Family caregivers satisfaction with home care for mental illness after the implementation of national health insurance in Taiwan.

The purposes of this study were to assess the level of family caregivers' satisfaction with home care for mental illness since the implementation of National Health Insurance (NHI) in Taiwan, investigate the factors that affect satisfaction, and identify the family's needs. Seventy-five family caregivers served in the military psychiatric hospital in Taipei were surveyed by completing three self-administrated questionnaires and one interview. The great majority of caregivers expressed a high satisfaction level. Caregiver's age, income, support from family, the amount of time spent in caregiving, feelings about having a mentally ill family, the number of services received, and the acceptance of home care if again needed were significantly associated with satisfaction. More than 41% of caregivers needed to be able to more easily contact home care workers by telephone and get quickly needed services in an emergency. However, the implementation of NHI has improved caregivers' perceptions of costs of services.

FAMILY CAREGIVERS' SATISFACTION WITH HOME CARE FOR MENTAL ILLNESS AFTER THE IMPLEMENTATION OF NATIONAL HEALTH INSURANCE IN TAIWAN by Wei-Chen Tung A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah December 1998 Copyright © Wei -Chen Tung 1998 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the University of Utah: I have read the thesis of Wei -chen Tung in its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the supervisory committee and is ready for submission to The Graduate School. O(dv~ I;), If(v'6 Date , ,/!Jia€J{ LRJJy \.../' Mary E. ffy Chair, Supervisor Committee Linda K. Amos ChairlDean Approved for the Graduate Council --=:t>.....;.A s:. ct..:1- -- - David S. Chapm Dean of The Graduate School ABSTRACT In Taiwan, family caregivers play an important role in the home care of the mentally ill. The purposes of this study were to (a) assess the level of family caregivers' satisfaction with the provision of home care services for mental illness since the implementation of National Health Insurance (NHI) in Taiwan, (b) investigate the factors that affect caregivers' satisfaction, (c) explore the possibility of continuous usage of home care and recommendation of home care to others based on the level of caregivers' satisfaction, and (d) identify the family's needs for home care. A total of 75 family caregivers served in the military psychiatric hospital in Taipei City were surveyed by completing three self-administrated questionnaires and one interview. The great majority of caregivers expressed a high level of general satisfaction; only 2.7% felt that there was a need for strong improvement. Caregivers refusing home care reported significantly lower satisfaction in three areas: getting clear explanations, obtaining speedy services, and maintaining patient's health from home care. Caregiver's age, income, support from family, the amount of time spent in caregiving, feelings about having a mentally ill family, the number of home care services received, and the acceptance of home care if again needed were significantly associated with satisfaction. More than 41 % of caregivers needed to be able to more easily contact home care workers by telephone and get quickly needed services in an emergency. However, the implementation of NHI has improved caregivers' perceptions of costs of services. T ABLE OF CONTENTS ABSTRACT ............................................................................................................. iv LIST OF FIGURES .................................................................................................. vii LIST OF TABLES ................................................................................................... viii ACKNOWLEDGMENTS . ......... ........... ........... ........ ..... ............. ... ....... ............. ....... x Chapter 1. INTRODUCTION ........................................................................................... 1 Background ................................................................................................ 1 Statement of Problem ................................................................................. 3 Purpose ....................................................................................................... 4 Significance to Nursing .............................................................................. 4 Research Questions .......................... ....................................................... ... 5 2. REVIEW OF THE LITERATURE ................... ................ ...................... .... .... 7 Introduction ................................................................................................ 7 The Chinese Characteristics and Attitudes toward Mental Disease ... ........ 8 Home Care for Mental Illness in Taiwan ...... ..... ................................... ..... 11 Family Caregiver's Satisfaction with Home Care ...................................... 13 Client/Patient Satisfaction ...... .......... .......... ...... ............ ............ ............ ...... 15 Conceptual Framework ..................................................................... ......... 17 3. METHOD ........................................................................................................ 24 Design ......................................................................................................... 24 Setting and Sampling ................ ................ ........................................ ......... 25 Procedure .................................................................................................... 25 Instruments ................................................................................................. 27 Data Analysis ............................................................................................. 30 4. RESULTS ....................................................................................................... 35 Reliability of the Satisfaction Tool ............................................................ 35 Description of Sample ................................................................................ 37 Findings ...................................................................................................... 40 5. SUMMARY AND RECOMMENDATIONS ................................................. 63 Summary of Results and Discussion ......... ............................... .......... ........ 63 Implications for Nursing ............................................................................ 68 Limitations of Study..................... ............................. ................................. 70 Recommendations ........................................ .............................................. 71 Appendices A. FAMILY CAREGIVER'S DEMOGRAPHIC CHARACTERISTIC QUESTIONNAIRE ......................................................................................... 75 B. INTERVIEW GUIDE ...................................................................................... 78 C. FAMILY CAREGIVER'S SATISFACTION SURVEY QUESTIONNAIR .......................................................................... 80 D. DEGREE OF CONGRUENCE BETWEEN ATTRffiUTES OF HOME CARE SERVICE DESIRED AND RECEIVED SURVEY QUESTIONNAIRE ......................................................................................... 83 E. INFORMED CONSENT AGREEMENT ....................................................... 86 REFERENCES .... .................................... ................ ................................................. 89 VI LIST OF FIGURES 1. Conceptual Framework .................................................................................. 19 2. The Distribution of General Satisfaction ....................................................... 49 LIST OF TABLES Table 1. Number of Family Caregivers Participating in Study .................................... 36 2. Demographic Characteristics of Family Caregivers ...................................... 38 3. Experiences of Family Caregivers ................................................................. 39 4. Attitudes of Family Caregivers ...................................................................... 41 5. Comparison of the Means of Family Caregivers' Satisfaction with Each Attribute of Home Care Services .................................................. 43 6. Comparison of the Means of Family Caregivers' Satisfaction with Each of the Five Categories ................................................................... 44 7. Comparison of the Means of Family Caregivers' Satisfaction with All 19 Attributes of Home Care Services .............................................. 46 8. Comparison of the Means of Family Caregivers' Overall Satisfaction with Home Care Services .......................................................... 46 9. Result of Paired t-test with the Means of Family Caregivers' Satisfaction with 19 Attributes of Home Care Services and the Means of Family Caregivers' Overall Satisfaction ................................. 47 10. General Satisfaction with Home Care Services ............................................ 47 11. The Number and Percentages of Caregivers' with A Lower or Higher Satisfaction by Levels of Demographic Variables ............................ 50 12. The Number and Percentages of Caregivers' with A Lower or Higher Satisfaction by Levels of Experience Variables ................................ 51 13. Correlations between Experiences and Satisfaction ...................................... 52 14. The Number and Percentages of Caregivers' with A Lower or Higher Satisfaction by Levels of Attitude Variables ..................................... 52 15. The Distribution of Numbers and Percentages of Family Caregivers Who Receive Attributes of Services Which Are Desired ................................................ ................. ......... .............. 55 16. Correlations between the Number of Attributes of Home Care Services Received and Satisfaction ...................................................... 55 17. Family Caregivers' Continued Use of Home Care and Recommendation of Home Care to Others ................................................... 57 18. The Number and Percentages of Caregivers' Continued Use of Home Care and Recommendation of Home Care to Others by Levels of A Lower or Higher Satisfaction Variables ............... ..................... 58 19. The Percentages of the Family Caregivers Who Did Not Receive the Attributes of Home Care Services That Were Desired (Unmet Needs) ........................................................................ 60 IX ACKNOWLEDGMENTS I gratefully acknowledge the assistance and support of the those people who served as my committee. From the College of Nursing, Mary E. Duffy, RN, PhD, chairperson, offered her generous support and expertise. Also from the College of Nursing, Susan L. Beck, RN, PhD, provided clear directions throughout this effort. From the Department of Psychiatry, Veterans General Hospital-Taipei, Hsien-jane Chiu, MPH, MD, offered valued direction regarding home care and mental illness in Taiwan. I would like to express my deepest gratitude to Hui-Min Chang, Home Care Nurse from the military psychiatric hospital in Taipei City, for providing encouragement and assistance in identifying those subjects to be interviewed. I also wish to especially thank those family caregivers who participated in this study and who were the subject of this study. Through their courage in participating in this research and their honest, revealing responses, they demonstrated a willingness to contribute to the understanding of the family's needs and satisfaction with the home care for mental illness. I am especially grateful to my family for their continued support and assistance throughout this effort. CHAPTER 1 INTRODUCTION Background In Taiwan, home care for mental illness is still in the early stages of development. Beginning in 1989, action has been taken to promote the rehabilitation of mentally ill patients in the community by subsidizing public and private hospitals to set up community rehabilitation centers, shelter workshops, half-way houses, and home treatments. The goals of this action are to assist discharged patients in adjusting to the realities of social life and to promote home care in order to avoid recurrence (Department of Health of the Executive Yuan of Taiwan, 1997). In 1995, the coverage by National Health Insurance (NHI) was extended to include a larger range of payment for home health care and community rehabilitation. Prior to the forn1ation of the National Health Insurance, only Government En1ployee Insurance offered nonpsychiatric home care. When the National Health Insurance was initiated, there were 31 home care agencies for mental illness signing contracts with the Bureau of the National Health Insurance to provide home care. All of these agencies remain active today (Department of Health of the Executive Yuan of Taiwan, 1997). Although the implementation of National Health Insurance offers more comprehensive benefits, K. Y. Tang (personal conversation, May 1, 1997) stated that several factors have contributed to create strong disincentives that 2 discourage family caregivers from involvement in home care. Among the factors are families' refusal of home visits by health professionals because of the stigma of a mentally ill family member in the home, and a preference for institutional care since the caregiver's burden can be reduced when patients are in an inpatient care facility. Another burden for family caregivers is the requirement of the National Health Insurance that the patient's insurance card should be renewed after every 12 home treatments. Often, 110 one can help them to take care of the patient when they leave the home to renew the insurance card (H. M. Chang, personal conversation, June 23, 1997). Home care for mental illness is relatively new in Taiwan; therefore, little research exists. Findings from the U.S. suggest that home care for mental illness is a feasible, cost-effective alternative to hospitalization or long-term institutionalization (Morris, 1996). Institutionalization for mental illness can lead to institutional dependency, progressive loss of social and vocational competencies, and the reduction of one's ability to act independently. Moreover, institutionalization may involve loss of contact with relatives and meaningful others (Kiesler, 1982). In contrast, home care for mental illness can promote independence and provide contact with family members and significant others (Morris, 1996). Financial savings (Bums, Raftery, Beadsmoors, McGuigan, & Dickson, 1993; Kiesler, 1982) and shorter hospital stays (Haber, 1997) for mental illness are also benefits of home care services. Given this recognition of the need for home care for mental illness in the future, family caregivers will be required to demonstrate a significant and valuable role in home care. Since home care provides clients and their families with a spectrum of health­related services in the home setting (Haber, 1997), the family caregiver is an integral part 3 of home care (Stanhope, 1996). While seeking assistance through the delivery of home health care, most patients who are cognitively impaired cannot interact with professional health care providers and home care services as frequently and directly as the family caregivers can. Thus, family caregivers playa very important role in the provision of home health care. Because of the heavy