Health Care Program Evaluation Plan Health And Social Care Essay

The question of how to treat people who are mentally ill is highly controversial. In the not-so-distant past, people with mental illness were confined in insane asylums, where they lived in conditions of degradation, physical abuse and squalor. Mental health professionals now agree that such treatment was barbaric and that patients should receive supportive care. Opinions differ sharply, however, on what kind of treatment best serves this population of people interests.

How mental illness is treated varies in every civilization, culture, century, and religion. Some religions encourage its members to do well even towards mentally ill people. The treatments carried out go from dancing to chants to tortures and exorcisms, and some treatments do more damage to the patient than good. As time passes by, the term mental illness carries with a stigma that affects not only the patient, but also his/her family.

With the increasing prominence of the health promotion theory, there exists a shift towards emphasizing wellness, empowerment, and empirically supported treatment. Mentally ill people are treated more humanely at present than when compared to the only several decades ago. Adjustments are being strategized in order to address the increasing demand of mental health education and ensure the implementation of new programs in order to maintain common ground among stakeholders.

Drastic changes and the need for mental health reform based on recurrences of violence within communities have played a vital role in stakeholders rethinking mental health issues, particularly what treatments are appropriate. Historically, practices of health promotion can be incorporated into evidence based with the treatment being used in programs that have been implemented for those co-morbid health conditions with mental health problems.

Background of the Problem

Mental health programs require a set of skills that are accessible and different from traditional programs that have been set in place but have failed the system. Through the use of monograph, a method of research or literature written about a single, specific subject, it can be deduced that the “pathways to effective care are often unclear and extremely difficult to negotiate, especially for young people and their families, and for people from backgrounds that are not part of the dominant mainstream culture” (National Health Strategy, 2000, p.7). In other words, there exists a disparity between social classes in the effective distribution of health care, that regarding mental health notwithstanding.

This socio-economic disparity is no longer a new issue. Even in other instances, especially in the realm of healthcare, care services are not equally distributed among those who need it. It is usual that patients from low socio-economic classes are the less privileged, subjected to public humiliation and unconventional treatment; while those with a secure financial capacity are more likely to receive immediate and humane treatment.

Intervention approaches into mental health vary depending on the disorder and severity of symptoms. Integrating programs and new policies in the decision-making intervention is in the forefront objective of the National Institute of Mental Health (NIMH).

According to the NHS (2000, p.89), the main actors in the delivery of health care should have a “pervasive awareness” of the diverse cultural and linguistic backgrounds of the people, as differences in culture and language, among others, can be a hurdle in the design and implementation of a health care program.

This is not to say that efforts were not carried out to create programs to address mental health problems. However, some programs are either lacking in content or is not applicable to a particular group of people. Therefore, a program may produce significant results for adult patients, but may fail when applied to younger patients with the same mental illness.

As such, the need for holistic and specific programs for mental health is high. Several measures should be taken into consideration first before a particular mental health program is to be designed and implemented. The severity of the illness and its symptoms, as well as the patient’s capacity to maintain treatment, among others, should be well taken into consideration.

Literature Review

This literature review has been prepared for evaluation of Mental Health programs, which will focus on the following topics: definition of mental health; mental health issues; treatments and therapy; global mental health policies, and legislation; and the process of evaluating a health care program, particularly that of mental health.

Available literature on mental health focuses on programs that are in place and the implementation of new programs through integrating health promotion where a review of literature illustrate how the field of health promotion can be mainstreamed into all aspects of community mental health care, in policies, principles, and practices. It contains an array of clinical cases, historical analyses, assessment models, evidence-based interventions and evaluation tools, and strategies for policy reform.

Definition of mental health

The World Health Organization (2013) defines mental health as the “state of complete physical, mental and social well-being, and not merely the absence of disease.” Furthermore, it is defined as a “state of well-being” where an individual can realize his potential as a person, adopt measures in coping with life’s stressors, work productively while staying emotionally well, and contribute to the development of the community with which he belongs to.

Mental health issues

Mental health treatments

Mental illnesses are developed due to various and sometimes interrelated factors, making it difficult to clearly predict the progress of a mentally ill person (SANE, 2010). Sometimes, the symptoms are so confusing that the patient himself is not aware that they are already experiencing a mental disorder.

