Study Area and Setting
The study was conducted at Amanuel Mental Specialized Hospital in Addis Ababa city, Ethiopia. It is a Tertiary Mental Health care center that renders comprehensive outpatient, inpatient and specialized psychiatry services such as neurology, old age, and rehabilitation from substance addiction. The hospital was organized by 8 case teams. Two of them were dedicated to serve patients with schizophrenia and other related psychotic disorders, bipolar and related disorder or depressive disorders that were the theme of this study by categorizing under severe mental illness.
Study Design and Period
The study was intended to describe the frequency and distribution of victimization by time, place and person so an institution based quantitative, Cross-sectional descriptive study design was chosen. Data were collected from May 16, 2018, to June 22, 2018.
Population
Source population
The source population was psychiatric patients who were attending treatment in Amanuel Mental Specialized Hospital outpatient departments.
Study population
The study population was psychiatric patients who were attending treatment in Amanuel Mental Specialized Hospital outpatient departments during the study period.
Inclusion and Exclusion Criteria
Psychiatric patients on follow up with full symptom remission, age greater than or equal to 18 years, who themselves appeared on the appointment date and who had two or more follow up dates were included. Patients with first visit and those who deemed to have difficulties in memory, concentration, and abnormal behavior at the time of the interview and those who suspected to provide irrelevant information were excluded as per the judgment of data collectors.
Sample Size Determination
The minimum sample size required for this study was determined by using single population proportion formulas with the assumption of 61% prevalence of victimization in Ethiopia (found from previous study [7], confidence level (Z)= 95%, margin of error (a)= 5%, precision (d)= 0.04 and 10% of the calculated sample size was added for the anticipated non- response rate as shown below
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Participant selection and Sampling Technique
A total of 7045 patients with severe illness were attended during a one month data collection period. Among them 3475 were actual patients and the rest 3570 visits were by representative family members. From the 3475 actual patients two thousand seven hundred patients had at least one previous visit and 775 of the patients were first visit for the Hospital.
Participants were selected at waiting areas of Card room and physician office. Patients who were available at the time of calling and having at least one previous visit were guided to data collectors at card room and OPD for selection to be interviewed. A systematic sampling technique was employed for the selection of the sampling units from available participants. Every 3rd patient, were requested for interview consecutively until the required sample size was reached. The first participant was selected from the first three patients by lottery method at each data collection sites.
As shown in Figure 1 below, 629 patients were selected from 2160 patients for the interview. Seven (1.1%) of them were excluded due to difficulties in memory, concentration or abnormal behavior at the time of the interview. Only 622 were eligible for the study. Of those eligible participants12 (1.93%) refused to be interviewed. Data was collected from 610 participants.
Variables and Measurement
Outcome variable
Victimization status was determined when participants respond at least one “yes” for questions that asked if they had suffered from Simple assault, aggravated assault, kidnapping, rape or attempted rape, attempted robbery, personal theft or vandalism of property. Standard International Crime Victim Survey (ICVS) questions and proposed Indicators of Violence questions were used to explore the occurrence of those sufferings within the participant’s life. The ICVS questions were designed to assess circumstances surrounding the incident such as time frame for the incident, (life time or previous 12 months), frequency of incidence, the offender who performed the incident, the place where the incident was happened, whether the sufferer reported and for whom reported the incident; and how much she/he satisfied by the response of reported body, likelihoods of future victimization and perception of safety and security [25-27].
Certain modifications were done to make the questions acceptable, understandable by people with mental disorder and relevant to time frame of their mental illness status. For example, under “Perceptions of Safety and Violence” participants had found in difficult to forecast future likelihood of being a victim in the next 12 months and the feeling of safety while they are walking down the street after dark in the area where they live. So, those questions were omitted during the actual data collection. “Life time prevalence” was modified into “since you become mentally ill” to exclude incidents of victimization before the illness (telescoping). The phrase “in health care institution” was added under place of incidence and “health professional” under perpetrator of victimization to explore the presence of violent acts against people with mental disorders in the health care settings by heath care professional.
Predictor Variables
Demographic related variables such as participants’ sex, current age, residence, marital status, religious affiliations, educational level, occupational status and housing ownership were assessedin order to determine their association with victimization. Mental illness related variables such as type of Mental illness, Number of Hospital Admissions, duration of mental illness and age at first onset of mental illness were assessed. And behavior related variables such as current & life time use of alcoholic beverages; chewing khat (a green leaf containing amphetamine like substance); smocking cigarette; violent acts; criminal history and suicidal behaviors were also assessed.
Data collectors directly diagnosed and/or searched medical records to ascertain type of Mental illness. Participants who started treatment with antipsychotic, antidepressant and or mood stabilizer at least one month prior to data collection were considered as people with severe mental disorder. And Substance use was assessed using questions adapted from the Alcohol, Smoking and Substance Involvement Screening Test” questions [28]. Participants were considered violent perpetrators if they had caused property damage, physical injury or sexual assaults [29] and criminal history was assessed by asking if they have had accused by police, arrested or jailed. Psychological distress following suffering from violence was assessed by asking the following question adapted from Greek study. “How much did this incident affect your mood or change your life? And they were requested to rate their feeling (mood) as High, Moderate or Low [8]. Suicidal behavior such as suicidal thought, plan and attempt were assessed by the following questions adapted from “Screening Tool for Assessing Risk of Suicide (STARS) [30]. Have you thought about suicide/ending your life? Have you ever made a plan in the past? Have you tried to end your life?
Data Collection Procedure
Data was collected by treating psychiatry clinicians by using semi structured interviewer administered questionnaire at card room and examination room. Questions were read and explained to every participant after their consent was obtained. Data collectors were strictly following psychiatry risk assessment procedure throughout the interview and they had recorded all responses provided by each participant.
All questions were pretested in 29 patients at Amanuel Mental Specialized Hospital one week prior to actual data collection. One day training was given to data collectors about the questions and the whole purpose of the research work. Overall activities during data collection were supervised by senior psychiatry professional with Master’s Degree in Integrated Clinical and Community Mental health and principal investigator.
Method of Data Analysis
Data were collected from 610 participants and analyzed using SPSS statistical packages version 20 for Windows. Descriptive analyses were carried out to explore the socio-demographic characteristics of participants and prevalence of violent victimization. A new data set was created from the main data set based on participants’ victimization status to examine circumstances surrounding violent incidents. Multi variable Binary logistic regression model was used to examine associated factors while odds ratio was used to measure the strength of the association between overall victimization and independent variables and 95%CI and p-value= 0.05 test were taken to determine the significance of the association.