responsibilities involved, the needs of families caring for mental illness should be addressed by health providers during the delivery of home health care. With the deinstitutionalization of mental illness, U.S. researchers have found that families have been forced to assume the role of caregivers for which they are poorly prepared (Parker, 1993; Peternelj-Taylor & Hartley, 1993). They experience the chronic stress associated with caring for a mentally ill family member. This stress is not only physical, but also emotional, financial, and cultural. Today and in the future, it is essential that health professionals pay attention to the dimensions of family caregivers' satisfaction through evaluation of the families' expectations regarding home health care, and their perceptions of the home care they receive. Statement of Problem In Taiwan, the characteristics of family caregivers playa significant role in the home care of the mentally ill. Two studies found that 60% of family caregivers and patients in Taiwan refused home visits because of privacy and the stigma associated with mental disease (Lu, Liu, Chen, Tsou, & Sim, 1995; Tsai, Lin, & Sim, 1993). Few studies reported in the literature have looked specifically at the satisfaction of family caregivers with home care services for the n1entally ill. The status of these family caregivers and their needs specific to home care appear to be largely ignored by health care professionals and researchers. In order to promote the delivery of optimal home health care, there is a need to evaluate the satisfaction of family caregivers with home care in meeting their needs and expectations. This type of evaluation is particularly important in Taiwan due to changes in services offered under the new health plan. Purpose 4 The main purposes of this exploratory study were to (a) assess the level of family caregivers' satisfaction with the provision of home care services for mental illness since the implementation of National Health Insurance in Taiwan, (b) explore the factors that affect family caregivers' satisfaction with home care services for mental illness, (c) explore the possibility of continuous usage of home care services and recommendation of home care services to others based on the level of satisfaction of family caregivers, and (d) identify the family's needs for home care in cases of mental illness and assess whether needs are being met. Significance to Nursing In Taiwan and the U.S., nurses are the largest group of professional providers of home health care (Barkaukas, 1990). They are also the primary providers of home health care services (Harrington, 1988). Nursing has significantly affected the delivery of home care. Through assessment and evaluation of the delivery of service, nurses can realize the value of their service. Such evaluations will also allow nurses to understand the family caregivers' needs, to define and assure the quality of care, to establish the appropriateness of services and access to those services, and to ameliorate health service deficits through clinical research and public advocacy. Research Questions A series of research questions related to the main purposes of the study were investigated. Each purpose, presented as a major research question, is given below. Purpose (1) To assess the level of family caregivers' satisfaction with the provision of home care services for mental illness since the implementation of National Health Insurance in Taiwan. Question (lA) What is the level of family caregivers' satisfaction with the specific home care services? Question (1 B) 5 Is there a difference in the level of satisfaction between family caregivers who are caring for mentally ill patients currently or have received home care visits within the past year, and the level of satisfaction of family caregivers caring for a mentally ill member who has previously received home care, but now has refused continuous home care services? Purpose (2) To explore the factors that affect family caregivers' satisfaction with home care services for mental illness. Question (2A) Is there a relationship between satisfaction of family caregivers and family caregivers' characteristics, experiences, and attitudes? Question (2B) Is there a relationship between the level of satisfaction of family caregivers and the number of attributes of home care services received? PUI]ose (3) To explore the possibility of continuous usage of home care services and recommendation of home care services to others based on the level of satisfaction of family caregivers. Question (3A) Is there a relationship between the level of satisfaction of family caregivers and continued use of home care and recommendation of home care to others? PUI]ose (4) To identify the family's needs for home care in cases of mental illness and assess whether needs are being met. Question (4A) 6 Is there a difference in the degree of congruence (received/desired %) between the desired attributes and those actually received among all the 19 attributes of home care services? CHAPTER 2 REVIEW OF THE LITERATURE In troducti on Limited research has looked at family caregivers' satisfaction with home care for the mentally ill. Most research on satisfaction has focused on "patients" in many health care settings (Bene-Kociemba, Cotton, & Fortgang, 1982; Feletti, Firman, & San-Fisher~ 1986; Heaman, Robinson, Thompson, & Helewa, 1994; Laferriere, 1993; Like & Zyzanski, 1987; Linder-Pelz, 1982; Linn, Dimatteo, Chang, & Cope, 1984; Morris, 1996: Oberst, 1984; Patrick, Scrivens, & Charlton, 1983; Wilson et aI., 1995; Zastowny, Roghmann, & Cafferata, 1989). Family caregivers' satisfaction with health care services and home care in Taiwan and the U.S. has been investigated (Chiu, 1997; Herman, 1994; Kristjanson, 1993; Proctor, Morrow-Howell, Albaz, & Weir, 1992). However, family caregivers' satisfaction with "home care for mental illness" in Taiwan and the U.S. has not been specifically addressed in any of these studies. Yet, family caregivers' satisfaction is an integral part of home care because family caregivers playa crucial role in the provision of care for the mentally ill, especially in the Chinese society. Due to the paucity of literature on family caregivers' satisfaction with home care for mental illness after the implementation of National Health Insurance in Taiwan, literature on related topics was explored. The literature review is divided into four sections: (a) the Chinese characteristics and attitudes toward mental disease, (b) home care for mental illness in Taiwan, (c) family caregiver's satisfaction with home care, and (d) client/patient satisfaction. The Chinese Characteristics and Attitudes toward Mental Disease 8 Deliverance of mental health services is deemed an important issue in the Chinese culture. The decision to seek mental health care is not made by the individual alone but usually includes his or her family, because the Chinese are a collective society who rely on their families, when they make important decisions (Chien, Lau, & Chen, 1994; Fan, Yeh, Lee, & Lin,1993; Lin et aI., 1987). Families are expected to take the bulk of the responsibility for seeking help and caring for a mentally ill individual (Wen, 1990). However, the strong feeling of stigma associated with mental illness has resulted in resistance to seek professional mental health care (Kuo & Kavanagh, 1994). The characteristics of family caregivers of the mentally ill patients have been addressed by researchers in Taiwan, and have been a concern of psychiatrists and other health care professionals involved in the inpatient and outpatient management of mental illness (Hsu & Tai, 1991a, 1991b; Hu et aI., 1994; Lin et al., 1987). Hu et ai. (1994) surveyed 10,360 subjects to explore the sociodemographic characteristics and attitudes of families of psychiatric inpatients in Taiwan. Results showed that more than 75% of the caregivers had a low education level (less than senior high school). Most often, caregivers (33.1 %) were the patients' parents, and the average age of these parents was more than 60 years old. The authors of this study concluded that the quality of caring for 9 mental illness could be problematic due to the low education level and old age of the chief caregivers. They also found that 26.30/c of the patients in hospitals should have been discharged. Most of these patients remained in hospitals because their families were unwilling to care for them at home. Others simply had no home. The main reasons for family caregivers' preference for institutional care for mentally ill members included long-term stress on the family caregivers, negative attitude toward the mentally ill in Taiwanese society, and inadequate con1munity rehabilitation facilities. Lin et al. (1987) studied the relationships among the demographic characteristics of families, help-seeking behaviors, and medical compliance. The researchers interviewed 107 psychiatric inpatients' families. They noted that whether each patient received regular treatment after discharge depended on the education level of that patient's family. Patients from families with a higher level of education were more likely to receive regular treatment at the outpatient department. Low-income families with less education preferred to seek medical help mainly from god worship, herbal medicine, and other nonprofessional sources. In addition to the characteristics of family caregivers, it is imperative to study the attitudes of the community and family toward mental disease. Two studies (Hsu & Tai, 1991a, 1991b) directly focused on the community and family's attitudes toward the mentally ill. Hsu and Tai interviewed 305 community members and the families of 198 psychiatric outpatients to compare the attitudes of these two groups toward mental illness. They reported that the families showed more tendency to describe the patients as cheating, lacking value, and being a failure. Both community and family members believed that those with mental disorders had an abnormal mentality and behavior. The 10 community members tended to believe that the patients had problems in character. Using the same sample, Hsu and Tai ( 1991 b) reported that community members with less education and those in low social class, living alone, living in the rural areas, and being older held more negative attitudes toward the mentally ill, and were more pessimistic about the possibility of the patients' recovery from mental illness. Both reports revealed that these negative attitudes could be associated with the recurrence of mental disease. Family caregivers' attitudes and beliefs toward the healing of the patients' mental illness often influence their decisions about help-seeking behaviors. Chien et al. (1994) explored the beliefs of the families of psychiatric outpatients on mental illness. A survey was conducted with a structured questionnaire on a 5-point scale. Four hundred eighty­eight families participated in the study. All were randomly selected from the outpatient department of a psychiatric hospital in Taipei City. The results showed that families' explanations for the etiology of psychiatric disorders included punishment by god or ancestors for past bad behavior by the family (9.20/0), inappropriate location of an ancestor's tomb or living houses (14.3%), invasion of one's body by a supernatural spirit (15.8%), experience of an unpleasant and enormous shock (41.20/0), or preoccupation with excelling in school (52.20/0). Consequently, the families' help-seeking behaviors were characterized by seeking pluralistic health care--not only Western medical care, but also traditional medical care. Such characteristics and attitudes of family caregivers and the community toward mental illness in Chinese society will affect the utilization and delivery of mental health services, including home care, day care, and rehabilitation programs reinforced with 11 inpatient facilities in Taiwan. Home Care for Mental Illness in Taiwan Before the implementation of National Health Insurance in Taiwan, only a few studies documented the need for home care for the mentally ill. However, there are no published studies after the implementation of National Health Insurance. One study by Lu et al. (1995) described the needs and satisfaction of both patients of a hospital-based psychiatric home care program and their families. The survey was conducted with a semistructured interview and a standardized questionnaire. Twenty-four patients and 38 family members participated in the study. The results showed that 70.80/0 of the patients and 94.8% of the families were satisfied with home care, but only 8.3% of the patients and 10.50/0 of the families needed home care; 79.20/0 of the patients and 60.50/0 of the families refused home visits, preferring instead to go to an outpatient clinic. There was a slight indication of preference for an outpatient clinic over home care. However, there were no data to explain why a higher satisfaction rate was associated with a low home care need. Furthermore, this study only used a single-item question to measure overall satisfaction. It did not focus on the measure of specific aspects of the relationships among satisfaction, home care providers/systems, and clients' characteristics, attitudes, and experiences. In another investigation (Tsai et aI., 1993) of a hospital-based psychiatric home care program, a higher--but still relatively low--need for home care was reported. Thirty­five patients and 42 family members participated in this study. Only 31.43% of the patients and 14.290/0 of the families expressed a need for home care. Sixty-two point 12 eighty-six percent of the patients and 61.90% of the families refused home visits. About half of those patients and families refused home visits by health professionals because of the stigma of having an ill family member at home. Both of the aforementioned studies showed a low perceived need for home care; however, there was no special or detailed information to identify the family's needs for home care. Noticeably, these studies noted that telephone counseling was the most preferred service among home care services. This result was the same in two other studies (Chou, Hsiung, & Huang, 1992a; Huang, Lee, & Mao, 1991). Although there was a low need for home care expressed in these studies, home care was reported as being helpful to patients and their families. Chou et al. (1992a, 1992b) measured the influence of home care on the daily living of schizophrenic patients, and on the perceived stress of their families. Twenty-three patients and their families participated in the study and were randomly assigned to experimental and control groups. Repeated measurements of the adjustment to daily living of the patients and the perceived stress of the families were taken at the time the patient was discharged, and in the first, third, and sixth months after the patient was discharged. They found that home health care significantly enhanced the adjustment to daily living of the patients in the experimental group in the first, third, and sixth months after discharge. The adjustment to daily living in the control group became worse during the 6 months after the patient was discharged. The perceived stress level in the caregiving process, the impact on the whole family, and the overall perceived stress were significantly decreased after receiving continuous home care services for 6 months in the experimental group. As a result, the researchers concluded that home care was a valuable intervention in reducing perceived 13 stresses of the families and in enhancing the adjustment to daily living of the patients. Payment resource issues have also been addressed in the literature. In several reports (Chou et aI., 1992a; Huang et aI., 1991; Lu et aI., 1995; Tsai et aI., 1993), most patients and their families considered that the home care services for mental illness should be paid for by a third party, or supported by the social welfare system, because they could not afford these services. However, these data were collected before the implementation of the national health care program that now covers costs for all mentally ill patients eligible for home care. Family Caregivers' Satisfaction with Home Care Family caregivers' satisfaction with home care in general has been more thoroughly investigated than home care for the mentally ill. Several studies (Chiu, 1997; Herman, 1994; Kristjanson, 1993; Liu, 1996; McCusker, 1984; Proctor et aI., 1992) have investigated family caregivers' satisfaction in a variety of settings. Two of these studies (Chiu, 1997; Liu, 1996) investigated family caregiver's satisfaction with home care before the implementation of National Health Insurance in Taiwan. Liu (1996) evaluated family caregiver's satisfaction in a home care setting and nursing home in Taiwan. He used a questionnaire, "Measuring Satisfaction and Preferences Regarding Long-Term and Terminal Care Scale" developed by McCusker (1984), to assess satisfaction among chronically and terminally ill patients and their families. General satisfaction, nursing competence, nursing availability, nursing attitudes, and communication with professionals were evaluated on a 5-point Likert scale with 18 iten1s. He reported that the home care group had significantly higher satisfaction than the nursing home group. However, the relationships between the level of satisfaction and other issues have never been investigated. 