Initial assessment is done to identify whether the patient is suffering from a mental disorder. The diagnosis will be derived from a particular pattern of symptoms that the doctor will have to observe in the patient. Symptoms include (SANE, 2010, in Better Health, 2012): 1) feeling down for a long period of time; 2) insomnia or inability to sleep; and 3) easily distracted and inability to concentrate.

From there, the doctor will decide how to best treat the symptoms and then further observe the patient for any other more specific symptoms. In the field of mental health, diagnoses can change several times as the symptoms change, progress, or disappear. Likewise, it can change as more information surfaces from the patient himself through their sessions together. The doctor then should be able to critically delineate the differences between symptoms and suggest a treatment that would best help the patient. In other words, there is no fixed treatment or medication for a single individual with a mental disorder until all the needed criteria appears in the patient’s behaviors (SANE, 2010, in Better Health, 2012).

There are, however, several ways in treating mental health disorders and helping patients cope and recover from mental illness. There are two main types of treatments: psychological treatments and medication.

Psychological treatments are carried out on patients with anxiety disorders or depression as it helps reduce stress levels brought about or has resulted to the symptoms experienced by the patient. These treatments, or therapies, are based on how an individual “react to, think about, and perceive things” (SANE, 2010, in Better Health, 2012). Therapies are also called “talking cure” (Discovery Health, 2013) because emotional and physical pain is alleviated by talking about it.

Medications are provided to patients who have a more serious form of the disorder. There is a specific type of medication for a specific type of disorder, and they are usually highly prescriptive. Sometimes, it is given with a combination of other prescriptive drugs or with psychological therapies. It includes (Better Health, 2012): 1) antidepressants, which is given to patients with depression primarily and, with psychotherapy, to those with phobias, panic disorders, obsessive compulsive disorder (OCD), or eating disorders (bulimia, anorexia); 2) antipsychotic medications, which is used to treat illnesses such as schizophrenia and bipolarism; and 3) mood stabilizing medications, which regulates the occurrence of major depression and high episodes in patients with manic disorder.

Care should be extended, however, when using medications for mental health disorders. Although the benefits are high, there are still some harmful side effects that might affect the patient especially when used for a long term at variable doses (SANE, 2010). If available, newer generations of medications are to be given to the patient, as this has lesser side-effects (Better Health, 2012).

Apart from these two major types of treatment, the concept of community support as a way to help patients cope and recover from mental illness is fast becoming a choice for professionals and patients alike. Community support efforts include “information, accommodation, help with finding suitable work, training and education, psychosocial rehabilitation and mutual support groups” (SANE, 2010; and Better Health, 2012).

Global mental health policies

Kiresuk and Sherman (1968) have identified the rather contrasting two-fold identity of the goals of the mental health enterprise: a) highly philosophical in that theories are formulated in distinct relationships; or b) highly objective and focuses mainly on patient-therapy goals. These goals may be used to calibrate a mental health program to better cater to a wider group of concerned people. Furthermore, understanding the elements interacting between the patient and therapist in various stages of their relationship can aid in designing programs for community mental health.

Mental health policies are rules and regulations written by the Government or its corresponding Health Ministry or Department. It includes the goals, priorities, and the main direction stakeholders have to take in order to effectively implement the services enclosed therein.

Some of the components of a mental health policy include (WHO, 2005): advocacy, which is the individual and social action on raising public awareness and policy support; promotion, enabling patients to take control of and improve their mental well-being; prevention or the immediate application of measures to promote individual and community well-being and educational and informational campaigns; treatment and the carrying out of relevant care, whether clinical or non-clinical, to reduce the negative impacts of mental illness and improve patients’ quality of life; and rehabilitation where knowledge and skills learning are provided to mentally ill patients to help them achieve a higher and better quality of life despite of their disorder.

Mental health policies are the main guiding framework in the design of mental health programs. Each of the components specified above can have its own health program that will help achieve its goals. In fact, mental health programs is to take into consideration both general and specific plans of action required by all stakeholders to undertake in order for the policy to take effect (WHO, 2005). It identifies what actions are to be done, who must do it, what specific timeframe should be followed, what resources are needed, and where can it be found.

According to the WHO (2005), 90.9 percent of countries in the Eastern Mediterranean have national mental health programs in place. More than three quarters, or 76.5 percent, of North and South Americas have such mental health programs while only 52.9 percent of Europe does.

