PUBLIC HEALTH BRIEFS 3. Bryant, T. E. Goals and potential of the neighborhood health centers. Medical Care 8: 93, 1970. 4. Mechanic, D. Public Expectations and Health Care. New York: Wiley-Interscience, 1971. 22-23. 5. Geiger, J. H. The neighborhood health center. Arch. Envir. Health, 14:912-916, 1967. 6. Schorr, L. B. and English, J. Background, context and significant issues in neighborhood health center programs. Medical Care, 6:289-296, 1968. 7. Schumaker, C. J. Major. Changes in health center sponsorship:
I. Impact on patterns of obtaining medical care. Am. J. Public Health, 61:1536-1544, 1971. 8. Cowen, D. L. and Sharbaro, J. A. Family centered health care-A viable reality? The Denver experience. Medical Care, 10:1964-1973, 1972. 9. Snoke, D. S. and Weinerman, E. R. Comprehensive care programs in university medical centers. Journal of Medical Education, 40:625-657, 1965. 10. Sparer, G., Dines, G. and Smith, D. Consumer participation in OEO-assisted neighborhood health centers. Am. J. Public Health, 60:1092, 1970.
Housing and Nutrition of Psychiatric Aftercare Patients KENNETH TARDIFF, MD, MPH Living arrangements have been a key issue in the increasing trend toward discharge of patients from large mental hospitals. Do patients fare better living with their families, in independent apartments, or with other patients in semi-supervised homes in the community? There has been some interest in the patient's adjustment in the family1-3 but most of the controversy has been concerned with group facilities in the community where formerly hospitalized patients live together in a semi-supervised setting. Some suggest these group facilities provide an effective, inexpensive alternative to mental hospitalization4 while others believe that they provide only custodial care and are nothing more than new back wards of mental hospitals transplanted into the community.5-8 It should be noted that previous studies have focused only on the interpersonal functioning of the patient and others living with him and not on such essentials as the physical characteristics of the patient's shelter and his daily diet. It is in the tradition of public health to consider housing and nutrition as essential for health. Mental health is no exception.
Methods Subjects were selected from the active caseload of the community mental health service in Vancouver, B.C. All active patients were sorted into four groups according to living arrangements: a) living alone in apartments; b) in group homes with an average of eight other patients; c) with their families and the patient not responsible for food preparation; Address reprint requests to Dr. Kenneth Tardiff, Assistant Professor of Psychiatry, State University of New York at Stony Brook, School of Medicine, Stony Brook, NY 11794. At the time of the study, he was a special consultant for the Greater Vancouver Mental Health Service, British Columbia, Canada. This paper, submitted to the Journal August 27, 1976, was revised and accepted for publication October 6, 1976. 182
and d) with their families and the patient responsible for food preparation. From the 159 potential subjects selected by a random number table, there were 121 patients available for interviews with no important differences between participants and non-participants except that non-participants tended to have used fewer services and to have been more likely employed. Research assistants interviewed patients and their therapists, and rated living arrangements of the patients. All data were recorded on pre-coded forms.*
Findings Significant demographic and clinical differences between patients in the four types of living arrangements are noted in Table 1. Physical health and number of psychiatric admissions in the past two years were most interesting in that patients living alone fared worst in both. As seen in Figure 1, patients living alone also had the poorest housing as rated by research assistants (Scales 4, 5, 7) and the least degree of satisfaction with their housing (Scale 1). Ratings of housing and satisfaction for patients in group homes were better than those for the patients living alone and comparable in some cases to patients living with families, who had the best in housing. On the other hand, group homes provided the least amount of autonomy and private living space (Scale 3). Despite poorer facilities for preparation of food, patients living alone were roughly equal to patients living with families and responsible for food preparation in regard to frequency of cooking, availability of food, and infrequency of dining outside the home, although patients living alone spent twice as much per person for food. Patients in group homes did not cook and ate at communal meals pro*Details of methodology and instruments available from the author on request. AJPH February 1977, Vol. 67, No. 2
PUBLIC HEALTH BRIEFS TABLE 1-Characteristics of Patients
Significantly Differing by Type of Living Arrangement Arrangement
A
Patient Characteristics
B
C
D
Family and
Family and Group not responsible responsible Alone Home for food for food
Statistic
F-ratio 1. Age (mean years) 2. Sex(% female)
42.7
56.6
35.1
35.2
59.
73.
20.
81.
14 1
13 1
19 10
5 12
14 29
16 30
1 30
15 32
24
18
8
4 2 30
6 6 30
18 6 32
3. Marital Status (number of patients)
Single Married Divorced-SeparatedWidowed Sub-Total
P
=
14.62
x2 = 27.89 d.f. = 3
0.0001 0.0001
x2 = 44.35 d.f. = 6
0.0001
x2 = 22.96 d.f. = 6
0.001
4. Diagnosis (number of patients)
Psychoses (excluding organic brain syndrome) 16 Neuroses + Personality Disorders 10 Other 3 Sub-Total 29 5. Previous Psychiatric
Inpatient Admissions (mean number) Total in lifetime In past two years 6. Physical health (% healthy)
2.6 1.0
26
3.1 0.4
52
vided by the staff. Regardless of differences in facilities for preparation of food, there were no differences between patients in relation to daily diet.