14 Chiu (1997) investigated family caregiver's satisfaction with home care in the Taipei metropolitan area. Seven hospitals in the Taipei metropolitan area were selected for this study. One hundred ten caregivers of home care patients were included. Chiu (1997) created and used a 5-point Likert scale questionnaire consisting of 19 items concerning satisfaction with the attributes of home care services. The result of this study showed that several factors were significantly associated with the degree of general satisfaction of family caregivers: the patient's health insurance coverage for home care services, life satisfaction of family caregivers, degree of congruence between attributes desired and received, and the amount of time that home care services are used. This survey also showed that the number of desired attributes that were actually received was a significant determinant of general satisfaction with home care services. Among 19 items concerning attributes of home care services, family caregivers who received at least 14 attributes tended to be more satisfied with home care services than the family caregivers who received fewer than 14. Chiu (1997) concluded that the majority of caregivers were generally satisfied with home care services. However, the extent of satisfaction with home care varied by specific attributes of home care services. For example, more than two-thirds of the family caregivers stated that the speedy provision of services in an emergency and the degree of ease of contacting home care workers by telephone needed improvement. Less than 3% of the caregivers felt that respect and consideration from home care workers needed moderate or complete improvement. 15 Chiu conceptualized satisfaction as an outcome and a dependent variable of using home care in Taiwan. Because home care in Taiwan was really a new development during the course of Chiu's research, most consumers had never come in contact with home care agencies and had rarely selected home care agencies for services. The linkage between consumers and home care agencies was a direct result of hospital referrals. This referral approach is still in continuous use even after the implementation of National Health Insurance. With respect to the present research proposal, Chiu' s (1997) study served as a model. The conceptual framework of this research proposal is also based upon "a conceptualization of satisfaction as an outcome and dependent variable." Therefore, Chiu' s (1994) instruments were adapted for this research proposal. Although these studies evaluated the level of family caregiver satisfaction, there is a scarcity of literature describing the definition and domains of family caregivers' satisfaction with any health care arena. Most of the literature addresses client or patient satisfaction and the concept of family satisfaction is not well understood. ClientlPatient Satisfaction Over the past two decades there have been numerous articles and reports published on client/patient satisfaction in various health care settings, but there seems to be a lack of standardization regarding the method of measuring the concept of client/patient satisfaction. Studies of satisfaction in primary care (Feletti et aI., 1986; Linn et aI., 1984), the hospital (Bene-Kociemba et aI., 1982; Lee, 1994), home care settings (Chiu, 1997; Heaman et aI., 1994; Laferriere, 1993; Morris, 1996; Westra et aI., 1995), public health (Zastowny et al., 1989), and long-term care facilities (McCusker, 16 1984) have been reported, but there is not one universally accepted conceptualization of client satisfaction. Early researchers (Hulka, Kupper, Daly, Cassel, & Schoen, 1975; Hulka, Zyzanski, Cassel, & Thompson, 1970; Zyzanski, Hulka, & Cassel, 1974) have identified the following dimensions of patient satisfaction: (a) personal quality of the physician-patient relationship, (b) cost and convenience aspects of medical care, and (c) perceived competence of the doctor. Later, Ware, Davies-Avery, and Stewart (1978) proposed a taxonomy of eight major dimensions of satisfaction: (a) art of care, (b) technical quality, (c) accessibility, (d) efficacy, (e) cost, (f) physical environment, (g) availability, and (h) continuity. This taxonomy by Ware and his colleagues has become a significant reference for more research regarding the measurement of client/patient satisfaction (Chiu, 1997; Feletti et aI., 1986; Linn et aI., 1984; McCusker, 1984; Patrick et ai., 1983; Penchansky & Thomas, 1981; Proctor et aI., 1992; Reeder & Chen, 1990; Westra, et aI., 1995). Alternatively, Oberst (1984) proposed the "framework of expectations." Oberst (1984) speculated that: Patients enter the health care system with a variety of characteristics, attitudes, and prior experiences. These, coupled with the knowledge and information they receive from health professionals, enable them to define their situation and to delineate what they perceive to be their own needs for care. (p. 2637) A set of patients' expectations is comprised of care outcomes, caregiver behaviors, and system performances. Patients' expectations and perceived reality resulted in a level of satisfaction and/or judgment of quality (Oberst, 1984). Although the work of Ware et al. and Oberst has contributed to many studies 17 regarding client/patient satisfaction in diverse health care settings, no one has applied their concepts to family caregivers' satisfaction with home care. Because family caregivers were classified as primary customers and as patients with specific needs and expectations in home care (Davis, 1994), satisfaction issues for family caregivers and patients may overlap in some instances. As a result, the framework of expectations of Oberst and the major dimensions of satisfaction from Ware et aI. could be used to help assess family caregivers' satisfaction as an outcome indicator of the quality of home care. Conceptual Framework The conceptual framework is derived from "the framework of client satisfaction" (Westra et aI., 1995), a revision of that proposed by Oberst (1984) and used in the development of the Home Care Client Satisfaction Instrument (HCCSI). In their framework, satisfaction was viewed as the evaluation of congruency between client expectations of care and perceptions of the care received. Because the conceptual framework of this research proposal is based upon "satisfaction as an outcome and dependent variable," it is befitting to utilize this conceptual framework for this research. Also, both clientele were selected from a similar population group--consumers of home care providers/systems. The aforementioned literature suggests that a large number of factors are associated with satisfaction (Hulk a et aI., 1970; Hulka et aI., 1975; Oberst, 1984; Ware et aI., 1978; Zyzanski et aI., 1974). Therefore, a basic framework for this study of family caregivers' satisfaction is conceptualized as proceeding from (a) the characteristics, experiences, and attitudes of the family caregivers; in interaction with (b) characteristics 18 and behaviors of home care providers/systems; which shape (c) family caregivers' expectations of health services; and further determine (d) the level of family caregivers' satisfaction with home care services. Finally, family caregivers' satisfaction is viewed as an outcome of care, and a predictor of continued use of home care services and recommendation of home care services to other people. The interrelations of these variables present in the flowchart (see Figure 1) are discussed below. Family Caregivers' Characteristics, Experiences, and Attitudes "Family caregivers enter the health care system with a variety of characteristics, attitudes, and prior experiences; moreover, prior experiences and underlying attitudes toward the health care system and health personnel influence judgments of satisfaction with current care" (Oberst, 1984, p. 2637). In this research, the family caregiver is the patient's family member who reports spending the most time taking care of the patient at home and who contacts home care providers. Family caregivers' characteristics. According to previous studies, the characteristics of family caregivers caring for a mentally ill member in the Chinese culture included such factors as age, relationship to the patient, education level, and income (Hsu & Tai, 1991a, 1991b; Hu et aI., 1994; Lin et aI., 1987). Gender and marital status were also assessed. Family caregivers' experiences. Family caregivers who experienced long-term stress as a result of caring for the patients without additional help tended to prefer institutional care for their mentally ill family members (Hu et aI., 1994). The researcher assessed family caregivers' experiences by asking for the duration of caring for the Family Caregivers Characteristics Attitudes Experiences Interaction Home Care Providers/Systems Characteristics M----------toI Behaviors Family Caregivers' Expectations I' Dependent Variable Level of Family Caregivers' Satisfaction Continued Use of Home Care Services Recommendation of Home Care Services to Others Family Caregivers' Characteristics Age, Gender, Marital Status, Relationship to Patient, Education, Monthly Gross Income Family Caregivers' Experiences Family support during weekdays, Family support at the weekend, Length of time utilized home care, Duration of caring for the patient Family Caregivers' Attitudes Having a mentally ill family member Possibility of curing mental illness, Possibility of home care helping mental illness Home Care Providers/Systems Characteristics and Behaviors Art of care, Technical quality, Cost, Availability, Efficacy Figure 1. Conceptual framework 19 20 patient, how long they have received home care, and how much support they receive from other family mernbers for caregiving. Both family caregivers' characteristics and experiences were assessed by using the Family Caregiver's Demographic Characteristic Questionnaire (see Appendix A). Family caregivers' attitudes. Family caregivers with negative attitudes about the recuperation of the mentally ill and the stigma associated with mental diseases will influence the utilization and delivery of home care services (Chien et aI., 1994; Hsu & Tai, 1991a, 1991b; Hu et aI., 1994; Lin, et aI., 1987; Lu et aI., 1995; Tsai et aI., 1993). Issues related to the family caregivers' attitudes of having a mentally ill family member at home, the possibility of the patients' recovery from their mental illness, and the possibility of home care services helping the patients to deal with mental illness were evaluated by using the "Interview Guide" (see Appendix B). Providers/Systems Characteristics and Behaviors Westra et aI. (1995) maintained that "specific expectations are related to the type of care provided, the number and types of care providers, and the kinds of interactions encountered, and the setting in which the care will be provided" (p. 394). In this study, the characteristics and behaviors of home care providers/systems were researched according to a taxonomy of dimensions of satisfaction proposed by Ware et al. (1978): (a) art of care, (b) technical quality, (c) availability, (d) cost, and (e) efficacy. These five dimensions, the basic characteristics and behaviors of the providers/systems of home care, also are used to determine satisfaction. In this study~ the 19 questions from the Family Caregiver's Satisfaction Survey Questionnaire (Chiu, 1994) based on these five subcategories was used (see Appendix C). A description for each of the five categories and their items is as follows: 21 Art of care. "The most frequently measured dimension of satisfaction pertains to the amount of caring shown toward patients, which is one aspect of provider conduct" (Ware, et al., 1978, p. 4). The questionnaire items in this study focused on respect shown to consumers by providers, the degree of consideration, accepting family caregivers' suggestions, concern for family caregivers' questions by providers, and the providers' technical skills. Technical quality. Ware et al. (1978) defined this dimension as it "focuses on the competence of providers and their adherence to high standards of diagnosis and treatment. Items assess patient perceptions regarding technical quality in terms of skills and abilities of providers and technical soundness and n10dernness of equipment and facilities" (p. 4). In this study, the questions emphasized on such providers' characteristicslbehaviors as knowledge, thoroughness, accuracy of diagnosis of the providers, the explanations of care from health providers, and providers' instruction on how to take care of patients. Availability. Whether there are enough physicians, nurses, and other providers, and such facilities as clinics and hospital in the area are usually measured in this dimension (Ware et al., 1978). This research for this dimension surveyed the satisfaction with the frequency of home visits, the timeliness of the home care services provided, and the convenience of the consumers' receiving help over the telephone. Cost. For the receipts of care, the ability to pay for services or to arrange for payment is an considerable factor. Cost is defined as the dollar costs of treatment, 22 flexibility of payment mechanisms, and the comprehensiveness of insurance coverage (Ware et al., 1978). The level of satisfaction with charges for home care services and the proportion of charges covered by insurance were assessed in this dimension. Efficacy. Ware et al. (1978) stated that "satisfaction with efficacy and outcomes of care is measured in terms of perceptions regarding the usefulness or helpfulness of medical care providers and specific treatment regimens in improving or maintaining health status" (p. 5). Family caregivers' satisfaction with the improvement and maintenance of patients' health status, spiritual support of the family caregivers, decreasing the burden on family caregivers, and the continuity of receiving needed services were measured in this