Living beyond the limitation: Rehabilitation, life and productivity of individuals with schizophrenia in South‐West Nigeria

Abstract Introduction Schizophrenia, the most chronic and stigmatized form of mental illness, can be described as a brain disorder that affects an individual's cognition. Individuals with schizophrenia exhibit socially unacceptable symptoms that affect their psychosocial lives. They suffer from reduced productivity due to the debilitating effect of the illness, and the negative symptoms impede their employability; such symptoms and effects aggravate the stigma around mental illness. However, when rehabilitation is successfully achieved, so is productivity, and this decreases the associated stigma. Thus, this study describes the rehabilitation experiences and productivity of individuals with schizophrenia in South‐West Nigeria. Methods and analysis A descriptive qualitative approach with semi‐structured interviews was used to gather information from mental health service users. The discharged users in this study received in‐hospital or outpatient rehabilitation care at four outpatient units within two specialist mental health‐care facilities in South‐West Nigeria. These facilities offer vocational training and rehabilitation services for individuals with schizophrenia. Twenty‐nine mental health service users were interviewed. The data from the interviews were independently analysed by two researchers through a content analysis approach using NVIVO version 11. The researchers compared the results of the analysis and reached an agreement on the conclusion. Findings and recommendations The rehabilitation services availed by patients in the research setting are of three types. Some attend occupational rehabilitation to learn a trade; they depend on professionals for the choice of skill but at a cost that is not affordable to many. Some stay in rehabilitation units linked to the hospital, rendering their services at a cost, and their living expenses and skill acquisition processes are based on the remuneration they get from the services rendered to the institution. Others depend on their family members' efforts to afford rehabilitation services but set up on job by family or employed in family business. The mental health service users in this study who offered their services to the institutions were able to make informed decisions and showed better performance with their chosen occupation than those who depended on their family or health professionals for the choice of rehabilitation service or vocational career. Therefore, this study concludes that prioritizing mental health facility users' preferences in terms of productive activities (sales, services, vocation) or rehabilitation goals should be encouraged.

tion is successfully achieved, so is productivity, and this decreases the associated stigma. Thus, this study describes the rehabilitation experiences and productivity of individuals with schizophrenia in South-West Nigeria.

Methods and analysis:
A descriptive qualitative approach with semi-structured interviews was used to gather information from mental health service users. The discharged users in this study received in-hospital or outpatient rehabilitation care at four outpatient units within two specialist mental health-care facilities in South-West Nigeria. These facilities offer vocational training and rehabilitation services for individuals with schizophrenia. Twenty-nine mental health service users were interviewed. The data from the interviews were independently analysed by two researchers through a content analysis approach using NVIVO version 11. The researchers compared the results of the analysis and reached an agreement on the conclusion.

Findings and recommendations:
The rehabilitation services availed by patients in the research setting are of three types. Some attend occupational rehabilitation to learn a trade; they depend on professionals for the choice of skill but at a cost that is not affordable to many. Some stay in rehabilitation units linked to the hospital, rendering their services at a cost, and their living expenses and skill acquisition processes are based on the remuneration they get from the services rendered to the institution.
Others depend on their family members' efforts to afford rehabilitation services but set up on job by family or employed in family business. The mental health service