Discussion Quantifying the physical quality of housing and nutrition among aftercare patients adds a new dimension in evaluating their adjustment in the community. As expected, patients living with their families had the best in living conditions. Since many patients have no families available, their options narrow to living in independent arrangements or in semi-supervised group homes. It is for these patients that the findings have special relevance. Patients living alone in apartments had the poorest in housing, although they did struggle to maintain their independence and nutrition. It has been suggested that the demands of independence may be stressful and increase readmissions.9 The present study suggests that poor physical quality of housing may be an important component of that stress. More importantly, this study points out the deficiencies inherent in using only one set of criteria for community adAJPH February, 1977, Vol. 67, No. 2
1.3 0.8 61
1.1
0.6
59
F-ratio = 7.27
F-ratio = 3.56 x2 = 8.43, d.f. = 3 p
0.0001
0.016 =
0.04
justment. A study in Canada used instrumental functioning as criteria and found that aftercare patients in group homes were more disadvantaged when compared to hospitalized patients.8 That study did not consider physical aspects of housing and did not compare patients in group homes to patients in other community living arrangements. Using the findings of the present study and previous studies, it would appear that, given limited public expenditures, a patient can either be independent or live in a physically desirable setting-but not both. Programs to achieve both may mean an increase in expenditures. For instance, development of active re-socialization programs in group homes aimed at increasing independence would require hiring staff to run these programs or to educate the existing group house staff, usually few in number. Using the opposite approach, there have been attempts to use landlords in assisting patients living in independent apartment settings.10 Although that study was valuable, especially in beginning to ad-
dress issues of cost, it quantified neither physical quality of
housing nor instrumental functioning. All studies, including the present one, seeking to determine which living arrangements are best for which aftercare
patients lack one or more components necessary to compre-
183
PUBLIC HEALTH BRIEFS 875 SCALE 1
n.-rre sa sfocticr ty futoer SCALE 2 negrcorncold satisfocctio ty
825
teviente
775
pital wards. These patients should be followed and compared with regard to instrumental functioning, treatment programs, and the physical quality of their housing and health. The relative benefits and detriments of each living arrangement and program must be weighed against the financial cost of each. Otherwise, we will continue to examine only fragments of the puzzle of psychiatric aftercare services.
O 725 a
30 SCALE 5 externcr of home roted
0) °
~
/
a) 24
~
a/
~
_
tby nterviewer)
SCALE 7 fccj preporaticr. foci;ities
{
rrated hy interviewer,
L) o E
-U -J
-H
D
18
q)
10
I. Impact on patterns of obtaining medical care. Am. J. Public Health, 61:1536-1544, 1971. 8. Cowen, D. L. and Sharbaro, J. A. Family centered health care-A viable reality? The Denver experience. Medical Care, 10:1964-1973, 1972. 9. Snoke, D. S. and Weinerman, E. R. Comprehensive care programs in university medical centers. Journal of Medical Education, 40:625-657, 1965. 10. Sparer, G., Dines, G. and Smith, D. Consumer participation in OEO-assisted neighborhood health centers. Am. J. Public Health, 60:1092, 1970.
Housing and Nutrition of Psychiatric Aftercare Patients KENNETH TARDIFF, MD, MPH Living arrangements have been a key issue in the increasing trend toward discharge of patients from large mental hospitals. Do patients fare better living with their families, in independent apartments, or with other patients in semi-supervised homes in the community? There has been some interest in the patient's adjustment in the family1-3 but most of the controversy has been concerned with group facilities in the community where formerly hospitalized patients live together in a semi-supervised setting. Some suggest these group facilities provide an effective, inexpensive alternative to mental hospitalization4 while others believe that they provide only custodial care and are nothing more than new back wards of mental hospitals transplanted into the community.5-8 It should be noted that previous studies have focused only on the interpersonal functioning of the patient and others living with him and not on such essentials as the physical characteristics of the patient's shelter and his daily diet. It is in the tradition of public health to consider housing and nutrition as essential for health. Mental health is no exception.