study. The remaining three dimensions in their study (Ware et aI., 1978) are accessibility, physical environment, and continuity. Because these three dimensions did not have any significant relation to this research, they were excluded. Family Caregivers' Expectations The characteristics, attitudes, and prior experiences of family caregivers' in interaction with the characteristics and behaviors of health care providers/systems will shape the expectations of caregivers. In this study, expectations were family caregivers' needs and the desired services. Expectations were measured by 19 questions from Chiu's (1994) "Degree of Congruence between Attributes of Home Care Services Desired and Received Survey" (see Appendix D). Family caregivers were asked to check which attributes they desired to receive and what they actually received to identify the their expected services (needs), This Questionnaire and Family Caregiver's Satisfaction 23 Survey Questionnaire (see Appendix C) use the same 19 items reflecting characteristics and behaviors of the providers/systems of home care. However, as the Family Caregiver's Satisfaction Survey Questionnaire is used to measure the level of satisfaction, the Attributes of Home Care Services Desired and Received Survey Questionnaire is used to survey the number of attributes of home care services received from providers/systems. Level of Family Caregivers' Satisfaction Based on this study, satisfaction is a multidimensional phenomenon, and also viewed as the outcome of the congruency between family caregiver's expectations of home care services and their perceptions of the home care services received fron1 the home care providers/systems. In addition, satisfaction is conceptualized as an outcome of care, and it predicts the continued use of home health services and recommendation of home care services to others. This study examined and compared the results on four levels. Using a 5-point Likert scale, family caregivers reported their degree of satisfaction with the attributes of home care service by responding to Chiu's (1994) "Family Caregiver's Satisfaction Survey Questionnaire" (see Appendix C). Besides, one item from the Interview Guide (see Appendix B) was also used to measure the level of overall satisfaction on a 5-point Likert scale. CHAPTER 3 METHOD Design A descriptive, comparative design was used in this study_ The data were used to: (a) evaluate the level of family caregivers' satisfaction with the provision of home care services for mental illness since the implementation of National Health Insurance in two different populations, (b) investigate the factors that influence family caregivers' satisfaction with home care for mental illness, (c) explore the possibility of continuous usage of home care services and recommendation of home care services to others based on the level of satisfaction of family caregivers, and (d) provide a better understanding of the family's needs for home care in cases of mental illness. Questionnaires and interviews were used to obtain data from two groups: (a) receiving home care group-­primary family caregivers who are caring for mentally ill patients and who are currently receiving home care visits (and have received a minimum of two home care visits within the past year), or who have previously received a minimum of two home care visits within the past year, but now have terminated services because the patient got better, and (b) refusing home care group--primary family caregivers caring for a mentally ill member who previously received one or more home visits, but now refuse continuous home care services. Participants were requested to complete three self-administered questionnaires, 25 and then were interviewed by the investigator. Setting and Samplin2: The setting for this research was the individual subject's home. The subjects were all family caregivers of patients currently or previously receiving home care from a military psychiatric hospital in Taipei City. This hospital has been providing home care for mental illness since 1990. There are one full-time nurse, one part-time social worker, and one part-time psychiatrist participating in the home care program. The home care program provided by this hospital has the largest clientele in the Greater Taipei area (N = 45-60). This particular home care program uses almost identical professional staff when compared to other hospitals' home care programs. The sample consisted of 49 family caregivers caring for a mentally ill family member currently or previously receiving home care within past year, and 34 family caregivers who received home care in the past, but were now refusing services. Additional san1pling criteria included (a) willingness to participate in the study, (b) ability to speak Mandarin or Taiwanese, (c) living in Taipei, and (d) receipt of home care after the implementation of National Health Insurance. Procedure Before undertaking the proposed study, the researcher sought approval from the Institutional Review Board (IRB) at the University of Utah, and the selected military psychiatric hospital in Taipei City. In order to protect the rights of the participants of this study, each primary family caregiver was asked to sign an informed consent form (see Appendix E). Also, all of the questionnaires were assigned a code to ensure 26 confidentiality of the respondents. The coded list and all the collected data were stored in separated locked boxes in order to provide security. After permission for the study was obtained from IRB and the military psychiatric hospital in Taipei City, the researcher carried out a pilot study at the public health center in Taipei. Three candidates were selected randomly for the pilot study. Those three candidates were selected from the family caregivers of a mentally ill patient who was currently under the care of the public health center home care program. The purposes of the pilot study were specifically to: 1. 2. 3. assess the suitability of the questionnaire and to detect any weakness regarding questions, enhance the researcher's familiarity with the use of the questionnaires and interview guide, and determine if the proper target population was chosen for this thesis study. Next, a complete list of potential participants' names and telephone numbers was provided for the researcher by the military psychiatric hospital in Taipei City. The release of a participant's information is legal under every jurisdiction of Taiwan as long as the hospital has approved the research study. The potential participants in the military psychiatric hospital in Taipei City were contacted by telephone, offered a brief introduction to the study, and asked to participate in the study. If the participant agreed, the investigator would arrange an appointment time to meet with each participant to sign the consent form and fill out all questionnaires. Three self-administrated questionnaires 27 and one interview were provided to two groups. After the participants completed the questionnaires, they were interviewed by the investigator and completed an interview guide. If the participants could not complete the self-administered questionnaires, the researcher read the questions to them and completed them according to the responses of each participant. Each subject took 30 to 60 minutes to participate in this study. Instruments The researcher personally translated the instruments from English to Chinese. The instruments were reviewed and edited by an American who lived in Taiwan for 2 years. His first language is English and he has been in contact with Mandarin and Taiwanese continuously. He is fluent in both speaking and writing Mandarin. He translated the instruments from Mandarin back to English to ensure that both the Mandarin and English versions of the instruments were the same meaning (Varricchio, 1997). To elicit family caregivers' demographic information, the investigator designed the "Family Caregiver's Demographic Characteristic Questionnaire" (see Appendix A) which contains 11 questions. This questionnaire assessed (a) family caregiver's characteristics such as age, gender, marital status, relationship to patient, education, monthly gross income and (b) family caregivers' experiences such as the amount of time spent in caregiving, the length of time that they have received home care, and the amount of support they received from other family members for caregiving. In addition to Family Caregiver's Demographic Characteristic Questionnaire, there were three other instruments: (a) Interview Guide (see Appendix B), (b) Family Caregiver's Satisfaction Survey Questionnaire (see Appendix C), and (c) Degree of Congruence between Attributes of Home Care Services Desired and Received Survey Questionnaire (see Appendix D). A description of each questionnaire follows. Interview Guide 28 This interview guide was developed by the researcher. It contains six questions which mainly (a) evaluate family caregivers' attitudes to mental illness and home care issues, (b) assess the possibility of the continued use of home care services and recommendation of home care services to others, and (c) determine family caregivers' overall satisfaction. These six questions form an interview guide that was used to obtain information about the various aspects of the family caregiver. The first three questions evaluated family caregivers' attitudes, information regarding those issues of family caregivers' thinking about having a mentally ill family member at home, the possibility of curing mental illness, and the possibility that home care services might help mental illness. The next two questions were used to elicit information in order to predict the possibility of family caregivers using home care services when the services are needed again and recommending home care services to others. The two questions were used in the analysis to assess relationships between the level of satisfaction of family caregivers and continued use of home care services and recommendation of home care services to others. Finally, to measure family caregivers' overall satisfaction, one question in regard to their overall satisfaction with home care services for mental illness was asked. The respondents were asked to indicate the level of overall satisfaction on a 5-point Likert scale (5 = Extren1ely satisfied, 4 = Satisfied, 3 = Uncertain, 2 = Dissatisfied, 1 = Extremely dissatisfied). The higher the score, the higher the overall satisfaction. Family Caregiver's Satisfaction Survey Questionnaire 29 The structured questionnaire developed for measuring family caregiver's satisfaction is used from Chiu's instrument (Chiu, 1994). It was modified by Chiu based on the results of a pilot study that consisted of 20 interviews with primary family caregivers. The questionnaire consists of a set of 19 questions concerning satisfaction with attributes of home care services. Based on the results from Chiu' s rotated factor analysis, 19 questions were grouped according to the five major dimensions of satisfaction proposed by Ware et al. (1978). For each item, the respondents were asked to indicate the level of the need for improvement on a 5-point Likert scale (5 = Needs no improvement, 4 = Needs mild improvement, 3 = Needs moderate improvement, 2 = Needs major improvement, 1 = Needs complete improvement). The lower the score, the higher the need for improvement. In other words, the lower the score, the lower the satisfaction. The questionnaire was intended to evaluate the level of family caregivers' satisfaction with home care services for the n1entally ill. The test-retest reliability of Chiu's study was 0.70 (Chiu, 1994). However, evidence in support of validity and Cronbach's alpha for this instrument was lacking in her dissertation (Chiu, 1994). The test-retest reliability and validity were assessed in the Chinese version of the questionnaire, but that questionnaire in Chinese version has been lost (L. Chiu, personal conversation, October 21, 1997). 30 Degree of Congruence between Attributes of Home Care Services Desired and Received Survey Questionnaire This questionnaire was created by Chiu (1994). The structured questionnaire was developed for measuring the nUlnber of attributes of home care services that were both desired and received. It consists of a set of 19 questions concerning attributes of home care services. Family caregivers were asked to check which attributes they desired to receive and what they actually received. The questionnaire was intended to (a) measure the relationships between the level of satisfaction of family caregivers and the number of attributes of home care services received, and (b) identify the family's needs for home care in cases of mental illness. The latter was accomplished by measuring the difference in the degree of congruence (received/desired %) between desired attributes and received among a1119 attributes of home care services. The test-retest reliability of Chiu' s study was 0.64 (Chiu, 1994). Evidence in support of validity and Cronbach's alpha for this instrument were also lacking. The test-retest reliability and validity were assessed in the Chinese version of the questionnaire, but that questionnaire in Chinese version has been lost (L. Chiu, personal conversation, October 21, 1997). Data Analysis The research questions and type of data collection directed the data analysis in this study. The analysis was done on SPSS (Statistical Package for the Social Science) for Windows Release 7.5 for personal computer. The following is a description of data analysis for each purpose and research question. Question (IA) What is the level of family caregivers' satisfaction with the specific home care services? Analysis (IA) 31 In Family Caregiver's Satisfaction Survey Questionnaire, each of 19 items representing one attribute of home care services was used to assess the first level of family caregivers' satisfaction with each attribute of home care services. A mean score for the five categories was also utilized to decide the second level of family caregivers' satisfaction with each category. The average scores across all 19 attributes of home care services indicated family caregivers' general satisfaction with home care services. Then, these data were utilized to the research question IB, 2A, 2B, and 3A. Here, the percentage, frequency distribution, mean, median, and standard deviation were used to describe those data. Moreover, in order to assess the overall level of family caregivers' satisfaction, one item from the Interview Guide (see Appendix B) was used to measure the overall satisfaction between two groups. The mean and standard deviation were used to summarize the response to this item. These data were used to the research question 1 B. Question (lB) Is there a difference in the level of satisfaction between family caregivers who are caring for mentally ill patients currently or have received home care visits within the past year, and the level of satisfaction of family caregivers caring for a mentally ill member who has previously received home care, but now has refused continuous home care services? Analysis (lB) T -test was used to examine if there was the significant difference in the level of satisfaction with each attribute and category of home care services, and general and overall satisfaction between two groups. Question (2A) 32 Is there a relationship between family caregivers' characteristics, experiences, and attitudes, and satisfaction of family caregivers? Analysis (2A) Percentage, frequency distribution, mean, median, and standard deviation were used to descriptively analyze the family caregivers' characteristics data, experiences data, and attitudes data from the Family Caregiver's Demographic Characteristic Questionnaire and Interview Guide. Correlation analysis and chi-square were used to examine the relationships among the level of family caregivers' satisfaction and family caregivers, demographics, experiences, and attitudes. Question (2B) Is there a relationship between level of family caregivers' satisfaction and the number of attributes of home care services received? 