| BACKG ROU N D
Schizophrenia constitutes 1% of the total global population 1 and 7% of the global burden of mental illnesses 2 ; however, there is a dearth of resources to estimate its prevalence in Africa. The rate of global increase in mental illnesses is considered significant since it has the highest rate of disabling effects (regarding low or no productivity) on individuals. 3,4 Schizophrenia has associated behavioural features that result in psychosocial challenges, 5 and it occurs at the stage of role identity development, that is 18-25 years among men and 25-35 years among women. 1 Individuals with schizophrenia lack motivation, face a reduced drive and impeded functionality and productivity, 6 with the latter affecting the family and national economy. 7 This is corroborated by global statistics-individuals with schizophrenia are at 24 million, 8 and health-care expenditure for schizophrenia is at 7%-12% of the gross national product (GNP) in each country. 7 In addition, individuals with schizophrenia are more prone to diabetes mellitus and cardiovascular disease, which are leading causes of long-term disability. 9,10 Two scholars have previously attributed low productivity to endocrine and cardiovascular disorders, which is aggravated when compounded by mental illness. 11,12 Life expectancy of schizophrenic individuals is usually 25 years lesser than the norm due to inactivity and associated disorders. 10 This strengthens the need for a proper rehabilitation plan before re-integrating individuals into the community. 13 It is important to note that the pursuit of rehabilitation for those living with schizophrenia commences before patients are discharged from the hospital and involves different therapies, including pharmacotherapy, family therapy, group therapy and occupational therapy. 14 The ideal step for instituting these therapies should be through shared decision-making processes. 15 However, the application of these processes varies for each therapy. Pharmacotherapy involves medication through the active participation of the patients on preferred choice and dosage 16 ; family therapy focuses on family and societal support through acceptance and empowerment 17 ; group therapy entails therapeutic use of recovered and well-rehabilitated individuals as role models for others with mental illnesses 18 ; and occupational therapy entails the re-training of previous social and vocational skills, which enables communications, relationship management and trade. 19 The benefits of rehabilitation are abound in the literature. It reduces disability, improves the quality of life and increases life expectancy among schizophrenic individuals. 20 While it does ensure productivity, it has been found that rehabilitation that entrenches independent living is best suited for optimal functioning. 21,22 Studies have shown that rehabilitation reduces the community stigma around mental illness 23 and exerts positive effects on the life and environment of individuals with schizophrenia. [21][22][23] Further, depression and suicide that arise from inactivity and hopelessness can be prevented by productivity. 24 However, there are limited studies on the rehabilitation and productivity of individuals with schizophrenia and the burden on low-and middle-income countries. 25,26 Therefore, this study was focused on assessing and describing the experiences, rehabilitation and productivity of schizophrenic individuals in South-West Nigeria and suggests possible ways of improvement.

| RE S E ARCH ME THODS
The experiences of individuals living with schizophrenia, their rehabilitation and levels of activity and productivity were studied, including their expectations of the rehabilitation exercise, the perceived benefits, changes since they began engaging in rehabilitation, the activities they engage in, their productivity levels, their concerns about rehabilitation and suggestions for improvement. A descriptive study design was adopted with a qualitative approach to data collection, specifically using semi-structured interviews.
Purposive sampling was used to select participants who were mental health service users living with schizophrenia, discharged from hospital but receiving in-hospital or outpatient rehabilitation care.
The interviews were conducted in April-September 2019, with each interview lasting 45-90 minutes. The researcher conducted about one to three interview sessions with each participant. The purposive sampling of mental health service users with schizophrenia was performed through record reviews and inputs from assistants of health professionals. The research setting constituted 62 patients accessing rehabilitation services, and 50 were eligible for the interview; however, 21 refused to give consent, users in this study who offered their services to the institutions were able to make informed decisions and showed better performance with their chosen occupation than those who depended on their family or health professionals for the choice of rehabilitation service or vocational career. Therefore, this study concludes that prioritizing mental health facility users' preferences in terms of productive activities (sales, services, vocation) or rehabilitation goals should be encouraged.

K E Y W O R D S
mental health service users, productivity, rehabilitation, schizophrenia while some withdrew their consent at the point of interview. In total, 29 mental health service users who gave their consent were interviewed. Table 1 depicts the demographic description of the participants.

| Research setting
This study was conducted in South-West Nigeria, which is where humanitarian psychiatric care first took off. 27  The second institution has only one unit that handles the rehabilitation of individuals with schizophrenia-the occupational therapy unit. Mental health service users come to this unit daily to engage in different rehabilitation services, from learning vocational skills (tailoring, hairdressing, shoemaking, bead-making, wool works) to behavioural habit training and psychosocial therapies (relationship and anger management).

