Assessment of the quality of medical services to relatives of the mentally ill who are in inpatient treatment

The mental state of the mentally ill is one of the most important factors in the treatment of the patient by a medical professional. But aggression, high-pitched communication, indifference of a doctor or health care worker can negatively affect the outcome of treatment and recovery of a patient with mental and behavioral disorders. The problem of modern medical deontology in Ukraine is the stigmatization of health workers to patients with mental disorders, which lead to self-stigmatization of both patients and their families. The purpose of the study is to enable the relatives of mentally ill people undergoing long-term inpatient treatment, to determine the quality of medical services in a psychoneurological hospital, to identify ethical and deontological shortcomings in the doctor's relationship with relatives of mentally ill person, to determine the level of self-stigmatization in relatives of the patient by medical staff. The analysis of domestic and foreign scientific sources, bibliosemantic, analytical and statistical research methods were used in the work. A questionnaire was conducted (using a specially designed questionnaire) with elements of interviews of 92 respondents (relatives of mentally ill patients who were treated at a psychoneurological hospital in Vinnytsia). The results were processed using the licensed standardized package "Statistica 6.1". The need to comply with state building codes for health care facilities in accordance with European requirements has been proven. This will eliminate the feeling of hopelessness during hospitalization in public psychoneurological hospitals, which are a great trauma for relatives of patients. It has been shown that in order to prevent stigmatization of relatives of patients in psychoneurological hospitals, it is necessary to conduct trainings and interviews after training, which will determine the degree of stigmatization and subsequent preventive measures. It is shown that for relatives of mentally ill on the basis of psychoneurological hospitals it is necessary to equip rooms for psychodiagnostics and further psychocorrection. Development of affordable correctional programs for relatives of patients will reduce maladaptation and improve life satisfaction.


Introduction
The rapid development of modern technologies in the medical field significantly increases the effectiveness of diagnosis and treatment of patients in European countries. Unfortunately, in Ukraine, the constant, total underfunding of the health care sector has led to the neglected material and technical and sanitary and hygienic condition in public health care facilities, namely: extortion of patients; obsolete equipment, furniture and beds; bed linen from home; personal hygiene products and medicines for patients' money; insufficient disinfectants, etc. The premises of the health care facilities are in a terrible state of emergency and need major repairs. There is a growing trend of nontransparent procurement and use of medicines. Work on any preventive measures with the mentally ill has been suspended and, worst of all, the violation of the rules of professional ethics and the basics of deontological culture of medical staff in communication with the mentally ill, relatives of patients, attitude (stigmatization) of medical