33 Analysis (2B) The researcher used percentage, frequency distribution, mean, median, and standard deviation to analyze descriptively the data about the number of attributes of home care services family caregivers desired and actually received. Correlation analysis was used to evaluate the relationships between the level of family caregivers' satisfaction and the number of attributes of home care services received. Question (3A) Is there a relationship between level of satisfaction of family caregivers and < continued use of home care services and recommendation of home care services to others? Analysis (3A) Percentage and frequency distribution were also used to analyze descriptively the continued use of home care services and recommendation of home care services to others. Chi-square analysis was used to examine the relationships between the level of family caregivers' satisfaction and continued use of home care services and recommendation of home care services to others. Question (4A) Is there a difference in the degree of congruence (received/desired %) between desired attributes and those actually received among all 19 attributes of home care services? 34 Analysis (4A) Percentage and frequency distribution were used to analyze descriptively the congruence between desired attributes and those actually received among all 19 attributes of home care services. The higher percentage, the higher the unmet need. CHAPTER 4 RESULTS Eighty-three family caregivers met the criteria specified for the sample. They included: (a) 49 family caregivers caring for a mentally ill family member currently or previously have received home visits within past year, and (b) 34 family caregivers who received home care in the past, but now have refused continuous home care services. Of these, 75 family caregivers served in this hospital agreed to participate in this study. This was 90.36% of the 83 possible participants. The reasons for nonparticipation are summarized in Table 1. Data collection began on April 8, 1998 and ended on May 4, 1998. The results of data analysis are presented for each specific purpose and research question in the following sections. Reliability of the Satisfaction Tool Responses by 75 eligible family caregivers who agreed to complete the 19 items from "Family Caregiver's Satisfaction Survey Questionnaire" were highly reliable, with the Cronbach's alpha coefficients of 0.95 for the total 19 items and 0.70 to 0.96 for the subscales, indicating moderate to high degree of internal consistency. 36 Table 1 Number of Family Caregivers Participating in Study Group Refusing Home Care Receiving Home Care Total Number of study 4 1 5 participation refusals NUluber moved 0 2 2 from Taipei Number of out of 0 1 1 contact Number participating 30 45 75 Description of Sample Family Caregivers' Characteristics 37 Family caregivers' demographic characteristics information are described in Table 2. Of the 75 respondents, 32.0% of the family caregivers were under 50 years and 30.7% were over 64. Fifty-four point seven percent were female and 45.3% were male. Approximately three-quarters (73.3%) of the caregivers in this study were married. More than half (56.0%) of the family caregivers were the patients' parents. About two-thirds (62.7%) of the caregivers had an education level that was lower than senior high; only 13.3% attained an education level that was higher than senior high. Two-thirds (69.3 % ) of the family caregivers reported that the average monthly incomes were less than NT $20,001 (U.S. $625). Only three caregivers (4%) reported average monthly incomes of more than NT $30,000 (U.S. $937). Fan-lily Caregivers' Experiences A description of the family caregivers' experiences is shown in Table 3. About half (54.7%) of the caregivers had no assistance from family members for caregiving during weekdays and half (53.3%) of the caregivers received no assistance from family members during weekends. The majority (72.0%) had received home care services from any agency for less than 1 year. The duration for taking care of a patient ranged from 2 months to 27 years (2160 months) respectively, with a mean of9.7 years (116.32 months); about half (50.7%) had cared for the patients for 5 years (60 months). In addition, the majority (92.0%) of the family caregivers spent 7 days per week in patient care. 38 Table 2 Demographic Characteristics of Family Caregivers (N = 75) Characteristics No. of Caregivers % of Caregivers Age: 20-49 24 32.0% 50-64 28 37.3% 265 23 30.70/0 Gender: Female 41 54.7% Male 34 45.3% Marital Status: Married 55 73.3% Never married 9 12.00/0 Widowed 11 14.7% Relationship to Patient: Spouse 13 17.3% Child 7 9.3% Parent 42 56.0% Friend 2 2.70/0 Relative 11 14.7% Education: Less than senior high 47 62.7% Senior high school graduate 18 24.0% Some college 7 9.3% University graduate 3 4.0% Monthly Gross Income: < NT$20,001 52 69.3% NT$20,00 1-30,000 20 26.7% NT$30,00 1-40,000 1 1.3% > NT$50,000 2 2.7% Table 3 Experiences of Family Caregivers eN = 75) Experiences No. of Caregivers % of Caregivers How many family members assist you in caring for the patient during weekdays? None One person Two persons More than two persons 41 22 2 10 54.7% 29.3% 2.7% 13.3% How many family members assist you in caring for the patient on weekends? None 40 53.3% One person 23 30.7% Two persons 2 2.7% More than two persons 10 13.3% How long ago did you begin to receive home care from any agencies? 1 - 12 Month(s) 54 72.0% 14 - 24 Month(s) 12 16.0% 30 - 36 Month(s) 3 4.0% 60 - 120 Month(s) 6 8.0% Mean Median Std dev. 15.293 6.000 24.400 How long have you been taking care of the patient at home? 2 - 60 Month(s) 38 72 - 120 Month(s) 16 140 - 240 Month(s) 18 260 - 2160 Month(s) 3 Mean 116.320 Median 60.000 Std dev. 252.360 How many days per week do you take care of the patient? 1 3.5 Day(s) 6 7.00 Day(s) 69 Mean 6.640 Median 7.000 Std dev. 1.256 50.7% 21.3% 24.0% 4.0% 8.0% 92.0% 39 40 Family Caregivers' Attitudes to Mental Illness and Home Care As shown in Table 4, 53.3% of the family caregivers felt that having a n1entally ill family member at home was a stigma; 46.7% felt that it was nothing unusual. Among the caregivers in this study, 61.3% thought that mental illness was curable, 32.0% felt that it was incurable, and the remainder had no idea about the curability of mental illness. About 65.3% of the caregivers indicated that home care services were likely to help mental illness; 34.7% thought otherwise. Findings Purpose (1) To assess the level of family caregivers' satisfaction with the provision of home care services for mental illness since the implementation of National Health Insurance in Taiwan. Question (lA) What is the level of family caregivers' satisfaction with the specific home care services? Question (lB) Is there a difference in the level of satisfaction between family caregivers who are caring for mentally ill patients currently or have received home care visits within the past year, and the level of satisfaction of family caregivers caring for a mentally ill member who has previously received home care, but now has refused continuous home care services? Table 4 Attitudes of Family Caregivers (N = 75) Attitudes No. of Caregivers % of Caregivers What do you feel about having a mentally ill family member at home? Stigmatized 40 53.3% Nothing unusual 35 46.7% What do you think about the possibility of curing mental illness? Curable 46 61.3% Incurable 24 32.0% I don't know 5 6.70/0 What do you think about the likelihood that home care services might help mental illness? Likely 49 Unlikely 26 L""' ~'<'u'I' ,;~.~,, 65.3% 34.7% 41 42 Satisfaction with each attribute of home care services. Table S outlines the mean scores of each attribute of home care services and t-test results for two groups. The results show that: (a) both groups had the highest mean scores in getting respect from home care workers (M = 4.84, SD = .367; M = 4.63, SD = .669), (b) caregivers refusing home care had the lowest mean score in getting services quickly eM = 3.37, SD = .999), (c) caregivers receiving home care services had the lowest mean score in decreasing the burdens from home care services (M = 4.09, SD = 1. 12S), (d) caregivers receiving home care had significantly higher satisfaction levels than caregivers refusing home care services in getting clear explanations from home care workers (M = 4.69, SD = .793 vs. M = 4.13, SD = .937,1 (7S) = .010, Q < .OS), obtaining speedy services (M = 4.22, SD = .974 vs. M = 3.37, SD = .999,1 (7S) = .000, Q < .OS), and maintaining the patient's health from home care services (M = 4.22, SD = .974 vs. M = 3.70, SD = 1.088, L(7S) = .033, Q < .OS), and (e) these two groups did not significantly differ on other attributes. Satisfaction with each category of home care services. Table 6 compares the mean scores of each of five categories between two groups. Both groups had the highest mean scores in art of care and the lowest mean scores in the efficacy dimension among the five categories. With respect to the availability of home care services, caregivers refusing home care services had a significantly lower satisfaction level eM = 3.7S, SD = 1.030) than caregivers receiving home care (M = 4.17, SD = .8S3), 1 (7S) = .002, Q < .OS. However, these two groups did not significantly differ on other categories. General satisfaction with 19 attributes of home care services. The average scores across all 19 attributes of home care services indicated general satisfaction in both groups. Caregivers receiving hon1e care had a significantly higher general satisfaction 43 Table 5 Comparison of the Means of Family Caregivers' Satisfaction with Each Attribute of Home Care Services Refusing Receiving Home Care (n = 30) Home Care (n = 45) Attribute M SD M SD t Art of care: 1. Respect 4.63 0.669 4.84 0.367 .122 2. Consideration 4.63 0.669 4.78 0.517 .296 3. Accepts suggestions 4.60 0.675 4.73 0.539 .346 4. Concern for 4.60 0.724 4.73 0.712 .360 questions 5. Familiar with 4.60 0.724 4.76 0.645 .333 technologies Technical quality: 6. Familiar with 4.57 0.728 4.76 0.609 .228 knowledge 7. Thoroughness 4.47 0.730 4.60 0.963 .521 8. Accurate judges 4.43 0.774 4.78 0.704 .055 9. Clear explanations 4.13 0.937 4.69 0.793 .010* 10. Teach skills 4.27 0.907 4.64 0.830 .073 Availability: 11. Frequent visits 4.40 0.894 4.76 0.743 .077 12. Get speedy services 3.37 0.999 4.22 0.974 .000* 13. Contact by 3.80 1.095 4.27 0.939 .052 telephone Cost: 14. Inexpensive 4.43 0.728 4.44 0.967 .957 charges 15. Insurance 4.33 0.994 4.44 0.967 .631 Efficacy: 16. Maintain health 3.70 1.088 4.22 0.974 .033* 17. Spiritual support 3.80 1.126 4.22 0.927 .094 18. Decrease the 3.80 1.095 4.09 1.125 .274 burdens Attribute 19. Continuity of services Table 5 Continued Refusing Home Care Cn = 30) M 3.70 1.208 Receiving Home Care Cn = 45) M 4.13 1.036 ! .101 Note. Based on 5-point Likert scale format, 1 = Needs complete improvement, 2 = Needs major improvement, 3 = Needs moderate improvement, 4 = Needs mild improvement, 5 = Needs no improvement. *ll < .05, (2-tailed). Table 6 Comparison of the Means of Family Caregivers' Satisfaction with Each of the Five Categories Refusing Receiving Home Care Cn = 30) Honle Care Cn = 45) Categories M SD M SD ! Art of care 4.61 0.683 4.77 0.448 .264 Technical quality 4.37 0.716 4.69 0.728 .064 Availability 3.86 0.720 4.41 0.729 .002* Cost 4.38 0.817 4.44 0.967 .777 Efficacy 3.75 1.030 4.17 0.853 .060 Note. Based on 5-point Likert scale format, 1 = Needs complete improvement, 2 = Needs major improvement, 3 = Needs moderate improvement, 4 = Needs mild improvement, 5 = Needs no improvement. *ll < .05, (2-tailed). 44 45 level (M = 4.53, SD = .609) than caregivers refusing home care services (M = 4.22, SD = .614), ! (75) = .035, g < .05 (see Table 7). Overall satisfaction. One question from Interview Guide concerning the caregiver's overall satisfaction with home care services for mental illness was designed to compare the means of two groups. Caregivers receiving home care had a significantly higher overall satisfaction level (M = 4.29, SD = .944) than caregivers refusing home care services (M = 3.36, SD = 1.033), ! (75) = .006, g < .05 (see Table 8). Results of the paired t-test for general and overall satisfaction. The paired t-test was performed to test the difference of using two instruments for all subjects (see Table 9). The mean scores of general satisfaction (mean of 19 items) for all respondents (M = 4.41, SD = .626) was significantly higher than overall satisfaction (M = 4.03, SD = 1.026), ! (75) = .000, g < .05. Distributions of general satisfaction with home care. Table 10 shows the satisfaction scores for all respondents (N= 75) by averaging across all 19 attributes of home care services. About 25.3% of those interviewed scored 5.00; indicating that in the opinion of these caregivers, home care services do not need to be improved at all. More than half (57.40/0) of the caregivers scored in the 4.00-4.99 range; suggesting the need for minimal improvement in home care services. About 14.70/0 scored in the 3.00-3.99 range, indicating a felt need for moderate improvement in services; and only 2.7% scored less than 3.00, expressing the need for strong or complete improvement. Therefore, the distribution of the 19 attributes of general satisfaction with home care services was strongly skewed in the direction of greater satisfaction, with the median represented as 4.579. In order to test the additional research questions, a decision was made to Table 7 Comparison of the Means of Family Caregivers' Satisfaction with All 19 Attributes of Home Care Services Refusing Home Care (n = 30) M 4.22 0.614 Receiving Home Care (n = 45) 4.53 0.609 .035* Note. Based on 5-point Likert scale format, 1 = Needs complete improvement, 2 = Needs major improvement, 3 = Needs moderate improvement, 4 = Needs mild improvement, 5 = Needs no improvement. *12 < .05, (2-tailed). Table 8 Comparison of the Means of Family Caregivers' Overall Satisfaction with Home Care Services Refusing Home Care (n = 30) M SD 3.36 1.033 Receiving Home Care (n = 45) 4.29 0.944 .006* Note. Based on 5-point Likert scale format, 1 = Extremely dissatisfied, 2 = Dissatisfied, 3 = Uncertain, 4 = Satisfied, 5 = Extremely satisfied. *12 < .05, (2-tailed). 46 Table 9 Result of Paired t-test with the Means of Family Caregivers' Satisfaction with 19 Attributes of Home Care Services and the Means of Family Caregivers' Overall Satisfaction (N = 75) 19 Attributes Overall M Pared l-test 4.41 0.626 4.03 1.026 .000* *]2 < .05, (2-tailed). Table 10 General Satisfaction with Home Care Services (N = 75) Scores Refusing Receiving Total Home Care (n=30} Home Care (n=45) n 0/0 2.00-2.99 1 1 2 2.70/0 3.00-3.99 7 4 11 14.70/0 4.00-4.25 4 4 8 10.70/0 4.26-4.579 10 7 17 22.70/0 4.58-4.75 0 7 7 9.3% 4.76-4.99 3 8 11 14.7% 5.00 5 14 19 25.3% Mean 4.410 Median 4.579 Std dev. .626 Note. Based on 5-point Likert scale format, 1 = Needs complete improvement, 2 = Needs major improvement, 3 = Needs moderate improvement, 4 = Needs mild improvement, 5 = Needs no improvement. 