| Sampling and procedure for data collection
Participants were purposively selected, and the prospective participants' files were sorted with the assistance of record officers before being reviewed by the investigator and nurses on duty. Inclusion criteria were that the individual had to have a diagnosis of schizophrenia and been mentally stable for not less than 3 months (research evidence shows that the risk of relapse is usually high from 1-3 months of discharge 28 ). Exclusion criteria were records of positive symptoms in the last 3 months (which can impede the interview process, such as flight of idea or slurred and incoherent speech), history of debilitating co-morbidity (such as head injury, cerebral cancer, poorly managed diabetes with injuries or wounds), affective co-morbidities (such as depression and mania) and individuals younger than 18 years. Those who satisfied the inclusion criteria were contacted and briefed about the study.
The eligible participants gave informed consent prior to their interview appointments. The interview sessions were held at each participant's preferred time, date and venue. Most of the participants were offered incentives (transport fare) at the close of the interview session; those who resided and were interviewed within the mental health facility were not given any transport fare but were thanked verbally.

| Qualitative rigour
As previously stated, all the participants gave informed consent.
To ensure the appropriateness, clarity and congruence of the study content with the set objectives and interview guide, the research was presented to a peer review committee as well as an expert review committee. In addition, the interview guide was reassessed post-validation. The fieldwork was performed by the first investigator (OO), and the co-researcher was periodically briefed at each stage of data collection. All the interview sessions, except one, were in English, and all of them were audio-recorded with the participants' permission and transcribed verbatim. There was a member checking with the participants after data transcription. Back translation occurred for the entire script of the one interview session conducted in the Yoruba language. Two researchers coded the data until they reached a consensus on the emerging themes. These steps, along with the efforts described below, enhance the credibility and trustworthiness of the work.

| Data analysis
Data analysis was performed using NVIVO 11 and the content analysis technique. 29 The transcribed script was imported into the software, and nodes and sub-nodes were developed. The nodes (primary node) presented the information pertaining to each particular question, while the sub-nodes constituted information with similar meanings under each primary node (also regarded as categories).
Similar categories were classified into themes, and the categorized data were reviewed for congruency with the corresponding principal nodes. Two independent researchers individually analysed the data before comparing the results and reaching a consensus. Four themes emerged from the analysis of participants' accounts, as described in the Results section. Table 2 presents the corresponding categories and themes.

| Theme 1: Rehabilitation approaches
The first theme generated in the description of the participants' engagement was rehabilitation approaches. This was expressed in three different perspectives which connotes, self and family initiative, hospice service and alternative/ traditional therapies.
In the description of self and family initiative, some of the participants reported that, although they were receiving training in TA B L E 1 Socio-demographic characteristic of participants

Rehabilitation experience (years) Vocation before illness Vocation after illness Dependency
On the other hand, one participant said that she faces no productivity-related challenges as far as her illness is concerned.
Her response shows self-initiative, as she was able to understand her own capabilities and chose the activity she found the easiest: I tried going into sales and supply, but that made me anxious. Later, I tried fashion designing, with which I am coping well. Besides giving me financial independence, I do it at my convenience.
Another group of participants reported another approach to rehabilitation which connotes hospital-based/stay training, hospital-based paid services, plus self-services within the hospital (hospice techniques). In their description, some said that they were provided job opportunities by the institutions and that the salary they receive from the hospital is sufficient for self-sustenance. The job description reported by one of the participants is as follows: We are employees of the hospital and on payroll … our employment is not from the government, but the hospital pays us. We clean and sweep every morning.
Similarly, another participant talked about the supportive nature, salary and use of the job the institution provided them: We serve as the hospital cleaners. We are trained to clean; we clean … It is this salary that we use to maintain ourselves. It's 200 naira per day (0.5 USD).
Two other participants stated that the scope of their work went beyond cleaning offices; they engage in some menial jobs for additional self-support alongside their institutional jobs. They described themselves as independent and able to meet their needs without having to depend on anybody as they said; We live here and clean offices and the toilets on the wards. In addition, I go from bed to bed to shave the hair of patients and also sell snacks. These help me to buy my medication and pay for my accommodation. I don't depend on anybody.
(C12Ar) Besides the cleaning duty, I also sell sachet water using the hospital fridge. I also sell cell-phone recharge cards to the nurses and the doctors. (C1Av) Besides job opportunities, hospice services also provide training.

