L. (2017). Experiencing stigma as a nurse with mental illness. Journal of Psychiatric and Mental Health Nursing, 24(5), 314–321. https://doi.org/10.1111/jpm.12306 Picchioni, M. M., & Murray, R. M. (2007). Schizophrenia. BMJ (Clinical Research Ed.), 335(7610), 91–5. https://doi.org/10.1136/bmj.39227.616447.BE Polit, D. F., & Beck, T. B. (2004). Qualitative research designs and approaches. In Nursing research: Principles and Methods (pp. 245–272). Rymer, S., Salloway, S., Norton, L., Malloy, P., Correia, S., & Monast, D. (2002). Impaired Awareness, Behavior Disturbance, and Caregiver Burden in Alzheimer Disease. Alzheimer Disease & Associated Disorders, 16(4), 248–253. https://doi.org/10.1097/00002093-200210000-00006 Sadik, S., Abdulrahman, S., Bradley, M., & Jenkins, R. (2011). Integrating mental health into primary health care in Iraq. Mental Health in Family Medicine, 8(1), 39–49. Retrieved from http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L3617 69008%5Cnhttp://docserver.ingentaconnect.com/deliver/connect/rmp/1756834x/v8n1/s7 .pdf?expires=1305260831&id=62722196&titleid=75003813&accname=Elsevier+Scien ce&checksum=DAF6D9D60DF1 Samele, C., & Manning, N. (2000). Level of caregiver burden among relatives of the mentally ill in South Verona. European Psychiatry, 15(3), 196–204. https://doi.org/10.1016/S0924-9338(00)00225-X Sanuade, O. A., & Boatemaa, S. (2015). Caregiver profiles and determinants of caregiving burden in Ghana. Public Health, 129(7), 941–947. https://doi.org/10.1016/j.puhe.2015.05.016 Serretti, A., Mandelli, L., Bajo, E., Cevenini, N., Papili, P., Mori, E., … Berardi, D. (2009). The socio-economical burden of schizophrenia: A simulation of cost-offset of early intervention program in Italy. European Psychiatry, 24(1), 11–16. https://doi.org/10.1016/j.eurpsy.2008.07.009 Singh, P. M., & Prajapati, A. (2013). Burden of schizophrenia on caregivers in Nepal. Nepal Medical College Journal : NMCJ, 15(2), 140–3. Sintayehu, M., Mulat, H., Yohannis, Z., Adera, T., & Fekade, M. (2015). Prevalence of mental distress and associated factors among caregivers of patients with severe mental illness in the outpatient unit of Amanuel Hospital, Addis Ababa, Ethiopia, 2013: Cross- 64 University of Ghana http://ugspace.ug.edu.gh sectional study. Journal of Molecular Psychiatry, 3(1), 9. https://doi.org/10.1186/s40303-015-0014-4 Sodzi-Tetteh, S. (2007). Just don‘t get mad in Ghana! Modern Ghana News. Retrieved from http://www.modernghana.com/blogs/142593/31/just-dont-get-mad-in-ghana.html Stewart, D. E., Gucciardi, E., & Grace, S. L. (2004). Depression. BMC Women’s Health, 4(Suppl 1), S19. https://doi.org/10.1186/1472-6874-4-S1-S19 Tandon, R., Nasrallah, H. A., & Keshavan, M. S. (2010). Schizophrenia, ―Just the Facts‖ 5. Treatment and prevention Past, present, and future. Schizophrenia Research. https://doi.org/10.1016/j.schres.2010.05.025 The WHO World Mental Health Survey Consortium. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the world health organization world mental health surveys. JAMA, 291(21), 2581–2590. https://doi.org/10.1001/jama.291.21.2581 Tracy, E. M., & Biegel, D. E. (1994). Preparing social workers for social network interventions in mental health practice. Journal of Teaching in Social Work, 10(1–2). https://doi.org/10.1300/J067v10n01_02 Turner, R. J., & Brown, R. L. (2010). Social Support and Mental Health. In A handbook for the study of mental health: social contexts, theories, and systems (pp. 200–212). Van Sant, S. P., & Buckley, P. F. (2011). Pharmacotherapy for treatment-refractory schizophrenia. Expert Opinion on Pharmacotherapy, 12(3), 411–434. https://doi.org/10.1517/14656566.2011.528200 Volkow, N. D. (2009). Substance Use Disorders in Schizophrenia--Clinical Implications of Comorbidity. Schizophrenia Bulletin, 35(3), 469–472. https://doi.org/10.1093/schbul/sbp016 WHO. (2001). The World Health Report : 2001 mental health. New Understanding New Hope, 178. https://doi.org/10.1007/s001270170010 WHO. (2010). Mental health and development: targeting