Community care is the most basic unit to perform and provide healthcare services to citizens. Therefore, their presence is vital in supporting patients with mental disorders at the community level. About 75 percent of North and South American countries have existing community care facilities (WHO, 2005).

On a global scale, however, a wider disparity is discovered. Only half of low-income countries have established community centers while 90-97 percent of high-income countries have such community centers. Some examples of these community centers are daycare centers, therapeutic and residential services, crisis residential services, sheltered homes, clubhouses, community mental health services which cater to all age groups (children, adolescents, elderly), and agricultural psychiatric rehabilitation villages, among others (WHO, 2005).

Global mental health legislation

Mental health legislation should not be confused with health policies. These are “legal provisions for the protection of the basic human and civil rights of people with mental disorders” (WHO, 2005). Mental health legislation deals not only with how dangerous mentally ill patients are to be restrained and protected, but also with the maintenance of treatment facilities and personnel, training of professionals, and the whole structure of providing mental health services. It also dictates and regulates the procedures in compulsory admissions, discharge procedures, and appeals, among others.

Laws on mental health are present in 75 percent of North and South American Countries. This is still low in contrast to 91.8 percent of European countries. Eastern Mediterranean countries have the smallest coverage at only 57.1 percent. Knowing the coverage of mental health laws is vital in understanding how mental health is prioritized on a global scale.

The timeliness of the laws needs to be considered as well. More recently existing laws may be more encompassing than older laws in the sense that evaluation processes have already been applied to it. Older laws may not be able on track with the fast changing pace of culture, society, and technology. As such, laws enacted earlier than 1990 may be ineffective because evidence-based treatment methods are not yet available during that time (WHO, 2005).

More than half of existing legislation across the globe is enacted between 1990 and 2004. North and South American countries with mental health laws have enacted 58.4 percent their most recent legislatures within this time frame. There still lies the fact, however, that half of the existing legislations were designed and enacted all the way back to the ’60s (WHO, 2005).

One of the major facets of mental health legislations is the provision of disability benefits for mentally ill patients and their families. In some cases, the disability benefit is incorporated in mental health laws. In others, particularly in countries without specific mental health legislation, the disability benefit is part of a wider scale of health legislation. Half of low-income countries have disability benefit provisions, while a hundred percent of all high-income countries are covered (WHO, 2005).

There are, however, less researches delving into the degree of implementation and the spread of coverage of mental health legislations and its accompanying provisions. Moreover, there is a need to identify what services or benefits do particular countries provided for individuals with mental health disorders. As such, these areas need to be researched into more to better accommodate to the needs of individuals and families who need it.

Evaluating mental health programs

Atkisson, et al (2010) has a conceptual model laying out the three components involved in evaluating a community mental health program. These three components are: a) levels of evaluative activity; b) functional roles of the evaluator; c) and the capability of the program information. This working model may be used in the assessment of the evaluation capability of mental health problems. Proper use of the model could generate a better evaluation strategy.

Although outdated, Hagedon, et al. (1976) has written a reliable manual on determining appropriate evaluation strategies and in planning evaluations. Evaluations, as the authors have suggested, should be done in cycles. Monitoring and evaluation should be schedule annually or bi-annually. This allows the program to be constantly updated, making it easily be adopted into a community. Changing cultural and technological elements could pose threats or opportunities to the conduct of the program.

Hargreaves, et al. (1977) states that addressing issues in a program’s information system and adequately assessing outcome studies eventually act on the program’s processes and integrity, as well as the stakeholders’ welfare. An effective mental health program should have a similarly effective system of collating and analyzing feedback, which may be used to further improve the program.

The evaluation plan describes in detail how a program will be monitored and evaluated. The intention of using the results for program development and decision-making should also be made clear (Centers for Disease Control and Prevention, 2011).

A program evaluation must be carried out with a clear purpose in mind. In fact, in designing a plan for program evaluation, the expectations to be derived from the conduct of the evaluation should be already considered.

However, the evaluation design and the actual implementation should not be carried out by just anybody. The evaluation should be done by someone knowledgeable of the processes of evaluation and must also have an understanding of the program being evaluated. Otherwise, the evaluation process might not be able to achieve its objectives.

The evaluation design should be able to identify the specific group or group of people for which the program is intended for and would have access to. The methods to be used should be able to capture the needs of the stakeholders while maintaining excellence in the delivery of health care.