| Theme 2: Perception
The theme of perception emerged from the participants' view of rehabilitation exposure and the description of its impact on them.

| Theme 3: Expectations
In contrast, the participants who live in their respective communities but visit the hospital for daily rehabilitation expressed their utmost desire to go back to the activities they had engaged in before the onset of their illness (rehabilitation to previous functioning). They believe they are doing well as far as rehabilitation is concerned and are determined to pursue their previous engagements. They believe that this will spare them the time required to venture into a new field. Excerpts from the participants' reports are given below: what I want is for them to help me to achieve going back to my school and graduating. I feel I will do well going back to school rather than learning a trade and wish to complete my study and work as a professional in the discipline I studied. (C6L) My aspiration in life is to become an administrative person, working for the government. I studied business administration at university and that's what I want to do.
(C9L) I was in school in a university outside the country when this illness started, but I was still studying. I had not gotten my degree; I still wish to study. (C7L) Another expectation that was different from community re-integration and previous patterns of functioning was the participants' rehabilitation through gaining desired skills and not prescribed ones.
Participants stated that they sometimes desire the acquisition of new skills and not necessarily the ones they focused on before, but they desire to choose from the available options on their own and not have the professionals decide for them. They reported experiencing frustration with skill pursuit when it was the professional's choice and not a self-driven one. An excerpt from a participant's recount is as follows: I wanted computer (science) but was directed to tailoring by the HOD. There, I couldn't pass thread into the needle. I just wasted the three years. Later, the HOD agreed for me to learn computer … in this computer age, I would like to be a computer analyst. (C5L) In summary, these participants expressed a desire for acceptance of their own views on skill acquisition and rehabilitation modality in general.

| Theme 4: Rehabilitation barriers
This theme answers the questions on the participants' concerns about the programme and their suggestions for improvement. Some participants complained about a lack of infrastructure in the community, which impedes their functionality and rehabilitation (structural barrier). A participant recount goes thus: I was brought back to the hospital by the social workers when the house I was to be discharged to was dilapidated. I do not even think anyone stays there anymore. (C7Av) Another barrier was psychosocial in nature. Some participants revealed that there is fear and an actual expression of non-acceptance by their family members. Social undesirability is a factor that limits their productive functioning in the community. Excerpts from a participant's statement is as follows: In short, these participants expressed their basic needs constituting barriers to rehabilitation.

| D ISCUSS I ON
This study revealed that individuals with schizophrenia are able to start small businesses, work in a formal setting and even learn new skills that will help them live and sustain a productive life. This is consistent with the finding that individuals with schizophrenia in paid jobs have boosted morale and increased quality of life. 30 Although the participants in this study earn less than a dollar per day, they stated that the amount is sufficient to meet their basic needs.
In terms of perception, the participants held negative and positive beliefs about themselves. Their negative beliefs evoked a feeling of worthlessness, primarily resulting from the rejection they experienced from their family. Their positive beliefs arose from being actively engaged in a vocation. This is consistent with findings that inactivity can cause mortality among schizophrenic patients. 31 Scholars have also reported that this feeling of worthlessness arises when individuals with schizophrenia experience abandonment by their family for any reason. 1,32,33 Notably, some participants' perceptions were influenced by defective insights into their diagnoses. the finding that the attitude of health professionals towards the disclosure of a schizophrenia diagnosis has a significant impact on the acceptance of this diagnosis by mental health service users as well as their relatives. 34 Literature indicates that a lack of insight can impede productivity, and the achievement of insight should be the first step towards rehabilitation. 35 Sánchez and colleagues declared that the inability to accept disability was a significant barrier to individual productivity and social functioning. 36 Additionally, this study revealed that individuals with schizophrenia have their own vision and expectations of life as well as the potential to live a meaningful life. Some of the participants dreamt of achieving their academic and career goals and even starting their own businesses; however, receiving suggestions for how their rehabilitation should proceed adversely affected their interests. This is consistent with a previous finding that a lack of interest results when an individual feels compelled to pursue a task, which serves as a significant constraint of the productivity of individuals with psychiatric conditions. 37 Souraya and colleagues also revealed that giving schizophrenic individuals the liberty to make an informed decision was vital for goal-orientated rehabilitation. 38 A study also reported that these individuals do better in their career or rehabilitation activities if the choice was self-initiated or self-driven. 39 Further, our study revealed barriers to the rehabilitation of people with schizophrenia. Resources such as housing affect the success of rehabilitation because even participants who can function independently within the community may have to remain accommodated in the hospital setting. Some of the study participants faced psychological implications due to their behaviours prior to diagnosis, leading to neglect from their family members. Such neglect impedes the success of rehabilitation. This is consistent with the finding that the public feels threatened by the presence of individuals with a history of schizophrenia coupled with violence. 40 The participants in this study indicated a will to return home, but they feared rejection, being punished for their wrongdoing, or even having no house to go back to; therefore, in a country like Nigeria with poor resources, structured accommodation for such individuals should be considered within the community and at a reasonable price.

