|Year : 2021 | Volume
| Issue : 3 | Page : 171-175
Can Microfinance-Based Poverty Alleviation Programs Help Patients with Severe Mental Illness?
Afzal Javed1, Farooq Naeem2
1 Pakistan Psychiatric Research Centre, Lahore, Pakistan; Institute of Applied Health Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
2 Staff Psychiatrist, Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
|Date of Submission||23-Sep-2021|
|Date of Decision||10-Nov-2021|
|Date of Acceptance||14-Nov-2021|
|Date of Web Publication||23-Dec-2021|
Prof. Afzal Javed
Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan; Institute of Applied Health Research, University of Birmingham, Birmingham
Source of Support: None, Conflict of Interest: None
Background: While the social security programs offer financial assistance to patients with severe mental illness in high-income countries, no such systems exist in low- and middle-income countries. During recent years, poverty alleviation programs have been found to alleviate poverty in many countries. However, such programs have not been tried in persons with severe mental illness. We report 1-year outcomes of a microfinance program to alleviate poverty in patients with schizophrenia in a low-income country. Objectives: The objectives were to assess the feasibility and acceptability of a poverty alleviation program and to study the effect of the program on clinical and financial variables. Methods: Twenty-five (25) unemployed, young persons (19–35) with severe mental illness living with the family were recruited into a microfinance-based poverty alleviation program. Feasibility was assessed through recruitment and retention. Psychopathology and functioning were assessed through Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale, and Global Assessment of Functioning at baseline and 12 months. Results: The program was feasible and acceptable, with excellent recruitment and retention rates. There were statistically significant improvements in PANSS-positive symptoms (P < 0.000), PANSS-negative symptoms (P < 0.000), PANSS-general score (P < 0.000), and functioning (P < 0.001). At 12 months, participants earned an average of $USD 40/month, with an average of $USD 10 spent on medication, $USD 12.5 on loan repayment, and $USD 17.5 contribution to family living. Conclusions: Poverty alleviation programs can be used to help younger persons with severe mental illness. However, this study has numerous limitations, and there is a need to conduct definitive trials in this area.
Keywords: Microfinance, poverty, poverty alleviation, schizophrenia, social recovery
|How to cite this article:|
Javed A, Naeem F. Can Microfinance-Based Poverty Alleviation Programs Help Patients with Severe Mental Illness?. World Soc Psychiatry 2021;3:171-5
| Introduction|| |
Evidence suggests a strong link between poverty and mental and physical health and life expectancy. The relationship between poverty and mental illness is cyclical: poverty increases the risk of having a mental illness, and having a mental illness increases the risk of descending into poverty. Evidence from the United Kingdom indicates that individuals living in the most deprived areas report higher levels of mental illness and lower levels of well-being than those living in the most affluent neighborhoods. In India, 3.4% of those in the lowest income quintile experience depression at any given time, compared with 1.9% of those in the highest quintile. Data from other low- and middle-income countries (LMICs) confirm these findings.
Schizophrenia spectrum disorders are some of the most impairing forms of psychopathology, frequently associated with a profound negative effect on the individual's educational, occupational, and social function. Cost of illness uniformly points to disquieting human and financial costs. Poverty has a strong association with schizophrenia. People with schizophrenia, in comparison with persons without mental health problems, are four times more likely to be unemployed or partly unemployed.
While financial assistance is provided to persons with severe mental illness through social welfare in high-income countries (HIC), such help is unavailable for patients with schizophrenia or their families in LMICs. Therefore, the burden of care for patients with schizophrenia in LMICs in the Global South lies with the family and the wider community.
Poverty alleviation programs range from simple cash transfers to multifaceted anti-poverty programs such as graduation programs. There is evidence to suggest that poverty reduction programs work. In addition, evidence indicates that anti-poverty programs improve mental health outcomes. Thus, poverty alleviation programs can help patients with severe mental illness in the Global South who otherwise struggle with making their ends meet and are unable to afford the treatment. However, such programs have not been assessed in patients with severe mental illness. This paper reports preliminary evidence based on a feasibility study to support such a program to improve income in patients with schizophrenia in Pakistan.
| Methods|| |
The study aimed to assess the feasibility and acceptability of a poverty alleviation program in a group of younger persons (19–35) with schizophrenia. The objectives were to assess the feasibility and acceptability of a poverty alleviation program to improve income in young persons with schizophrenia, to study the effect of the program on clinical and financial variables, and to obtain outcome data to inform future definitive trials.
