INTRODUCTION:

Mental health problems are among the most important contributors to the burden of disease and disability worldwide. Mental health problems are the fifth leading cause of disability worldwide.

It has been estimated that around 450 million people suffer from a mental or behavioural disorder in the world. But only a small minority of them receive even the most basic treatment. Unfortunately, in most part of the world mental health and mental disorders are not given importance like the physical health. Mental illnesses have been largely ignored or neglected and stigmatized (WHO, 2001). According to ICD-10,Schizophrenia is a group of disorders manifested by fundamental disturbance or distortion in thinking, mood and behavior, last for at least a month of active phase symptoms like delusions, hallucinations, disorganized speech, grossly diagnosed or catatonic behavior, negative symptoms such as shallow or flat effect, alogia or avolition and incongruos mood.ⁱⁱⁱSchizophrenia is the most common psychotic illness in Kerala State, comprising 1.3 per cent of the burden-diseases in the State. It is estimated that 320,000 people in Kerala suffer from schizophrenia.ⁱ Schizophrenia is often described in terms of positive and negative (or deficit) symptoms. Positive symptoms are those that most individuals do not normally experience, but are present in people with schizophrenia. They can include delusions, disordered thoughts and speech, and tactile, auditory, visual, olfactory and gustatory hallucinations, typically regarded as manifestations of psychosis.^v Schizophrenia is one of the most persistent and disabling mental illness that an individual can suffer from fundamental and characteristic distortions of thinking and perception, inappropriate or blunted affect, cognitive deficits, delusions, hallucinations and impairment in overall quality of some aspects of personal behavior which manifest as loss of interest, aimlessness, idleness, a self absorbed attitude and social withdrawal.

Disability in schizophrenia develops first in peripheral social contacts, then in the circles closer to the person and finally the inner most circle of personal self-care. When psychotic episode resolves, the disabilities tend to improve in the reverse order. Schizophrenia imposed the functional limitations that results in disturbances of the ability to perform certain activities. The disability include poor self-care skills (Cooking, cleaning, grooming and tooth care), social withdrawal, seductiveness, abandonment of family responsibility and working capacity. Nowadays varieties of pharmacologic treatments are available for schizophrenia. In addition to that, A number of psychosocial interventions may be useful in the treatment of schizophrenia including: family therapy, assertive community treatment, supported employment, cognitive remediation, skills training, token economic interventions, and psychosocial interventions for substance use and weight management.ⁱⁱ Token economy programs are generally used in long-term care setting such as long-stay inpatient units and residential care settings, but can be adapted for shorter stay and less intensive treatment programs as well. The primary goal of a token economy is to increase desirable behavior and decrease undesirable behavior.

NEED AND SIGNIFICANCE OF THE STUDY:

The efficacy of token economieshas been demonstrated in a variety of inpatient settings andwith numerous populations. Which included chronic psychiatricpatients, mentally retarded adults and children,patients with brain injuries, and individuals in alcoholtreatment. Due to apathy or lack of motivation over the course of the illness, poor personal hygiene can be a problem for clients who are experiencing psychotic symptoms as well as for all clients with schizophrenia. Positive reinforcement helps to motivate the demotivated patients to do activities of daily living. Token economy is the most effective positive reinforcement intervention.^ivFor the lack of motivation, only few numbers of patients were involved in psychosocial therapies. So patients need positive reinforcement along with medication for improving the social skill and self care ability. The psychiatric mental health nurse led a major role in the mental health team. Activities of daily living skills are an exclusive area where nurses are totally responsible. Activities of daily living of the patients with schizophrenia need to improve are essential and this could be made possible by providing reinforcement. As far as the researcher’s knowledge is considered, so far no study has been conducted to prove the effect of Token economy on Self care management of patient with schizophrenia. Hence, the investigator thought of doing a study to evaluate the effect of Token economy on self care management of patient with schizophrenia in our settings.

STATEMENT OF THE PROBLEM:

Evaluate the Effect of Token economy on Self care Management of Patients with Schizophrenia at Government Mental Health Centre, Kuthiravattom, Kozhikode.

OBJECTIVES:

1. Assess the Self care management of patients with Schizophrenia before and after the administration of Token economy as measured by Modified Social-Adaptive Functioning Evaluation Scale (SAFE).

2. Evaluate the effect of Token economy on self care management of patients with Schizophrenia.

3. Find out the association between the effect of Token economy on Self care management of patients with Schizophrenia and selected variables.

Hypotheses:

H_1.There will be significant difference in the rating score of Self care management of patients with Schizophrenia before and after the administration of Token economy.