| CON CLUS ION
This study shows that the rehabilitation programme followed by the hospitals is a good initiative and has enabled the mental health service users to regain some level of independence and productive living. However, there are still lapses and weaknesses in the execution, such as variations in the approach to rehabilitation, the lack of a unified guide to rehabilitation, and prolonged institutionalization rather than re-integration of the service users who lacked accommodation or acceptance by their relatives. Therefore, it can be concluded that the rehabilitation of individuals with schizophrenia, though a good effort, can be improved upon through active involvement of service users in their rehabilitation decision-making process. This can potentially help mental health professionals better serve the interest of the service users and community as a whole.

| RECOMMENDATIONS
Considering the demographic profile and the participants' reports of undergoing rehabilitation and learning a trade for many years, ranging from five to 30, there seems to be no end to rehabilitation. Therefore, the setting of broad, individualized goals before the commencement of rehabilitation is recommended.
Further, collaborations between different settings and other parts of the world that have recorded evidence-based success in rehabilitation are advisable. Wide variations were also noted between the intervention approaches taken by the health professionals; therefore, a practice guide for uniformity of practice is also recommended.

E TH I C A L A PPROVA L
The full approval was secured from the first institution on the Beneficence was promoted in this study, as there were no physical risks. Although the mental health service users are a vulnerable population, their rights were protected by strictly adhering to the enquiry on what this study is purposed. The inclusion criteria also considered mental health service users' vulnerability to determine those who were eligible to participate, part of which was clinical stability of 3 months, the evidence of which was confirmed through the follow-up report. Co-morbidity with an affective disorder that increases the tendency of the emotional breakdown was also excluded to minimize the emotional risk. This study posed no harm, although recounting the experience could bring about an emotional reaction in individuals with schizophrenia, despite the consideration of that for exclusion, the researcher, before the commencement of the research, liaised with the Psychology Unit of the hospitals that in the event any participant broke down emotionally during or even after the data collection would be referred at the researcher's cost; this was because mental health service users pay for this service and the section will be discontinued. The researcher developed a referral slip, and the Head of the Psychology Unit approved the referral of participants, but no participant had an emotional breakdown throughout the study.

P OS ITI O N I N G TH E R E S E A RCH E R S
Both researchers are Mental Health Lecturers. The first researcher is a Nigerian, a PhD Candidate and a registered psychiatric lecturer, lecturing in a university about 500km from the research settings, with no connection to the facility and the participants of the research settings. This allowed participants to express themselves freely. The researcher sought consent from each participant, and participant who declined participation was excused from the study without sanction or prejudice. The other researcher is a South African and a lecturer at a South African institution with no affiliation or any form of contact with the research settings.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data collected for this study and all documents on the research work were kept in a pass-worded computer of the principal investigator, OO The data have no form of an identifier as pseudonyms were used to represent the participant's identity in compliance with the ethics requirement. The data dissemination statement was included, in consent (written and verbal) taken from the participants and in ethics application forms, that the data will be used for the research purpose and publications ONLY. Also in line with one of the requirements for securing ethical clearance for this study, data will only be divulged to individual readers on request with the consent of the institutional ethics committees where the study was conducted.