Study design and setting
This proof-of-concept study used a single-arm design. It was conducted between 2017 and 2020 at the Fountain House, Lahore, Pakistan. Ethics approval was obtained from the Ethics Committee of the Pakistan Psychiatric Research Centre and Fountain House, Lahore, Pakistan. After a complete description of the study, all participants provided written informed consent before entering the study.
The Fountain House (http://www.fountainhouse.com.pk/), Lahore, Pakistan, is the second Fountain House of the world after Fountain House New York N.Y. (USA), established in 1965. Indoor facility at the Fountain House, Lahore, caters to the rehabilitation needs of 400 patients, including 100 females. The outpatient department provides psychiatric and psychological consultation to poverty-stricken persons suffering from mental disorders from across the country. Free medicine is offered to deserving patients. Outpatient services are provided to 100–125 patients per day.
Inclusions and exclusion criteria
Suitability for the program was assessed in two stages. In stage 1, individuals were included if they were aged 19–35, diagnosed with schizophrenia or schizoaffective disorder according to ICD-10, were currently without a source of income, living with family and engaged with mental health service, and were considered stable for at least 6 months. The second stage involved a suitability assessment by the poverty alleviation program staff members. Individuals with substance dependence, organic brain syndrome, or intellectual disability were excluded. In addition, those with active psychosis and high levels of disturbed behavior were also excluded.
Individuals with schizophrenia or schizoaffective disorders were recruited from Fountain House, Lahore, Pakistan. Participants were identified by their health workers initially. Those considered suitable were then contacted by a research team member and invited to participate in the study. Consenting participants were randomly allocated to one arm of the trial. Participants had a mean age of 27.1 years (standard deviation [SD] = 4.8). Briefly, the sample comprised 40% (n = 10) female, 68% (n = 17) single, 4% divorced (n = 1), 28% (n = 7) married, and had a mean of 11 (SD = 2.8) years of education. Mean monthly family income was $USD 112.5 (SD = 38.9). All (n = 25) lived within a joint or extended family system. The majority (18, 72%) of the key care supervisors (KCSs) were a parent with the rest (7, 28%) being siblings. The KCS was on average 50 (SD = 23.9) years old with an average of 10 (SD = 4.5) years of education. Mean duration of illness was 6 (SD = 2.5) years.
[Figure 1] shows the study flow.
Assessment of feasibility and acceptability
Feasibility was assessed through recruitment, retention, and dropouts. Participants at the end of the intervention were asked to describe their experience. Acceptability was evaluated by direct feedback from patients.
Assessment of clinical and financial outcomes
Outcome assessments were carried out by trained psychiatrists, independent of those providing the intervention. The following assessments were performed at baseline and 12 months: Positive and Negative Syndrome Scale for Schizophrenia (PANSS), and the Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Functioning (GAF). Medication adherence was measured using self-reports and reports from the family. Most of the patients with schizophrenia were on antipsychotic depot injections that were administered by the clinical team.
The financial outcomes included monthly income, the ability to pay back the loan, help the family, and pay for their medication to help with their illness.
Participants received interest-free loans as well as guidance in setting up a small business. The intervention was provided by Akhuwat – a microfinance initiative-based Nongovernmental Organization (http://www.akhuwat.org.pk/) in Pakistan with more than 800 branches that offers interest-free loans to the poor so that they may acquire a sustainable livelihood through setting up small businesses. The loan cycles are often relatively short, and the loan amounts increase as individuals successfully repay their loans.
Participants meeting the study criteria and their families were introduced to the Akhuwat program staff and were given a detailed explanation of the microfinance services offered by the Akhuwat. A representative of the Akhuwat assessed the suitability of those meeting the recovery criteria for the microfinance project. Willing participants were invited to join the program and a KCS (usually a family member living with the patient for at least 6 months and is trusted by the patient as their primary care support). Both the patient and their KCSs were provided education over illness, its causes, treatment, and consequences. Emphasis was placed on the importance of work and social functioning in recovery. They were also provided training in setting up a small business. Finally, a contract was drawn that emphasized income to be divided into three parts for loan repayment, contribution to family income, and purchase of medication.