The Minnesota Department of Health (2010), identified six reasons on why there is a need to monitor and evaluate the processes of a program: 1) to determine whether the objectives of the program is being achieved in the short-term; 2) to improve how the program is being implemented; 3) to provide a degree of liability to the funding agencies and the community with which the program is intended for; 4) to increase the stakeholders’ awareness of the program and encourage support; 5) to contribution to the current pool of knowledge and practices in the scientific undertaking of public health interventions; and lastly, 5) to inform and influence the decisions of the higher policy-making body, e.g., the government.

A scientifically-sound evaluation has similarly scientifically-sound program objectives. According to Wilburn and Wilburn (n.d.), program objectives should be S-M-A-R-T: specific, measureable, achievable, realistic, and time-specific.

It is ideal that an evaluation design is all-encompassing; however, as was said in the introduction, that it has to be specific to be able to fit the needs of the stakeholders better. Measureable concepts should be incorporated into each objective to aid in the attainment of quantifiable variables. It should also be realistic, not idealistic, and should follow a practical timeframe.

The “right” questions should be able to answer the questions “what,” “how,” and “why it matters” (Centers for Disease Control and Prevention, 2011). The evaluation design should be able to: 1) state the need for the implementation of the program and its relation to the intended effects (clarify the purpose and anticipated outcomes); 2) lay down the processes in the program implementation and identify whether it works well with the overall evaluation design; 3) clarify with short-term information if changes need to be done in the existing processes of the program; and 4) provide a rationale about the program’s importance and impact to the field of mental health.

The evaluation must apply not only to the program per se, but also to how the application of changes will affect the program’s intended outcomes. There are other variables to be considered for evaluation.

One is the nature of the stakeholders. Is the program able to capture the stakeholders and address their needs? Are they the right ones with whom to apply the program? Identifying the right stakeholders for the implementation of the program is vital in ensuring that the message is carried across.

As such, the location where the program was implemented should also be evaluated. Cultural, social, and political issues must be considered as these could have an effect in the distribution of the program. Likewise, time should also be evaluated. This pertains not only to the timeframe or schedule of implementation of the program activities, but also on the timeliness of the program implementation.

The last thing that should be subjected to evaluation is the output. Is it what the program intends to achieve? What went wrong?

All the information from the monitoring and evaluation will be collated and considered as vital feedback. Feedback needs to be gathered to be used in the further development and improvement of the program’s design.

After the step-by-step process of evaluation is completed, the results will be integrated into the original mental health program. Recommendations for future researchers will be produced, such as the conduct of a second evaluation on the same program after it had been subjected to changes as a result of the initial evaluation.

The design and methodological processes to be followed in the evaluation of a mental health program will be discussed in detail in the succeeding paragraphs.

Goals and Objectives

This research study primarily aims to identify a method that will be used to effectively evaluate mental health programs.

Specifically, this research aims to:

Identify the socio-demographic characteristics of the patients and families using the mental health program;

Identify their information needs;

Determine their attitudes and perception towards the mental health program; and

Determine the strengths and weaknesses of the program through a professionals perspective.

Theoretical Framework

The main reason for conducting a program evaluation is to determine the efficiency of a program, particularly in terms of whether physical and financial resources are being used wisely, the program’s performance and objectives are working with the design, and is following the processes set for it (Lindeman, 2010).

Based on the literature review gathered for this research, mental health program evaluations mostly focus on how the program could better adapt to certain situations. Certain social conditions call for a more customized program, given that the current specifications of a program may not be suitable for another individual or group of individuals. Therefore, interventions must be carried out to ascertain the effectiveness of a mental health program.

By using a program theory, the evaluation of the program may be guided accordingly. The program theory is only recently integrated into the field of public health, as it is mainly used in social science research. The program theory, by definition, is a “conceptual plan, with some details about what the program is and how it is expected to work” (Issel, 2009).

The program theory has two main components: 1) process theory; and 2) effect theory. Process theory is concerned with the program per se, while the effect theory is concerned with the use of interventions. Similar programs, like in the realm of public health and its programs against obesity, consider evaluation as a very important process. It follows the same way of formulation of objectives and the creation of sound evaluation plan.

Evaluation Model Design

This research will follow a multi-design evaluation. It will make use of the responsive evaluation, followed by the participatory/collaborative form of evaluation, and then the utilization-focused evaluation. The use of a multi-design evaluation allows the researcher to better make use of the information that will be gathered for evaluation.