47 dichotomize this variable into higher and lower levels of general satisfaction of family caregivers. The cutpoint of 4.579 was found to be the most meaningful based on the significant associations of many variables with the satisfaction level as defined on 48 the basis of this cutpoint. Then, these categories were used to test research questions 2A, 2B, and 3A. When the cutpoint of 4.579 was used to compare frequency distribution between the two groups, caregivers receiving home care had more frequent distributions than caregivers refusing home care in the higher level of general satisfaction (see Figure 2). Purpose (2) To explore the factors that affect family caregivers' satisfaction with home care services for mental illness. Question (2A) Is there a relationship between satisfaction of family caregivers and family caregivers' characteristics, experiences, and attitudes? The effects of family factors. Several family variables were significantly related to the satisfaction of family caregivers (see Table 11, 12, 13, and 14). The results of the chi-square test indicated that the family caregivers' age was significantly associated with the degree of general satisfaction of family caregivers: of 23 the caregivers whose age was over than 64, 15 (65.2%) expressed a higher rate of higher general satisfaction than did other caregivers whose age was 50 to 64 (57.1 %) or 20 to 49 (25.0%), X2 (2, N = 75) = 8.690,12. < .05. The study also evaluated the association between the monthly gross income level and the level of general satisfaction of family caregivers. Only two family 14 12 10 8 6 4 2 o Figure 2. The distribution of general satisfaction 49 • Refusing Home Care o Receiving Home Care 50 Table 11 The Number and Percentages of Caregivers' with A Lower or Higher Satisfaction by Levels of Demographic Variables (N = 75) General Satisfaction Lower Higher Total Characteristics No. % No. % No. % X2 Age 20-49 18 75.0 6 25.0 24 32.0 50-64 12 42.9 16 57.1 28 37.3 ~65 8 34.8 15 65.2 23 30.7 8.690* Total 38 50.7 37 49.3 75 100.0 Gender Female 22 53.7 19 46.3 41 54.7 Male 16 47.1 18 52.9 34 45.3 .324 Total 38 50.7 37 49.3 75 100.0 Marital status Married 26 47.3 29 52.7 55 73.3 Never married 7 77.8 2 22.2 9 12.0 Widowed 5 45.5 6 54.5 11 14.7 3.019 Total 38 50.7 37 49.3 75 100.0 Relationship to patient Spouse 6 46.2 7 53.8 13 17.3 Child 6 85.7 1 14.3 7 9.3 Parent 17 40.5 25 59.5 42 56.0 Friend 1 50.0 1 50.0 2 2.7 Relative 8 72.7 3 27.3 11 14.7 7.918 Total 38 50.7 37 49.3 75 100.0 Education Less than senior 23 48.9 24 51.1 47 62.7 Senior high 10 55.6 8 44.4 18 24.0 Some college 3 42.9 4 57.1 7 9.3 University 2 66.7 1 33.3 3 4.0 .714 Total 38 50.7 37 49.3 75 100.0 51 Table 11 Continued General Satisfaction Lower Higher Total Characteristics No. % No. % No. 0/0 X2 Monthly gross income <20,001 22 42.3 30 57.7 52 69.3 20,001- 30,000 15 75.0 5 25.0 20 26.7 30,001- 40,000 1 100.0 0 0.0 1 1.3 >50,000 0 0.0 2 100.0 2 2.7 10.614* Total 38 50.7 37 49.3 75 100.0 *Q < .05. Table 12 The Number and Percentages of Caregivers' with A Lower or Higher Satisfaction by Levels of Experience Variables (N = 75) General Satisfaction Lower Higher Total Experiences No. % No. 0/0 No. % X2 Weekdays None 15 36.6 26 63.4 41 54.7 One person 12 54.5 10 45.5 22 29.3 Two persons 1 50.0 1 50.0 2 2.7 More than two People 10 100.0 0 0.0 10 13.3 17.019* Total 38 50.7 37 49.3 75 100.0 Weekends None 14 35.0 26 65.0 40 53.3 One person 13 56.5 10 43.5 23 30.7 Two persons 1 50.0 1 50.0 2 2.7 More than two People 10 100.0 0 0.0 10 13.3 17.898* Total 38 50.7 37 49.3 75 100.0 *Q < .05. 52 Table 13 Correlations between Experiences and Satisfaction (N = 75) Experiences Satisfaction Coefficients (r) Duration of Receiving General Satisfaction r = .1901 Home Care Duration of Caring for the General Satisfaction r=-·1954 Patient Amount of Time Spent in General Satisfaction r= .3558* Caregiving (days /week) *12 < .01. Table 14 The Number and Percentages of Caregivers' with A Lower or Higher Satisfaction by Levels of Attitude Variables (N = 75) General Satisfaction Lower Higher Total Attitudes No. % No. % No. 0/0 The feeling about having a mentally ill family member at home Stigmatized 25 62.5 15 37.5 40 53.3 Nothing Unusual 13 37.1 22 62.9 35 46.7 4.802* Total 38 50.7 37 49.3 75 100.0 The possibility of curing mental illness Curable 22 47.8 24 52.1 46 61.3 Incurable 13 54.2 11 45.8 24 32.0 I don't know 3 60.0 2 40.0 5 6.7 .440 Total 38 50.7 37 49.3 75 100.0 The likelihood that home care services might help mental illness Likely 24 49.0 25 51.0 49 65.3 Unlikely 14 53.8 12 46.2 26 34.7 .161 Total 38 50.7 37 49.3 75 100.0 *12 < .05. 53 caregivers had a monthly gross income over NT $50,000. Both stated a high rate of satisfaction with home care services. The majority (69.3%) earned less than NT $20,00l. Of these, 57.7% had a higher satisfaction rating. There was no significant relation to gender, martial status, relationship to patient, and education. Family support for caregiving during weekdays and weekends was significantly associated with the degree of general satisfaction of family caregivers (see Table 12); of 41 caregivers who received no support from family members during the weekdays and 40 who received no support during weekends, 26 exhibited a higher rate (63.4% & 65%) respectively of higher satisfaction level than other caregivers who received support from family members, X2 (3, N = 75) = 17.019, g < .05; X2 (3, N = 75) = 17.898,12. < .05. However, 10 of the caregivers who received support from more than two family members during the weekdays and weekends, 10 (100%) reported a lower satisfaction rating. The amount of time spent in patient care per week was significantly related to the degree of general satisfaction of family caregivers (r = .3558,12. < .01), indicating that caregivers who spent more time in patient care per week had higher general satisfaction (see Table 13). There was no significant correlation to the duration of receiving horne care and caring for the patient at horne. The results of the chi-square test also suggested that the family caregivers' feelings about having a mentally ill family member at horne were significantly associated with general satisfaction of family caregivers (see Table 14): of 40 caregivers with stigmatized feelings about having a mentally ill family member at horne, 25 (62.5%) had a higher rate of lower general satisfaction than did caregivers with no unusual feelings about having a mentally ill family member at horne (37.1 %), X2 (1, N = 75) = 4.801, 12. < 54 .05. However, there was no significant finding between the lower or higher level of satisfaction and family caregivers' attitudes toward the possibility of curing mental illness and the likeness of helping mental illness by home care. Question (2B) Is there a relationship between the level of satisfaction of family caregivers and the nUITlber of attributes of home care services received? The number of attributes of home care services both desired and received. When asked to check which attributes they desired to receive and how many they actually received, about half (51.9%) received at least 16 (see Table 15). Only three (3.9%) of the family caregivers reported that they received less than half of the attributes of home care services which they considered to be desirable. The effects of the number of attributes of home care services received. A significant positive relationship was found between the number of attributes of home care services received and the level of satisfaction of family caregivers (r = .6116, Q. < .01) (see Table 16), indicating that caregivers who received more attributes of home care services had a higher level of general satisfaction. PUIpose (3) To explore the possibility of continuous usage of home care services and recommendation of home care services to others based on the level of satisfaction of family caregivers. 55 Table 15 The Distribution of Numbers and Percentages of Family Caregivers Who Receive Attributes of Services Which Are Desired (N = 75) Numbers No. of Caregivers % of Caregivers 3 1 1.3% 7 1 1.3% 9 1 1.3% 10 8 10.7% 11 2 2.7% 12 7 9.3% 13 8 10.7% 14 3 4.00/0 15 5 6.7% 16 7 9.3% 17 4 5.3% 18 16 21.3% 19 12 16.0% Mean 14.960 Median 16.000 Std dev. 3.551 Table 16 Correlations between the Number of Attributes of Home Care Services Received and Satisfaction (N = 75) Number Satisfaction Coefficients (D Number of Home Care General Satisfaction [=.6116* Services Received *12 < .01. Question (3A) Is there a relationship between the level of satisfaction of family caregivers and continued use of home care services and recommendation of home care services to others? 56 About 68.0% of the family caregivers reported that they would use home care services when the services were needed again (see Table 17); 32.0% indicated they would reject the services. About half (52.0%) of the family caregivers stated that they would recommend home care services to others if they needed home care; one-third (34.7%) would not recommend home care services to others if they needed home care; the remainder (13.30/0) did not express a position on this issue. The results of the chi-square test indicated a significant relationship between the possibility of family caregivers using home care services when the services were needed again and the degree of general satisfaction of family caregivers (see Table 18). Of 37 caregivers with higher general satisfaction, 30 (81.1 %) would accept home care again. However, of 38 caregivers with lower general satisfaction, only 21 (55.30/0) would accept home care again, X2 (1, N = 75) = 5.742, I! < .05. There was no significant finding between the level of satisfaction of family caregivers and recommendation of home care services to others. Purpose (4) To identify the family's needs for home care in cases of mental illness and assess whether needs are being met. Table 17 Family Caregivers' Continued Use of Home Care and Recommendation of Home Care to Others (N = 75) No. of Caregivers % of Caregivers What would you do if your mentally ill family member need home care again? Accept home care 51 68.00/0 Reject home care 24 32.00/0 Would you recommend home care services to your family or friends if they needed home care? Yes 39 No 26 I don't know 10 52.0% 34.7% 13.3% 57 58 Table 18 The Number and Percentages of Caregivers' Continued Use of Home Care and Recommendation of Home Care to Others by Levels of A Lower or Higher Satisfaction Variables (N = 75) Accemt Home Care Reject Home Care Total Satisfaction No. % No. % No. % X2 Lower 21 55.3 17 44.7 38 50.7 Higher 30 81.1 7 18.9 37 49.3 5.743* Total 51 68.0 24 32.0 75 100.0 Recommend Yes No I don't know Total Satisfaction No. % No. % No. % No. % X2 Lower 15 39.5 18 47.3 5 13.2 38 50.7 Higher 24 64.9 8 21.6 5 13.5 37 49.3 5.911 Total 39 52.0 26 34.7 10 13.3 75 100.0 *12 < .05. 59 Question (4A) Is there a difference in the degree of congruence (received/desired %) between desired attributes and those actually received among all the 19 attributes of home care services? Table 19 outlines family caregivers' needs. In the category of the art of care, only 1.3% of family caregivers expressed that their needs had not been met. With respect to attributes related to the technical quality, 17.3% stated that their needs had not been met in obtaining clear explanations of care and the worker's instruction on how to take care of the patient. Of greatest concern was the availability of home care services, with more than 41 % of the family caregivers indicating that they did not receive timely home care services, and the convenience of receiving help over the telephone, which they desired. Timeliness of home care services provided was found to be the most prevalent unmet need (45.3%) among the19 attributes. However, only 10.7% of the family caregivers indicated that they did not receive the frequency of home visiting required by the patient. On the dimension of cost, about 21 % of the family caregivers felt that their needs had not been met with regard to the charges for home care services and the proportion of ! charges covered by insurrnce. I According to the survey results on the dimension of efficacy, approximately one- I third of the family caregirers stated that they needed home care which could effectively i maintain the patients' health (33.3%) and give them the spiritual support (30.7%), but that they did not receive Family caregivers also indicated that they needed help from Table 19 The Percentages of the Family Caregivers Who Did Not Receive the Attributes of Home Care Services That Were Desired (Unmet Needs) (N = 75) Attributes Unmet Needs (Not ReceivedlDesired %) Art of care: 1. Respect from home care workers 2. Consideration from home care workers 3. The home care worker accepts my suggestions 4. The home care worker has concern for my questions 5. The home care worker is familiar with professional technologies Technical quality: 6. The home care worker is familiar with professional knowledge 7. The home care worker practices health services thoroughly 8. The home care worker judges accurately the needs and health conditions of the patients 9. The home care worker gives clear explanations to me regarding the practice of home care services provided 10. The home care worker teaches me knowledge and technology needed for taking care of the patient Availability: 11. More frequent home visits when needed by the patient 12. The patient can speedily get the needed services in an emergency 13. It is easy to contact the home care worker by telephoning Cost: 14. The charges for home care services are inexpensive 15. The health insurance covers part of the cost of home care services Efficacy: 16. Home care can effectively maintain the patient's health 0% 0% 0% 1.3% 1.3% 4.0% 5.30/0 12.0% 17.3% 17.3% 10.7% 45.3% 41.3% 22.70/0 21.30/0 33.3% 60 Table 19 Continued Attributes Unmet Needs (Not Received/Desired %) 17. The home care services can spiritually support the patient's family 18. Home care services decrease the burden on patient's family for taking care of the patient 19. The patient can get the needed home care services continuously 30.7% 36.0% 29.3% 61 62 home care to decrease their burden (36.0%), and they wished to receive continuous home care services (29.3%), but did not receive it. CHAPTER 5 SUMMARY AND RECOMMENDATIONS Summary of Results and Discussion The Characteristics, Experiences, and Attitudes of Family Caregivers Of all family caregivers, 68.0% of the family caregivers were over 50 years; more than half (56.0%) of the family caregivers were the patients' parents. About 63.70/0 of the caregivers had less than senior high school education; only 13.30/0 had more than senior high school education. In addition, when the national monthly income average was about NT $28,584 (U.S. $893) (Department of Accounting of the Executive Yuan of Taiwan, 1997), about two-thirds (69.3%) of the family caregivers reported that their average monthly incomes were less than NT $20,001 (U.S. $625) and only three caregivers (4%) reported monthly average income of more than NT $30,000 (U.S. $937). The data suggest that most family caregivers were elderly parents with less than senior high school education and low income. These findings are similar to the results of the study by Hu et al. (1994). The majority (92.0%) of the family caregivers spent 7 days per week taking care of the patients. About half of the caregivers received no assistance from family members both during the weekdays and weekends. Moreover, about half (50.7%) have cared for the patients for 5 years; the average duration for taking care of a patient was 9.7 years. These data indicate that the burdens on family caregivers were heavy and that little assistance was available from others. 