Methods Subjects were selected from the active caseload of the community mental health service in Vancouver, B.C. All active patients were sorted into four groups according to living arrangements: a) living alone in apartments; b) in group homes with an average of eight other patients; c) with their families and the patient not responsible for food preparation; Address reprint requests to Dr. Kenneth Tardiff, Assistant Professor of Psychiatry, State University of New York at Stony Brook, School of Medicine, Stony Brook, NY 11794. At the time of the study, he was a special consultant for the Greater Vancouver Mental Health Service, British Columbia, Canada. This paper, submitted to the Journal August 27, 1976, was revised and accepted for publication October 6, 1976. 182
and d) with their families and the patient responsible for food preparation. From the 159 potential subjects selected by a random number table, there were 121 patients available for interviews with no important differences between participants and non-participants except that non-participants tended to have used fewer services and to have been more likely employed. Research assistants interviewed patients and their therapists, and rated living arrangements of the patients. All data were recorded on pre-coded forms.*
Findings Significant demographic and clinical differences between patients in the four types of living arrangements are noted in Table 1. Physical health and number of psychiatric admissions in the past two years were most interesting in that patients living alone fared worst in both. As seen in Figure 1, patients living alone also had the poorest housing as rated by research assistants (Scales 4, 5, 7) and the least degree of satisfaction with their housing (Scale 1). Ratings of housing and satisfaction for patients in group homes were better than those for the patients living alone and comparable in some cases to patients living with families, who had the best in housing. On the other hand, group homes provided the least amount of autonomy and private living space (Scale 3). Despite poorer facilities for preparation of food, patients living alone were roughly equal to patients living with families and responsible for food preparation in regard to frequency of cooking, availability of food, and infrequency of dining outside the home, although patients living alone spent twice as much per person for food. Patients in group homes did not cook and ate at communal meals pro*Details of methodology and instruments available from the author on request. AJPH February 1977, Vol. 67, No. 2
PUBLIC HEALTH BRIEFS TABLE 1-Characteristics of Patients
Significantly Differing by Type of Living Arrangement Arrangement
A
Patient Characteristics
B
C
D
Family and
Family and Group not responsible responsible Alone Home for food for food
Statistic
F-ratio 1. Age (mean years) 2. Sex(% female)
42.7
56.6
35.1
35.2
59.
73.
20.
81.
14 1
13 1
19 10
5 12
14 29
16 30
1 30
15 32
24
18
8
4 2 30
6 6 30
18 6 32
3. Marital Status (number of patients)
Single Married Divorced-SeparatedWidowed Sub-Total
P
=
14.62
x2 = 27.89 d.f. = 3
0.0001 0.0001
x2 = 44.35 d.f. = 6
0.0001
x2 = 22.96 d.f. = 6
0.001
4. Diagnosis (number of patients)
Psychoses (excluding organic brain syndrome) 16 Neuroses + Personality Disorders 10 Other 3 Sub-Total 29 5. Previous Psychiatric
Inpatient Admissions (mean number) Total in lifetime In past two years 6. Physical health (% healthy)
2.6 1.0
26
3.1 0.4
52
vided by the staff. Regardless of differences in facilities for preparation of food, there were no differences between patients in relation to daily diet.
Discussion Quantifying the physical quality of housing and nutrition among aftercare patients adds a new dimension in evaluating their adjustment in the community. As expected, patients living with their families had the best in living conditions. Since many patients have no families available, their options narrow to living in independent arrangements or in semi-supervised group homes. It is for these patients that the findings have special relevance. Patients living alone in apartments had the poorest in housing, although they did struggle to maintain their independence and nutrition. It has been suggested that the demands of independence may be stressful and increase readmissions.9 The present study suggests that poor physical quality of housing may be an important component of that stress. More importantly, this study points out the deficiencies inherent in using only one set of criteria for community adAJPH February, 1977, Vol. 67, No. 2
1.3 0.8 61
1.1
0.6
59
F-ratio = 7.27
F-ratio = 3.56 x2 = 8.43, d.f. = 3 p
0.0001
0.016 =
0.04
justment. A study in Canada used instrumental functioning as criteria and found that aftercare patients in group homes were more disadvantaged when compared to hospitalized patients.8 That study did not consider physical aspects of housing and did not compare patients in group homes to patients in other community living arrangements. Using the findings of the present study and previous studies, it would appear that, given limited public expenditures, a patient can either be independent or live in a physically desirable setting-but not both. Programs to achieve both may mean an increase in expenditures. For instance, development of active re-socialization programs in group homes aimed at increasing independence would require hiring staff to run these programs or to educate the existing group house staff, usually few in number. Using the opposite approach, there have been attempts to use landlords in assisting patients living in independent apartment settings.10 Although that study was valuable, especially in beginning to ad-
dress issues of cost, it quantified neither physical quality of
housing nor instrumental functioning. All studies, including the present one, seeking to determine which living arrangements are best for which aftercare
patients lack one or more components necessary to compre-
183
PUBLIC HEALTH BRIEFS 875 SCALE 1
n.-rre sa sfocticr ty futoer SCALE 2 negrcorncold satisfocctio ty
825
teviente
775
pital wards. These patients should be followed and compared with regard to instrumental functioning, treatment programs, and the physical quality of their housing and health. The relative benefits and detriments of each living arrangement and program must be weighed against the financial cost of each. Otherwise, we will continue to examine only fragments of the puzzle of psychiatric aftercare services.
O 725 a
30 SCALE 5 externcr of home roted
0) °
~
/
a) 24
~
a/
~
_
tby nterviewer)
SCALE 7 fccj preporaticr. foci;ities
{
rrated hy interviewer,
L) o E
-U -J
-H
D
18
q)
10