The data were analyzed using SPSS v26, Armonk, NY, IBM Corp, USA. Both frequency and descriptive commands were used to measure descriptive statistics. In addition, SPSS explore command was used to measure the normality of the data. Changes in clinical measures at 2 time points were measured using a paired t-test. Statistical significance was kept at P < 0.05 for all tests.
| Results|| |
Feasibility: Recruitment, retention, and acceptability
Recruitment and retention
The study generated much interest, and the staff identified 38 individuals within 8 weeks. Of these, 28 were considered suitable on first screening (clinical screening), and 26 were deemed to be suitable on second screening (financial screening). One participant and his family moved out of the catchment area before joining the program, and therefore, data were available for 25 participants. Retention to the intervention group was excellent, with all 25 subjects still engaged with the program at 1-year follow-up. All the patients were on antipsychotic depot injections. None of the participants missed an injection during the 12-month study period. Informal feedback from the participants and the professionals was positive, who described the intervention as acceptable and helpful. The carers described the intervention as particularly useful in helping with medication and contribution to the family income. One participant noted, “We never thought our son would be able to work again.”
[Table 1] shows participants' details.
There were statistically significant differences between the baseline and the follow-up in all the clinical measures – BPRS (baseline, mean = 50.5 [SD 18.8], follow-up, mean = 33.65 [SD 13.9], P < 0.000), PANSS-positive symptoms (baseline, mean = 19.4 [SD 8.5], follow-up, mean = 14.8 [SD 6.8], P < 0.000), PANSS-negative symptoms (baseline, mean = 20.9 [SD 7.1], follow-up, mean = 14.25 [SD 6.3], P < 0.000), PANSS General scores (baseline, mean = 55.8 [SD 18.7], follow-up, mean = 37.4 [SD 14.9], P < 0.000), and GAF (baseline, mean = 76.7 [SD 29.9], follow-up, mean = 86.6 [SD 33.4], P < 0.001).
Participants received an average loan of US$ 375 (range = $USD 300–450). At the end of 12 months, all the participants were running their small businesses with the support of their families. Participants reported their monthly average income to be $USD 40 (range = 30–50). They spent $USD 10 (range = 5–15) on their medication, $USD 12.5 (range = 10–15) on loan repayment, and $USD 17.5 (15–20) toward their contribution to family living.
| Discussion|| |
As far as we are aware, this is the first report of using a microfinance program in patients with schizophrenia. It is feasible to use a microfinance program that provides interest-free loans for alleviating poverty. The program was also found to improve mental health.
Current research has shown that antipsychotic medication can reduce psychotic symptoms and prevent relapse. However, symptom improvement and relapse prevention alone do not necessarily improve patients' quality of life, help to complete education, find employment, and have social relationships. This realization has led to an interest in treatment models that focus on functional recovery.
However, the unemployment rates among patients with schizophrenia remain very high, with one study reporting rates as high as 90%. Furthermore, gainful employment positively affects patients' well-being, including social integration, economic viability, self-worth, and independence. Most significantly, employment can improve clinical and social functioning and reduce positive and negative symptoms, depression, and relapse risk. Our study provides preliminary evidence to confirm some of these assertions, such as improving mental health as the economic outcomes improve.
The social welfare systems remain the primary source of assistance for patients with schizophrenia in the Global North, with direct costs of schizophrenia in HICs ranging from 1.6% to 2.6% of total health-care expenditures. The burden of care for patients with schizophrenia in LMICs in the Global South lies with the family and the wider community. Most LMICs do not have a social welfare system that can provide free treatment or assistance with the cost of living. Most LMICs spend <1% of their health budget to address mental health problems. A combination of long duration of untreated psychosis and poverty leads to poorer outcomes of schizophrenia in LMICs.
It, therefore, follows that if patients with schizophrenia in LMICs are provided with opportunities to make a living, they cannot only afford their medication and cost of living, but it will also improve their mental health and self-esteem.
This pilot project had a few methodological problems, such as a small sample size, lack of a control group, and a short-term follow-up. Many aspects, including the variables that could potentially influence the intervention, were not studied due to limited resources, for example, the effect of the intervention on family's well-being, their relationships, and improvement in patients' self-efficacy. Detailed analyses were also not carried out due to the small sample size. We are planning a larger trial to address these issues.
| Conclusions|| |
It is feasible to use a poverty alleviation program to help patients with schizophrenia increase their income. The program can also improve the mental well-being of patients. However, this pilot study has some methodological problems, and future research should focus on larger randomized controlled trials with better methodology. Future research can also incorporate psychological interventions to improve self-efficacy and emotional well-being and include patients with other mental health problems.
We are grateful to our patients and staff at the Fountain House. We are also thankful to the team at Ahuwat. Finally, we express our gratitude to Dr. Muhammad Amjad Saqib, founder and CEO of Ahuwat.
Financial support and sponsorship
Fountain House and Akhuwat.
Conflicts of interest
There are no conflicts of interest.
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