The first design is the Responsive Evaluation type of evaluation model and approach, which is concerned with identifying how the program would look like to different people. This design must take into consideration what stakeholders need to satisfy their thirst for information.

In relation to responsive evaluation design, the participatory/collaborative form of evaluation may be used to further identify how the stakeholders view the program and what they could suggest be done to improve it. Their information needs will then be enumerated and considered.

Once the information needs are identified, this will undergo utilization-focused evaluation. This allows stakeholders to take part in the evaluation process, which will be used ultimately in the decision-making phase of the evaluation. The information will also be integrated into the program itself so as to better calibrate it to fit the specific needs of the stakeholders.

The model below shows how these evaluation designs will be utilized to be able to evaluate a mental health program better.

INPUT

OUTPUT

PROCESS

STAKEHOLDERS

How does the program look like to different people?

PARTICIPATORY/COLLABORATIVE

What are the information needs of those closest to the program?

CONSUMERS

EXPERT

INFORMATION NEEDS

“What are the information needs of stakeholders, and how will they use the findings?

Figure 1. The Multi-Design Evaluation Model

The study aims to create a viable evaluation model to use in evaluating mental health programs. For this research, both primary and secondary research will be utilized. The primary research will be conducted with the use of a survey questionnaire and interview for research instrument to gather both quantitative and qualitative information. Respondents will be identified and the questionnaire will be distributed to them. Interviews will be scheduled accordingly.

Quantitative methods will be employed as this is a flexible and iterative approach in researching information. Consecutively, the research will also make use of qualitative information which will be used to locate and develop theories that would explicate the relationship of one variable with another. As such, behavior, attitudes, opinions, and beliefs on the subject matter at hand will be identified and quantified easier.

Secondary research will also be carried out as well. Statistics and results from previous studies will be incorporated into this research and then compared with the results of this study.

Evaluation Methods

Respondents of the Study

Following the evaluation designs stated above, this research will identify stakeholders to help in evaluating the program. Consumers and professionals will be asked to assess the program and their attitudes and perceptions toward it will be gauged. It is vital to determine and identify the respondents to be used for this study.

The consumers may be the direct beneficiaries of the program to their close relatives who have personally observed how the program was implemented. Their personal experience on the program implementation would paint a picture of the applicability and fit of the program to various demographic.

On the other hand, the professionals will be third-party experts who are knowledgeable in the field. These may be psychiatrists, psychologists, or program implementers. Their expertise on the field would contribute to the identification of what’s lacking or missing in the program.

Sampling Method

The researcher will use two sampling strategies: random and purposive. The purposive type of sampling allows for a more flexible way of choosing respondents, given that the classifications needed are not entirely that applicable to a general group of people. Likewise, this is easier to carry out by the researcher without compromising the results of the study. Psychologists, psychiatrists, and program implementers will be purposively identified based on their availability on the subject matter at hand.

On the other hand, the program consumers will be identified randomly. A list of the program beneficiaries will be retrieved from authorities. Then, random sampling will be used to identify who among the beneficiaries will be interviewed. If ever the patient beneficiary will be unavailable for interview, their immediate family members will be contacted in their place.

Research Instrument

To gather pertinent information from the respondents, the researcher will create a questionnaire, one set for each of the respondents. The instrument will include socio-demographic characteristics, identification of attitudes and perceptions towards the program, suggestions for improvement, among others.

The major objective of using a survey questionnaire is to gather both quantitative and qualitative information from the respondents. The research instrument will use a combination of open and closed questions. Closed questions will be used at the most, especially in identifying the socio-demographic characteristics of the respondents. Through the use of closed questions, the choices will be limited within the scope of the study; thus, allowing the researcher to easily encode the answers. Moreover, using closed-ended questions would help keep the results in line with the research’s problem statement and objectives.

As such, open-ended questions will nonetheless be used. Using this type of questions will allow the researcher to gather qualitative data. For example, their experiences on how the mental health program was implemented on them are better off detailed than limited to a set of questions. Themes are captured as they emerge from the respondents’ accounts.