BIOMEDICAL AND BIOSOCIAL ANTHROPOLOGY
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However, ethical and deontological issues, namely the concept of "deontological culture", are ignored and do not find a place in the hearts of medical staff who work with the mentally ill and constantly communicate with their relatives or guardians. Every medical professional should have a basic understanding of the origins of medical deontology in order not to indulge in immoral things with patients, and especially with the mentally ill. Deontology is a science that studies the rules and norms of the duty of a specialist in the field of his professional activity. The term "deontology" was introduced into scientific circulation at the beginning of the nineteenth century by the English philosopher and jurist Jeremiah Bentham (1748Bentham ( -1832, to define the science of the professional duty of man [2,10].
Summarizing the retrospective approaches and scientific statements of prominent scientists on the study of medical ethics and deontology, we recommend considering "deontological culture" as one of the most important components of professional culture and characterize it as a set of spiritual, intellectual and intellectual, which will help determine the significance and specificity of their professional activities [21].
Thus, the reflection of deontological requirements, professional norms in the mind of a medical professional will allow him to more fully and adequately perceive professional reality, navigate in it, develop strategy and tactics, goals and specific plans of professional activity, and recognition and acceptance of these norms as basic principles. professional duty will help him to form a proper attitude to the chosen profession and professional activity in general.
Under no circumstances should not patients' rights to emergency, highly qualified medical care be fully violated to all those who need it, regardless of age, social status, religion or race; humane treatment of the patient, and especially to patients with severe, incurable diseases or mental disorders; observance of confidentiality and medical secrecy as specified in the International Code of Medical Ethics "Geneva Declaration" adopted in 1949 [23].
Another problem of modern medical deontology in Ukraine is the stigmatization of health workers to HIVinfected patients, tuberculosis patients, currently COVID-19 patients, and especially to patients with mental disorders and any mental health problems, which lead to selfstigmatization of both patients and their families, who are left alone in solving this problem.
In the EU countries, various measures have been introduced to stigmatize health workers in relation to patients, and measures are constantly taken to prevent and prevent such phenomena in society. The main principles in treatment in the EU are "restoration of human life", spiritual recovery of patients, reintegration into society and a full life. Forms for overcoming the stigma of health care workers in European countries are different, for example: training, coaching, psychological consultations with health care workers and relatives who care for relatives; persons caring for patients (for money or free of charge), etc. [12].
The Law of the Republic of Poland "On the Protection of Mental Health" ("Ustawa o ochronie zdrowia psychicznego"), which has been in force for 26 years (adopted on 19.08.1994) defines the term "mental health is the main personal good of a person, and protection the rights of persons with mental disorders are the duty of the state". This law regulates the rights of a psychiatric hospital patient who has the right to appoint an ombudsman, whose responsibilities include protecting the rights of patients with mental disorders in matters related to admission, treatment, conditions of stay and discharge from hospital, as well as access to medical care. documentation with the consent of the patient, guardian. Consultation, treatment of such patients is free, comprehensive (medical, social, legal) which is a great support for Polish citizens with mental disorders and the prospect of their socialization.
The purpose of the study is to enable the relatives of mentally ill people undergoing long-term inpatient treatment, to determine the quality of medical services in a psychoneurological hospital, to identify ethical and deontological shortcomings in the doctor's relationship with relatives of mentally ill, determine the level of selfstigmatization in relatives of the patient by medical staff.

Materials and methods
The analysis of domestic and foreign scientific sources, bibliosemantic, analytical and statistical research methods were used in the work. 92 respondents, relatives of the mentally ill, took part in the survey with elements of the interview. Patients with mental disorders were treated at the Vinnytsia Regional Clinical Psychoneurological Hospital named after Academician O. I. Yushchenko of the Vinnytsia Regional Council, of which men -29.3 % and women -70.7 %, (under the age of 20 -3.3 %, from 21 to 30 years -9.8 %, from 31 to 40 years -17.4 %, from 41 to 50 years -33.7 % and over 50 years -35.9 %). Respondents with basic secondary education -10.9 %, specialized secondary education -23.9 %, vocational education -30.4 %, higher education -34.8 % took part in the survey with elements of interviews. The survey was conducted using a specially designed questionnaire: "Method of determining the quality of medical care by relatives of a patient in a psychiatric hospital and the relationship "doctor-relative"", recognized as an innovation from 16.01.2020 and registered in the journal of innovation proposals National Pirogov Memorial Medical University, Vinnytsya for № 2 and "Method of determining the personal opinion of the patient's relatives about the payment of medical care in a psychiatric hospital" from 16.01.2020 and registered in the register of innovation proposals of National Pirogov Memorial Medical University, Vinnytsya for № 3.
The results of the questionnaire were processed using the licensed standardized package "Statistica 6.1".