64 It is interesting to see that the majority (72.0%) of the caregivers received home care services from agencies for less than 1 year. Although family caregivers took care of their ill family members on a long-term basis, they tended to seek only short-term home care services. The findings by Lin et aL (1987) suggested that low-income families with less education may prefer to seek medical help mainly from god worship, herbal medicine, and other nonprofessional sources. Even though these variables were not investigated in this study, such characteristics of family caregivers might affect the utilization and delivery of home care services. Approximately 53.3% of the family caregivers thought that having a mentally ill family member at home was a stigma. Family caregivers who are elderly, have less education, and are low in social status, held more negative attitudes toward the mentally ill and were more pessimistic about the possibility of the patients' recovery from mental illness (Hsu & Tai, 1991b). In this study, the majority of the respondents were the elderly with low income. Therefore, the respondents might have a tendency to possess negative attitudes toward the mentally ilL These findings are consistent with the findings by Hsu and Tai (1991b). However, more than 61 % believed that mental illness was curable and home care services were likely to help mental illness, which conflicts with Hsu and Tai's findings. It is also interesting to find that 68.0% of the family caregivers would use home care services when the services were needed again; however, only half (52.0%) of the family caregivers stated that they would recommend home care services to others if they 65 needed home care; 13.30/0 did not express a position on this issue. The difference of 16% in using and recommending home care could be that caregivers have feelings of stigma toward their mentally ill member and therefore dislike to recommend home care to others. Furthermore, it could also be that caregivers were uncertain, or unwilling to answer this question due to lack of information about the process of the recommendations. Results of Comparing the Satisfaction Level of Two Groups The findings indicate that the great majority of caregivers expressed a high level of general satisfaction; only 2.7% felt that there was a need for strong improvement. These findings are similar to Chiu's findings (1994). Caregivers receiving home care had significantly higher general and overall satisfaction levels than caregivers refusing home care services. Caregivers refusing home care had a significantly lower satisfaction level in three areas: obtaining clear explanations, speed of services, and maintaining the patient's health from home care. The significantly lower satisfaction levels in these three specific questions seem to be reasons for the rejection of continuous services. Also, concerning availability of home care services, caregivers refusing home care services had a significantly lower satisfaction level than caregivers receiving home care. In the interviews, caregivers expressed negative opinions of unavailability: the mentally ill family member could not get the needed services in an emergency, and it was difficult to contact the home care worker by telephone. The caregivers mentioned that without abundant assistance, home care is just a waste of money. Both groups had the highest means scores in art of care. This finding is echoed in 66 the study by Chiu (1994). This indicates that family caregivers were highly satisfied with this dimension represented in the five attributes: respect shown to them by providers, the degree of consideration, accepting caregivers' suggestions, concern for caregivers' questions by providers, and the providers' technical skills. This also implies well­maintained home care practitioners' attitudes toward helping patients and a well-trained pool of home care professionals. The significant difference between the mean scores of general and overall satisfaction for 75 family caregivers could be that one overall satisfaction question is not as sensitive to some of the specific items that are represented in the 19 attributes. The Factors that Affect General Satisfaction of Family Caregivers Family caregiver's age, monthly income, support from family members to assist the caregiver during weekdays and weekends, the amount of time spent in caregiving, feelings about having a mentally ill family member at home, the number of home care services received, and the acceptance of home care if again needed were significantly associated with the degree of general satisfaction. These important findings relate to the conceptual framework of this study regarding the association between variables and the level of satisfaction. However, due to the design of questionnaires and data analysis, these findings do not offer a clear explanation of why the variables are related. It is interesting to find that those caregivers who received no support from family members during weekdays and weekends showed significantly higher general satisfaction compared to caregivers who received support from family members. Also, caregivers who spent more time in patient care per week had a higher level of general satisfaction. 67 These results conflict with findings by the study (Hu et aI., 1994) that demonstrated that family caregivers who experienced long-term stress as a result of caring for the patients without additional help "tended to prefer institutional care for their mentally ill family members." It is possible that the sample size of this study was too small compared to previous studies; as a result, the demographics were too limited and confined. Caregivers who received more of the desired home care services had a higher level of general satisfaction. This result is consistent with Chiu's findings (1997). This implies that health providers and systems that provide diversified home care services would better meet caregivers' different foci and needs. Other significant data in this research are that: (a) older family caregivers with lower incomes expressed a significantly higher level of satisfaction than other caregivers, (b) caregivers with stigmatized feelings about having a mentally ill family member at home had a higher rate of lower general satisfaction than others with no such feelings, and (c) caregivers with a higher level of general satisfaction stated a higher rate of acceptance of home care when needed again compared to caregivers with a lower level of general satisfaction. Family Caregivers' Needs for Home Care In the category of art of care, less than 2% of the caregivers reported that their needs had not been met, indicating exceptional fulfillment of art of care. The lowest level of congruence between the attributes desired and received was in the dimension of availability of home care services; more than 41 % of caregivers reported that they needed to be able to more easily contact the home care workers by telephone and to be able to obtain rapidly needed services in an emergency. This finding parallels Chiu's research (1994). Services in these two particular areas have not been improved over 4 years. 68 When comparing these findings to Chiu's research, which was completed in 1994 before the NHI was implemented, only about 20% of the caregivers in this study felt the home care services were expensive, as compared to 50% in Chiu's study. That implies that the implementation of the NHI has improved caregivers' perceptions of costs of services. The findings show 17.3% of caregivers desired but did not receive a much clearer explanation from home care workers teaching them how to take care of patients. This finding might be because the worker does not give the explanation at the level of understanding of the less educated, or does not provide adequate information. Implications for Nursing Implications for Nursing Practice Completion of this research will allow for "the framework of client satisfaction" (Westra et aI., 1995) to be implemented in current home care nursing practice in Taiwan, providing a model that can be individualized to best fit the different settings of home care nurses. The findings showed that some variables were significantly associated with the degree of general satisfaction. These variables are very important to nursing practices. They include family caregiver's age, income, support from family members, the amount of time spent in caregiving, feelings about having a mentally ill family member, the number of home care services received, and the acceptance of home care if again needed. Thus, nurses should pay close attention to these variables to avoid a lower satisfaction level from family caregivers and refusal of home care. This study also enhances nurses' understanding of the most recent family caregivers' satisfaction levels and needs. Besides, home care nurses could use the satisfaction questionnaire to make appropriate adjustments when needed. Implications for Nursing Research The "Family Caregiver's Satisfaction Survey Questionnaire" in this study has exceptionally high reliability. It is suggested that this instrument be subject to future testing. The instrument developed in this study might be of value to the nursing profession. 69 Furthermore, the findings provide a satisfaction tool and a conceptual framework of satisfaction to determine and clarify family caregivers' satisfaction regarding home care services, especially when home care services in Taiwan are still relatively new and lacking research and a testing instrument. Implications for Nursing Education The research topic of "satisfaction" is still new in Taiwan; therefore, the concept of satisfaction has not been established. To offer better quality care, it is important to encourage incorporation of the concept into community health nursing curricula from basic nursing training to doctoral levels. 70 Limitations of Study Because this study included only family caregivers who utilized services from a hospital in Taipei City, the results of this study cannot be generalized to family caregivers who utilized home care services from the other hospitals in Taiwan. There are no data to support the proposition that characteristics of family caregivers and their health providers from that Taipei hospital are similar to those from other medical centers, regional hospitals, and local public health centers in Taiwan. Also, hospitals run different programs and the medical practitioners involved are different. Thus, it is inappropriate to assume that services would be performed at identical levels. The results of this study are also inappropriate for determining the family caregivers' satisfaction levels and attitudes toward home care services in other Taiwan cities. Taipei City is a major economic center and the political capital of Taiwan. Like other major cities in Taiwan, people who reside in Taipei generally enjoy better health services and more attentive care from medical providers. Under these conditions, the past experiences and attitudes of the family caregivers toward home care services in other sub­city areas are likely to be different from those interviewed in this study. The targeted population in this study is limited to 75 family caregivers in a hospital in Taipei. This targeted population is too small to estimate the extent of the entire home care market in Taiwan. It is recommended that the sample size be increased to include different cities and hospitals. It is possible that some recall bias may exist in this survey. Although some caregivers received home care within "the past year," there could have discrepancies between care actually received and the caregivers' memories of care actually received. It is recommended that prospective and longitudinal surveys be conducted to track the changing needs for home care services. Recommendations Recommendations for Policy and Hospital 71 About two-thirds (69.3%) of the family caregivers reported a low average monthly income of NT $20,001 (U.S. $625). Although coverage by the National Health Insurance was extended to include a wide range of payments for home health care, about 21 % of the family caregivers still thought that charges for home care were expensive and they were less satisfied with the inadequate coverage provided by NHL The data collection and interviews indicated that many caregivers considered the mandatory monthly fee for each individual covered by NHI to be a large financial burden. Compared to other health services, home care service is the only service that carries additional transportation and doctor's fees. Most family caregivers interviewed suggested cancellation of those additional fees or the monthly NHI fees. In this study, most family caregivers took care of their ill family members on a long-term basis, but they tended to seek short-term home care services. Since the implementation of NHI in 1995, the majority have received home care services from any agency for less than 1 year. Due to the strict coverage policy, it is recommended that the NHI loosen the criteria for enrollment in mental illness home care programs, and broaden their insurance coverage to all those who need home care services. Also, it is recommended that the hospitals do a periodic evaluation of their home care services personnel to avoid discontinuing use of their services due to dissatisfied family 72 caregivers. Educating family caregivers about new home care programs before the patients are discharged can encourage invol vement in home care, and reduce the amount of care sought from nonprofessionals. Furthermore, these family caregivers carry a considerable burden. It is recommended that 24-hour home care programs such as the U.S. home care services or volunteer programs be set up to relieve family caregivers from these burdens. It is also recommended that caregivers be educated to access social resources, where social workers can help them with daily chores, such as changing NHI cards. Under these circumstances, the burden upon families will be reduced with the provision of supportive services. To provide quality and prornpt services in case of emergencies, recruiting more home care workers from other medical services in order to meet the heavy demand of home care services is recommended. Also, an effective referral system could help patients and family caregivers in obtaining the needed services in case of emergencies. It is further recommended that some hospitals' rules be amended to provide a flexible time schedule for home care nurses so that they can conduct frequent visits to patients without any penalty whenever help is needed. Educating caregivers to efficiently use the urgent hot line provided by the police or some hospitals in case of medical emergencies is suggested (H. 1. Chiu, personal conversation, June 9, 1998). Moreover, enforcement of policies that loosen up the number of home care nurses to enhance the quality of home care is recommended. Of all family caregivers in this study, most of them were elderly parents with low 73 education and low income. About half of the family caregivers thought that having a mentally ill family member at home was a stigma. Taipei hospital can plan and advertise their programs with the understanding of the above-mentioned family caregivers' characteristics and attitudes. Furthermore, home care nurses who wish to work in mental illness programs should be required to attend and receive training at a public health center for at least 6 months in order to understand family caregivers' characteristics within that particular region (R. J. Chiu, personal conversation, June 9, 1998). The hospital could try to provide home care education to family caregivers before the patients are actually enrolled in their program. In order to avoid the feelings of stigma, home care providers should try to educate the public and family about mental illness, to