H_2.There will be significant association between the performance of Self care of patients with Schizophrenia and selected variables.

MATERIALS AND METHODS:

Research Approach:

Quantitative Research Approach

Research design:

one group pre test post test quasi experimental design

Research Setting:

Government Mental Health Centre (GMHC), Kuthiravattom, Kozhikode

Population and Sample:

The target population of this study was the patients with Schizophrenia. The sample constituted of 30 patients with Schizophrenia admitted in the male and female family therapy wards of Government Mental Health Centre (GMHC), Kuthiravattom, Kozhikode who fulfilled the criteria for sample selection.

Inclusion Criteria:

Patients

· Diagnosed as schizophrenic with poor self care management those who score 10 or below in Modified Social-Adaptive Functioning Evaluation scale.

· Between the age group of 16-65 years.

· Duration of illness- more than one year.

· Those who are able to follow the concept of Token economy.

· Those who are able to follow investigator instruction.

Exclusion criteria

Patients

· With Aggressive behavior.

· Those who are diagnosed as Schizophrenic and performing adequate Self care.

· Those who are mentally and physically challenged.

Sampling technique:

Non probability purposive sampling

Tools and Technique

· The data collection technique used for the investigation consist of interview, observation and review of clinical data sheet.

· Tool-I -- Structured interview schedule to collect socio-personal data of patients with Schizophrenia.

· Tool-II--Modified Social-Adaptive Functioning Evaluation Scale to assess the Self care Management of patients with Schizophrenia.

Data Collection Process:

The investigator screened the population using Tool-II (Modified SAFE Scale) and selected the sample (N=30) who fulfilled inclusion criteria. A structured interview schedule was used to collect the Socio-personal data and clinical data. Pretest was conducted using Tool II for assessing the self care management ability of patients with schizophrenia for consecutive 3 (1-3) days. Proper instructions were given by the investigator to care givers and patients regarding administration of Token economy intervention on the 3^rd day of the pre test. From the next day onwards token economy intervention was started, assessing the self care management ability using Tool-II through observation and caregiver interviews. At the end of each day tokens were given to the patients based on the Self care performance scores in the Tool II. Each token can be exchanged in to packed snacks (biscuits, sweets, etc..) as a privilege on daily basis. It was continued for consecutive 7(day 4-10) days. Post test was conducted on next 3 consecutive days (day 11-13) for assessing the self care management ability of patients with schizophrenia without token economy intervention using the Tool-II.

Mode of Token:

In this study mode of token is directly proportional to the scores on each sub areas; it means if the initial score is 0 (extreme impairment) and subsequently it reduces to 1 (severe impairment) the patient gets one token, likewise the score reduces the number of token increases and it is directly proportional. Same like each 5sub areas should assess daily. Token valance is estimated for patient who attained maximum of 24 tokens.

Table 1 Frequency and Percentage Distribution of Subjects Based on socio-personal data N=30

Characteristics

Frequency

Percentage

Age

16-25yrs

26-35yrs

36-45yrs

46-55yrs

Sex

Male

Female

Care giver

mother

father

siblings

spouse

26.7

13.3

53.3

46.7

23.3

Table 1 shows that, among the subjects 40% belongs to the age group of 26- 35 years, 53.3% of them are males and 46.7% subjects are cared by their mothers.

Figure 1. Distribution of subjects based on duration of mental illness.

Figure 1 shows that the duration of mental illness was 4-6 years in 50% of the subjects.

Figure 2. Distribution of subjects based on duration of treatment.

Figure 2 shows that the duration of treatment was 4-6 years in 50% of the subjects.

Figure 3: Distribution of subjects based on number of hospitalization in last year.

Figure 5 shows that 80% of subject have the history of hospitalization in the last year.

Table 2. Distribution of sample based on self care management score N=30

Self care Management	Score range	Pre test		Post test
Self care Management	Score range	f	%	f	%
Extreme impairment	0	0	0	0	0
Severe impairment	1-5	17	56.7	0	0
Moderate impairment	6-10	13	43.3	0	0
Mild impairment	11-15	0	0	14	46.6
No impairment	16-20	0	0	16	53.3

Table 2 shows that subject having 56.7% were severe impairment and 43.3% moderate impairment in self care management before administration of token economy. After implementing token economy 53.3% subjects had no impairment in self care management.