The attitudes of the respondents toward the mental health program will be gauged with the use of a five-point Likert scale. The Likert scale is a rating scale that allows the respondents to indicate his/her level of agreement or disagreement towards a particular event, situation, or part of the program. The equivalent weights that would correspond to the degree of agreement or disagreement are as follows:

RANGE

INTERPRETATION

4.50 – 5.00

Strongly agree

3.50 – 4.49

Agree

2.50 – 3.49

Uncertain

1.50 – 2.49

Disagree

1.00 – 1.49

Strongly disagree

To test its reliability, the one-shot research administered survey instrument will be pre-tested to a group of individuals. The instrument will then be revised as per the comments and suggestions derived from the pre-testing.

The survey questionnaire is chosen as a research instrument since they are easy to construct. Likewise, questionnaires may be easily reproduced and can be delivered to the respondents by mail or by hand.

Data Collection

For this research, data will be gathered; information will be collated from previously published studies from local and international universities. The researcher will then summarize the secondary information, make a conclusion and a generalization, if applicable, and then provide recommendations which may be useful for this research.

The researcher will identify five third-party individuals who are likewise knowledgeable of the mental health program to be evaluated. They will be administered with the initial draft of the survey questionnaire. The readability and validity of the instrument will be analyzed, and proper revisions shall be made. This ensures that the administration of the questionnaire to the actual respondents will not encounter problems, such as confusing questions and misunderstood instructions. Thus, the number of void questionnaires will be limited, if not totally avoided. The data collection process will ideally be done in a month to give way to the transcription and encoding of the research results. The revised research instrument will be given to the respondents personally so as to avoid the loss of documents. The researcher will be present in the answering process to assist the respondents in any way possible. However, the researcher will try to limit the interaction so as to avoid the interviewer’s bias from affecting the results of the study. The process should remain objective than subjective; the researcher should not blatantly state his own opinions so the respondents’ answers and comments will not be influenced.

Data Analysis and Reporting

Data analysis refers to the process of organizing, encoding, summarizing, and classification of the information derived from the respondents with the use of a survey questionnaire. Descriptive statistics will be used to determine the attitudes and perceptions of the respondents, as well as their socio-demographic profile. As such, frequency counts, percentages, mean and Likert-type scales will be used.

After identifying the quantifiable variables, the data will undergo analysis with the use of SPSS. The use of the SPSS software as a medium for carrying out appropriate statistical tests will show the similarities and differences of the respondents according to the independent variables identified relevant by this study.

Concrete conclusion will be drawn from the SPSS results using inferential statistics. Inferential statistics is employed so the researcher could identify the characteristics of the sample and the relationships that exist between them.

The data gathered with the use of the research instrument may hold significant identifiers per se; however, it will not bear importance if it does not undergo proper and appropriate data analysis. The raw data should be analyzed and simultaneously compared with the mental health program’s standards. This would produce findings that are grounded and highly validated. Consequently, the evaluation results will be more credible and will be more likely to be utilized for further evaluation and research.

Graphs, charts, and tables will be used to describe the results of the study. The use of these presentation mechanisms allows the end users of this research to easily identify the data. Moreover, lay people who would have access to this research will be able to break through the jargons and utilize the results to its full extent.

Economic Evaluation

An economic evaluation is an initiative to analyze the input of resources and the outputs in form of outcomes that a research undertaking should take into consideration. Assessing the economic value of the research would ultimately help the researcher identify whether a particular worth of a resource could produce an output of the same worth (CDCP, 2013).

Ethical, Equity, and Leadership Considerations

]The time to be used in gathering the data should be taken into consideration as well. The longer the time given for the mental health program to proceed before conducting the evaluation, the more accurate the findings may be. Newly-implemented programs might not have achieved its initial goals yet; thus, its actual potential might be overlooked and regarded as an inability to reach its goals. As such, the researcher must be able to start at a time where the program has already ripened and have produced results, ensuring that the variables that affect the program as a whole is a contributor to its results.

Since the respondents of this study are patients, their family, and mental health professionals, the ethical implications of the study must be determined and taken into consideration. Limitations should be set so as not to cross the boundaries of doctor-patient relationships and to maintain the integrity of the patients and their family. Considering the ethical implications of the research does not only give respect to the respondents, but will also contribute to the credibility and validity of the study.

Before the research instrument is to be distributed, the patient respondents or their families will be given a consent letter, which they will have to sign should they wish to proceed with answering the research instrument. In this consent letter, the purpose of the study, as well as the end use of the results should be indicated. When the intent is clear, the respondents are more likely to open up to the respondents. This should be done carefully, as their experiences and accounts are extremely valuable to the study; it would be a waste if they would feel that they would not benefit from the study