assist family caregivers and help to build the interaction between different family caregivers, and also give family support (Taylor & Dear, 1981). By so doing, hospitals could increase the satisfaction level of the patients and their caregivers. Recommendations for Future Research Future studies involving larger samples with socioeconomic diversity and drawn from more than one home care agency would provide a more representative view of family caregivers' satisfaction with home care for mental illness in Taiwan. A longitudinal study of recipients of home care is needed to determine the effects of home care on the conditions of the mentally ill and their caregivers' needs over a more, extended period. The majority of patients in this study received services for 1 year. Studies are also needed to determine if home care for mental illness has lasting effects beyond the period of care. 74 Further research is also needed to determine if home care for mental illness is, in fact, reducing patients' need for hospitalization, and if so, what aspects of care are producing this effect. More research is needed to determine how home care treatment modalities can be most effectively coordinated to ensure comprehensiveness and continuity of care. These types of evaluation are particularly important in Taiwan, due to the limited existing research, and changes in services offered under the new health plan. Rigorous testing of the "Family Caregiver's Satisfaction Survey Questionnaire" using larger samples with ethnic and socioeconomic diversity in alternative home care settings is needed to develop more valid and reliable tools to measure family caregiver's satisfaction. Repeated experiments of "the framework of client satisfaction" (Westra et aI., 1995) are needed to find out if there are other interactive relationships in this conceptual framework. Such experiments will enable researchers to address questions about care satisfaction and the relationship of this framework to other variables. This knowledge would be important to health professionals interested in improving the quality of home care to increase the satisfaction level offamily caregivers. APPENDIX A FAMILY CAREGIVER'S DEMOGRAPHIC CHARACTERISTIC QUESTIONNAIRE 1. Age <20 20-49 50-64 ;:::65 2. Gender female male 3. Marital Status married divorced never married widowed _ separated 4. Relationship to Patient _ spouse child _ parent friend relative other: ______ _ 5. Education _ less than senior high school _ senior high school graduate _ some college _ university graduate _ pos t graduate other: ------- 6. Monthly Gross Income _ < NT$20,001 _ NT$20,001-30,000 _ NT$30,001-40,000 _ NT$40,001-50,000 _ > NT$50,000 7. How many family members assist you in caring for the patient during weekdays? ___ none one person ___ two persons ___ more than two persons 8. How many family members assist you in caring for the patient on weekends? ___ none one person ___ two persons ___ more than two persons 76 9. How long ago did you begin to receive home care from any agency? ___ month(s) 10. How long have you been taking care of the patient at home? ___ month(s) 11. How many days per week do you take care of the patient? ___ days 77 APPENDIXB INTERVIEW GUIDE 1. What do you feel about having a mentally ill family member at home? _ stigmatized nothing unusual other: ----- 2. What do you think about the possibility of curing mental illness? curable incurable other: ____ _ 3. What do you think about the likelihood that home care services might help mental illness? _likely _ unlikely other: ____ _ 4. What would you do if your mentally ill family member need home care again? _ accept home care _ reject home care other: ____ _ 5. Would you recommend home care services to your family or friends if they needed home care? _yes no other: ----- 6. How satisfied were you with the home care services for mental illness overall? _ 1 extremely dissatisfied 2 dissatisfied 3 uncertain 4 satisfied _ 5 extremely satisfied 79 APPENDIX C FAMILY CAREGIVER'S SATISFACTION SURVEY QUESTIONNAIRE Read that statement bellowing before each numbered item, then circle one answer indicating the degree of needed improvement for 19 attributes of home care services. 5 = Needs no improvement. 4 = Needs mild improvement. . 3 = Needs moderate improvement. 2 = Needs major improvement. 1 = Needs complete improvement. 1. Respect from home care workers 2. Consideration from home care workers 3. The home care worker accepts my suggestions 4. The home care worker has concern for my questions 5. The home care worker is familiar with professional technologies 6. The home care worker is familiar with professional knowledge 7. The home care worker practices health services thoroughly 8. The home care worker judges accurately the needs and health conditions of the patients 9. The home care worker gives clear explanations to me regarding the practice of home care services provided 10. The home care worker teaches me knowledge and technology needed for taking care of the patient 11. More frequent home visits when needed by the patient 12. The patient can speedily get the needed services in an emergency 13. It is easy to contact the home care worker by telephoning 14. The charges for home care services are inexpensive 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 81 82 15. The health insurance covers part of the cost of home care services 5 4 3 2 1 16. Home care can effectively maintain the patient's health 5 4 3 2 1 17. The home care services can spiritually support the patient's family 5 4 3 2 1 18. Home care services decrease the burden on patient's family for taking care of the patient 5 4 3 2 1 19. The patient can get the needed home care services continuously 5 4 3 2 1 APPENDIXD DEGREE OF CONGRUENCE BETWEEN ATTRIBUTES OF HOME CARE SERVICES DESIRED AND RECEIVED SURVEY QUESTIONNAIRE 84 Please check bellowing attributes of home care services you desired to receive CD), then, and check which desired attributes were actually received CR). 1. Respect from home care workers 2. Consideration from home care workers 3. The home care worker accepts my suggestions 4. The home care worker has concern for my questions 5. The home care worker is familiar with professional technologies 6. The home care worker is familiar with professional knowledge 7. The home care worker practices health services thoroughly 8. The home care worker judges accurately the needs and health conditions of the patients 9. The home care worker gives clear explanations to me regarding the practice of home care services provided 10. The home care worker teaches me knowledge and technology needed for taking care of the patient 11. More frequent home visits when needed by the patient 12. The patient can speedily get the needed services in an emergency 13. It is easy to contact the home care worker by telephoning 14. The charges for home care services are inexpensive 15. The health insurance covers part of the cost of home care services D R 16. Home care can effectively maintain the patient's health 17. The home care services can spiritually support the patient's family 18. Home care services decrease the burden on patient's family for taking care of the patient 19. The patient can get the needed home care services continuously 85 D R APPENDIXE INFORMED CONSENT AGREEMENT 87 1. Background You are being asked to participate in a study that intends to assess the level of family caregivers' satisfaction with hon1e care services for mental illness provided to them since the implementation of National Health Insurance and to identify the family needs for home care in cases of mental illness. The;;tudy is being conducted by Wei-Chen Tung. I am a graduate student in the College of Nursing at the University of Utah, USA. 2. Study Procedure Should you agree to be in this study, you will be asked to complete questionnaires and partici pate in an interview with me in your home that will last approximately 30-60 minutes. 3. Risks The research and, in particular, the interview do not involve pain, embarrassment, or risk of injury. 4. Benefits You will be contributing toward a better understanding of the family caregivers' satisfaction with home care for mental illness since the implementation of National Health Insurance. 5. Alternative Procedures If, for some reason, the interview becomes distressful (e.g., you develop a headache), then it will be discontinued and you may either withdraw or resume the interview later. 6. Confidentiality All records and other information obtained are kept strictly confidential. Your specific responses will not be released to any person, professional, or institution without your written consent. Results will be reported in aggregate to prepare for scholarly journals. However, in no case will your name be included in any publication. 7. Person to Contact If you have questions about the study or about your participation, you may call Wei­Chen Tung, RN, at 02- 8962095. This is a 24-hour telephone number. 8. Institutional Review Board If you have questions regarding your rights as a research subject, or if problems arise which you do not feel you can discuss with the investigator, please contact the Institutional Review Board Office at 002-1-801-581-3655. 9. Medical Treatment or Compensation for Injury In the event you sustain injury resulting from your participation in the research project, the University of Utah can provide to you, without charge, emergency and temporary medical treatment not otherwise covered by your own insurance. If you believe that you 88 have sustained an injury as a result of your participation in this research program, please contact the Office of the Vice President for Research, telephone number (801 }581-7236. By signing this document you are not giving up your right to pursue legal action against any and all parties involved with this research, in accordance with the Utah Governmental Immunity Act, Section 63-30-1:63-30-34 Utah Code Ann. 1953 (as amended). 10. Voluntary Participation Your participation in this study is completely voluntary. You may withdraw at any time without negative consequences. Such a decision will not influence the psychiatric care to which you are otherwise entitled. 11. Unforeseeable Risks The research does not involve risks that are currently unforeseeable. 12. Right of Investigators to Withdraw Subjects The investigator has the right to withdraw participants who do not meet the study criteria. 13. Costs to Subjects There are no costs to you with this research. 14. New Information Any significant new findings developed during the course of the research will be provided to you. 15. Number of Subjects There will be seventy-four participants in this study. 16. Consent I have received the consent form and related documents and I have had the opportunity to ask the researcher questions. I voluntarily agree to participate in this study. Signature of Participant Date Signature of Witness Date REFERENCES Barkaukas, V. H. (1990). Home health care: Responding to need, growth, and cost containment. In N. L. Chaska (Ed.), The nursing profession: Turning points (pp. 394- 404). St. Louis, MO: C. V. Mosby. Bene-Kociemba, A., Cotton, P. G., & Fortgang, R. C. (1982). Assessing patient satisfaction with state hospital and aftercare services. American Journal of Psychiatry, 139(5), 660-662. Burns, T., Raftery, J., Beadsmoors, A., McGuigan, S., & Dickson, M. (1993). A controlled trial of home-based acute psychiatric services II: Treatment patterns and costs. British Journal of Psychiatry, 163, 55-61. Chien, C. B., Lau, C. I, & Chen, C. C. (1994). A study on family caregivers' medical­seeking behaviors and attitudes toward mental illness in a psychiatric hospital in Taipei City. Health Education, 73, 44-54. Chiu, L. (1994). The attitudes of family caregivers toward home care services in the Taipei metropolitan area. Unpublished doctoral dissertation, The Johns Hopkins University, Maryland. Chiu, L. (1997). Family caregiver satisfaction with home care in the Taipei metropolitan area. Public Health Nursing, 14(1),42-50. Chou, C. F., Hsiung, P. C., & Huang, R. Y. (1992a). The influence of home care on perceived stress of family with schizophrenic patient. The Journal of Nursing-Taipei, 39(1), 55-64. Chou, C. F., Hsiung, P. C., & Huang, R. Y. (1992b). The influence of home care on daily living of schizophrenic patients. The Journal of Nursing-Taipei, 39(3), 119-125. Davis, E. R. (1994). Total quality management for honle care. Gaithersburg, MD: Aspen. Department of Accounting, Executive Yuan, Taipei, Taiwan, R.O.C. (1997). Directorate General Budget Accounting Statistics, 82, 2. Department of Health, Executive Yuan, Taipei, Taiwan. (1997). Introduction to National Health Insurance [ On-line]. 90 Fan, B. Y., Yeh, K., Lee, S. I, & Lin, S. S. (1993). The medical care seeking behavior of psychiatric patients. Public Health, 20( 1), 83-98. Feletti, G., Firman, D., & San-Fisher, R. (1986). Patient satisfaction with primary-care consultation. Journal of Behavior Medicine, 9(4),389-399. Haber, J. (1997). Psychiatric home care. In J. Haber, B. Krainovich-Miller, A. L. McMahon, & P. Price-Hoskins (5th Ed.), Comprehensive psychiatric nursing (pp. 366- 381). St. Louis, MO: Mosby. Harrington, C. (1988). Quality, access, and costs: Public policy and home health care. Nursing Outlook, 36(4), 164-166. Heaman, M., Robinson, M. A., Thompson, L., & Helewa, M. (1994). Patient satisfaction with an antepartum home-care program. Journal of Obstetric Gynecologic Neonatal Nursing, 23(8), 707-713. Herman, S. E. (1994). Cash subsidy program: Family satisfaction and need. Mental Retardation, 32(6),416-421. Hsu, W. Y., & Tai, C. W. (1991a). The community and family's attitudes toward the mental ill. Chinese Journal of Mental Health, 5(1), 35-48. Hsu, W. Y., & Tai, C. W. (1991b). The community'S concepts and attitudes toward the mental ill. Chinese Journal of Mental Health, 5 (2), 71-87. Hu, H. K., Lin, S., Chen, C. R., Chang, S. F., Huang, M. G., & Yeh, L. L. (1994). A clinical study on institutional mentally-ill patients and their families in Taiwan. Chinese Medicine of Psychiatry, 9( 1), 16-30. Huang, P. L., Lee, Y. Y., & Mao, C. L. (1991). An investigation of the family burden experience of ex-schizophrenic patients during home care period. The Journal of Nursing-Taipei, 38(4), 77-87. Hulka, B. S., Kupper, L., Daly, M., Cassel, J. C., & Schoen, F. (1975). Correlates of satisfaction and dissatisfaction with medical care: A community perspective. Medical Care, 13, 648. Hulka, B. S., Zyzanski, S. J., Cassel, J. C., & Thompson, S. J. (1970). Scale for the measurement of attitudes toward physicians and primary medical care. Medical Care, 8, 429. Kiesler, C. A. (1982). Mental hospitals and alternative care: Noninstitutionalization as potential public policy for mental patients. An1erican Psychologist, 37(4), 349-360. 91 Krisljanson, L. J. (1993). Validity and reliability testing of the famcar scale: Measuring family satisfaction with advanced cancer care. Social Science Medicine, 36(5), 693-701. Kuo, C. L., & Kavanagh, K. H. (1994). Chinese perspectives on culture and mental health. Issue in Mental Health Nursing, 15(6), 551-567. Laferriere, R. (1993). Client satisfaction with home health care nursing. Journal of Community Health Nursing, 10(2),67-76. Lee, A. J. (1994). A study on military-service personnel for their understanding, utilization, and satisfaction toward medical service. Public Health, 20(4), 353-362. Like, R., & Zyzanski, S. (1987). Patient satisfaction with the clinical encounter: Social psychological determinants. Social Science Medicine, 24(4), 351-357. Lin, M. J., Lu, R. B., Ko, S., Lee, I. M., Lin, Y. T., & Feng, Y. (1987). An explorati