Results
Conditions of patients' stay in psychiatric hospitals of Ukraine encourage patients and their relatives to seek medical help in psychiatric hospitals only in case of exacerbated diseases (crisis conditions): deterioration of health of the total number of respondents-68.5 %; reregistration of disability group for mental disorders -21.7 %; the psychogenic load of family and household nature -8.7 % (Table 1).
According to the survey of relatives of inpatients, 32.6 % of the total number of respondents applied to a psychiatric hospital without a referral (37.0 % of them were male relatives and 30.8 % were female relatives); according to the direction of the psychoneurologist of the polyclinic -27.2 % (29.2 % of them are female relatives and 22.2 % are male relatives); in the referral of a family doctor -22.8 % (of which 23.1 % -female relatives and 22.2 % -male relatives); 10.0 % of the total number of respondents (of whom 11.1 % were male relatives and 10.8 % were female relatives) were referred by a psychoneurological dispensary; an ambulance crew took 6.0 % of patients to a psychoneurological hospital on call of relatives (7.4 % of them were male relatives and 6.2 % were female relatives) (Fig. 1).
In the questionnaire to the question "How often do you meet with your relative's doctor?", the following answers were received from relatives of patients: every day when visiting their sick relative they talked to a doctor -8.7 % of the total number of respondents (of which 7.4 % -male relatives and 9.2 % -female relatives); twice a week talked to a doctor -32.6 % (of which 18.5 % -male relatives and 38.5 % -female relatives); once a week -42.4 % (of which 55.6 % were male relatives and 36.9 % were female relatives), talked to the doctor twice a month -9.8 % (of which 3.7 % -male relatives and 12.3 % -female relatives) and only 6.5 % of the total number of respondents (of whom 14.8 % -male relatives and 3.1 % -female relatives)communicated once a month due to the fact that they visited their sick relatives rarely because they get to hospital them more than three hours (Fig. 2).
In the questionnaire "How often do you visit your sick relative?", the following answers were received from relatives of patients: every day they visited their sick relative -28.3 % of the total number of respondents (of which 29.6 % -male relatives and 27.7 % -relatives-women); twice a week -33.7 % (of which 29.6 % were male relatives and 35.4 % were female relatives); once a week -25.0 %   (of which 25.9 % are male relatives and 24.6 % are female relatives), visited their sick relatives twice a month -6.5 % (of which 3.7 % -male relatives and 7.7 % -female relatives) and 6.5 % of the total number of respondents (of whom 11.2 % -male relatives and 4.6 % -female relatives)visited sick relatives once a month due to the fact that they get to the hospital more than three hours (Fig. 3).

Relatives of patients
According to the results of our research, we established the time spent by relatives waiting for a doctor to communicate about a relative. Of the total number of respondents -68.5 % of relatives of patients waited up to 30 minutes; 29.3 % -from 30 minutes to one hour; 2.2 %from one hour to two hours, while the doctors of the psychoneurological hospital are not urgent, emergency doctors. But the generally accepted ethical principles in the daily activities of a doctor are: trust, openness, the desire to be useful to the patient, to be able to put himself in the place of the patient, to look at the world through his eyes. All the variety of approaches to the cooperation of the doctor and the relative of the mentally ill should be manifested in emotional support, understanding, respect and compassion.
The doctor's respect for the patient's relative should be manifested in his recognition as an individual. It is necessary not only to write a long list of drugs, but also to listen to the person, the main thing -to show that his words are important to him, to recognize the significance of events that bother the patient's relative because he has no one to share with the "burden" he carries all life. Therefore, we also investigated how much time the doctor spent talking to a relative of the patient: up to 10 minutes the doctor talked about the patient from the total number of respondents -52.2 %; from 10 to 20 minutes -42.4 % and only -5.4 % of doctors talked from 20 to 30 minutes, from 30 minutes and more -there were no such doctors. According to the results of the survey, female relatives talked to doctors for the longest time, from 10 to 20 minutes -43.1 %, and among male relatives -40.7 %; only female relatives communicated from 20 to 30 minutes -7.7 %.
In analyzing the questionnaires, we found that 54.3 % of the total number of respondents agreed that they had enough time to resolve all issues with the attending physician about their relative, and 45.7 % of relatives did not have enough time. Therefore, 32.6 % of relatives out of the total number of respondents thought that the doctor did not fully understand the patient's problem. Doctors must honestly perform their professional duties and remember the words of the Oath of the Doctor of Ukraine: "I do not cure a disease, but a living person".
Research on the structure of difficulties that arise in families with mental disorders and faced by the family -is the financial cost of treatment in a psychoneurological hospital for the purchase of products -96.0 %, for drugs -85.3 %, for personal care hygiene -81.3 % and on the way to the hospital -68.0 % of the total number of respondents.
Relatives who took part in any programs on psychocorrectional and psycho-educational measures accounted for only 3.3 % of the total number of respondents, and the remaining 96.7 % did not take or did not know about such measures. We proposed a list of programs in which they would like to participate and get the following results ( Table 2).
According to the survey, it was found that 85.2 % of men who care for their sick wives need communication, support, participation in psycho-educational programs; 81.5 % of men want to participate in programs for the prevention of chronic fatigue syndrome; 66.7 % of men want to take part in programs for communication and understanding with a sick woman. Female relatives also most often choose such programs (see Table 2). In addition, in contrast to men, female relatives quite often (27.7 %) choose trainings on prevention of self-stigmatization (see Table 2).