people with mental health conditions as a vulnerable group. World Health Organization Publication, 1–74. World Health Organisation. (1948). WHO definition of health. Retrieved from http://www.who.int/about/definition/en/print.html World Health Organisation, & Organization, W. H. (2008). Maternal mental health and child health and development in low and middle income countries: report of the meeting, Geneva, Switzerland, 30 January-1 February, 2008. World Health. Yusuf, A. J., & Nuhu, F. T. (2011). Factors associated with emotional distress among caregivers of patients with schizophrenia in Katsina, Nigeria. Social Psychiatry and Psychiatric Epidemiology, 46(1), 11–16. https://doi.org/10.1007/s00127-009-0166-6 65 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX 1: INTERVIEW GUIDE Initials…………………………… Age…………………. Sex………………………………… Marital Status……………………………. H  ome L  ocati  on……………………………………… Length   of stay with patient…………………………………… Durati  on   of illness   of patient…………………………………………   occupati  on   of caregiver……………………………………………………. Frequency   of visits t  o h  ospital………………………………………………….. Time it takes t  o visit the h  ospital………………………………………………….. M  onthly c  ost   of medicati  ons…………………………………………………………… C ost   of transp ortati  on………………………………………………………………………… Average inc  ome   of caregiver………………………………………………………………….. Stigma…………………………………………………………………………. Supp  ort fr  om   other family members…………………………………………………………….. Quality   of life   of caregiver eg sleep pattern, feeling anxi  ous, Ability t  o engage in   other s  ocial activities, h osting friends at h ome, etc………………………………………………… 66 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2: V  OLUTARY C ONSENT F ORM V oluntary Consent I have read the inf  ormati  on given ab  ove,   or the inf  ormati  on given ab  ove has been read t  o me and I understand. I have been given a chance t  o ask questi  ons c  oncerning the study; questi  ons have been answered t  o my satisfacti  on. I n  ow v  oluntarily agree, and als  o v  oluntarily agree f  or my relative t  o participate in this study kn  owing that I have the right t  o withdraw fr  om this study at any time with  out affecting future health care service. ………………… ……………………… ……………… …………………… Caregiver Name Signature Thumbprint Date …………………… ………………………. ……………… …………………. Witness Name Signature Thumbprint Date ……………… …………………… ……………… ………………… Name   of Researcher Signature Thumbprint Date ……………… …………………… ……………… ………………… Name   of interviewee Signature Thumbprint Date 67 University of Ghana http://ugspace.ug.edu.gh Interviewer’s Statement I, the undersigned, have explained this c  onsent t  o the subject in English language/ Twi / and that he/she understands the purp  ose   of the study, pr  ocedures t  o be f  oll  owed as well as the risks and benefits   of the study. The participant has fully agreed t  o participate in the study. Signature   of the interviewer ……………………………………………… Date ………………………………………………. Address ………………………………………………. ………………………………………………. If y  ou have any questi  on later please, c  ontact Researcher: Naa Ad  oley Add  o (0207049592) Administrat  or   of GHS-ERC: Ms. Hannah Frimpong (0243235225/0507041223) 68 University of Ghana http://ugspace.ug.edu.gh Appendix 3 Table 2: A Table representing the c  odes and pseud  onyms   of participants C ODE PSEUD ONYM 001 Mark 002 J  ohn 003 Tim 004 Daniel 005 Vivian 006 Jerry 007 Ruth 008 Ken 009 Philip 010 Mary 69 University of Ghana http://ugspace.ug.edu.gh Appendix 4 Themes and Sub-Themes f  or consequences   of caring for mentally- ill patients Theme Sub-Themes Em oti onal c onsequences  Depression  Strain in marital relationship  Psych ol ogical Distress and physical ill- health  Anxiety Economic c  onsequences  Loss   of productive time  Economic distractions  Reduced quality   of life Social c  onsequences  Family effects  Risk   of isolation  Stigmatisati on  Reducti on in physical activity  Reduced leisure  Change in domestic routines 70 University of Ghana http://ugspace.ug.edu.gh APPENDIX 5: ETHICAL APPR  OVAL 71