From Table3 it is clear that there is significant difference between the pre test and post test mean scores in bathing and grooming (t₍₂₉₎= 41.71, p-value <0.001), clothing and dressing (t₍₂₉₎= 32.514, p-value <0.001), eating and feeding (t₍₂₉₎= 27.149, p-value <0.001), neatness and maintenance activities (t₍₂₉₎= 30.483, p-value <0.001), recreation/leisure (t₍₂₉₎= 28.176, p-value <0.001) and total self care management of patients with Schizophrenia (t₍₂₉₎= 54.598, p-value <0.001). Hence the null hypothesis rejected at 0.05 level. The findings indicate that Token economy is effective in improving self care management of patients with Schizophrenia.

DISCUSSION:

The study has evaluated the effect of Token economy on self care management patients with Schizophrenia. The study revealed that 56.7% of the patients with Schizophrenia had severe impairment and 43.3%of the patients with schizophrenia had moderate impairment in self care management. In the study, 30 patients with schizophrenia subjected to token economy intervention had shown significant improvement (p<0.001) in total self care management such as bathing and grooming, clothing and dressing ,eating and feeding, neatness and maintenance activities and recreation/leisure activities. In the study, 30 patients with schizophrenia were subjected to token economy intervention for seven days and the effect on self care management was tested, 53.3% of the subject shows no impairment and 46.6% of the subjects shows mild impairment in self care management after token economy. This findings show token economy was effective in self care management of patients with schizophrenia. On the whole token economy is effective in improving self care management of patient with schizophrenia.

CONCLUSION:

Based on the findings of study, the following conclusions were made

· Patients with schizophrenia suffered from impairment in self care management.

· Token economy intervention produced a significant improvement in the self care management of patents with schizophrenia.

NURSING IMPLICATIONS:

The findings of the study have implications to nursing practice, nursing education, nursing administration and nursing research.

Nursing Practice:

Patients with schizophrenia have significant dysfunction in one or more major areas of life activities such as interpersonal relations, work or education, self-care family life, and communication. Lack of motivation is the one of the main schizophrenic negative symptom. . Motivation is the essential factor for getting back the clients maladaptive behavior into adaptive behavior. Psychiatric nurses play an important role in the mental health care team for motivating the patients who are not interested in taking care of him/her self. Behavioral therapy occupies important position among clinical interventions for modifying behavior of patient with schizophrenia. Psychiatric nurses should implement token economy as a positive reinforcement intervention for motivating the clients.

Nursing Education:

Nurses should be equipped with adequate knowledge and necessary skill in the rehabilitation of the mentally ill. The nursing curriculum should be revamped lying importance on various psychotherapies like behavioral, cognitive, family, individual and group therapies. The student should recognize its importance and should become part of its practice. Appropriate measures should be adopted to implement the curriculum effectively, which includes close observation of the behavior patterns of the clients, visits to rehabilitation centers, clinical posting at different psychosocial therapy units, and working out different therapies with the patients.

Nursing Administration:

Every effort must be made to increase the psychosocial, cognitive, behavioral and occupational therapeutic facilities in the psychiatric hospitals and in the community. The nurse administrators should take due interest to plan and implement policies regarding rehabilitation programs to maintain a therapeutic milieu.

Nursing Research:

Nurses should come forward to conduct research on the effect of token economy in various psychiatric disabilities. The evidence base practice should be promoted to improve the quality of care rendered to the clients.

RECOMMENDATIONS:

· Similar study can be conducted on a larger sample and different setting.

· Similar study can be conducted with a control group.

· Similar study can be conducted in wards where no bystanders are permitted.

· Similar study can be conducted to check the long term effect of intervention.

· Similar study can be conducted on patients with other psychiatric disorders like depressive disorders.

REFERENCE:

1. Sureshkumar PN, Impact of vocational rehabilitation on social functioning, cognitive functioning, and psychopathology in patients with chronic schizophrenia. Indian Journal of Psychiatry.50(4); 2008: 257-261.

2. Dixon LB, Dickerson F, Bellack AS, et al, The schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin. 36 (1); 2010:48–70.

3. Neeraja KP, Essentials of mental health and psychiatric Nursing. Jay pee publication, New Delhi. 2006; 1^st ed: pp.375-376.

4. Kaplan and Sadock's, Comprehensive Textbook of Psychiatry. Edited by Sadock, and Benjamin J, New York. 2005; 8th ed: pp.2405-2408.

5. Electronic journal article/ World Wide Web

6. Kneisl C. and Trigoboff E. Contemporary Psychiatric- Mental Health Nursing. A review. Available from: URL: https://en.wikipedia.org/wiki/Schizophrenia.

Received on 18.07.2016 Modified on 02.09.2016

Int. J. Adv. Nur. Management. 2016; 4(4): 334-338.

DOI: 10.5958/2454-2652.2016.00075.5