Discussion
According to the results of the monitoring of the Ukrainian Helsinki Union in three regional psychoneurological hospitals (Mykolaiv, Poltava, Kherson) and according to its analytical report on human rights in 2015, the lack of material and technical and sanitary conditions of psychiatric facilities in Ukraine is practically repeated: patient privacy -we are talking about noncompliance with the area per patient (6 m2), but after the second stage of medical reform from April 1, 2020 in the field of psychiatry, after reducing inpatient care for patients  today this rule is met, but the following shortcomings remain: old furniture and bed linen; bathrooms and toilets are located away from the wards; bath day once a week, and only then patients receive clean linen; eating clearly on schedule; telephone use is limited, etc. [9]. For comparison, the psychoneurological hospital in Ząbki within the walls of former military barracks began operating in 1903 at the initiative of doctor and public figure Pelagia Poplawska, who received medical education in Switzerland and founded the Warsaw Society of Medical Care and Care for Mental and Nervous Diseases. In 2018, a modern complex of new buildings (Pas Projekt Archi Studio) was opened. The architects considered the needs of patients as much as possible: music therapy rooms, rehabilitation center, cafe, reading room, conference hall, winter hall, etc. (Fig. 4).
After deinstitutionalization in European countries during the reconstruction, construction of psychiatric health facilities, the following interior elements are observed, which take into account the average length of stay of patients, features of diagnoses, severity of diseases, age and degree of medical conditions, safety of patients and medical staff, convenience and the comfort of using its equipment, provide the conditions for patients to stay in a "typical living environment" to return the patient to normal life as soon as possible. Architects from European countries work closely with hospital staff, patient groups, interior designers and psychiatric hospital consultants [3,6].
In Ukraine, after the reform in the field of health care, the issue of the first diagnosis of patients with mental disorders, the issuance of prescriptions for psychotropic drugs, referral for inpatient treatment is entrusted to primary care physicians. As a result of insufficient psychiatric qualifications for a family doctor, there is a certain professional complexity. Therefore, very often family doctors turn to specialists (psychiatrists, neurologists of district or regional medical institutions) for help on the above specific issues.
Interpersonal relations between a doctor and a relative of a patient with mental disorders should be based on the principle of practical interaction and mutual assistance because trust as a moral and psychological trait determines the doctor's attitude to the patient. Trust is a necessary component in treatment and an integral part of communication between the doctor, the patient and his relatives. It helps to improve relationships and helps to achieve a successful therapeutic effect in the treatment process, which accelerates the patient's recovery, stimulates their interest in life and increases the emotional state of relatives who are constantly with aggressive, conflicted, unbalanced patients, long-term communication with which emotionally devastates them. However, patients with mental illness remember well the general aspects of communication with the doctor, attitude to him, when communicating patients assess the professionalism of the doctor and the degree of trust in him [13,15].
According to a survey of relatives of patients on the frequency of visits to the doctor and a survey of relatives of patients on the frequency of visits to their relatives in the hospital, we observe self-stigmatization, which manifests itself in "cornering" and "carrying the burden alone." This is typical only for our country, which is considered to be a country with a low level of quality of life.
The Human Development Index in Ukraine increased from 0.705 to 0.750, but the growth rate of the consolidated budget expenditures on health care to gross domestic product compared to 1995/2015, the total amount of expenditures decreased by 25.0 % (so in 2013 it was -12.2 %, in 2016-2017 -4.2 % and in 2018 -2.5 % of gross domestic product) and therefore the quality of life of the population of Ukraine is lower than the standards set by the United Nations [4,5,7].
Today's stigmatization depends on the level of solidarity, integration, and humanity of society. Characteristic features of our society in relation to the mentally ill and their relatives are the following: • social contempt, mistrust, prejudice and fear, which leads to self-stigmatization of relatives; • dissatisfaction with their sick relatives, shame and pain; • lack of information about the course of the disease and limited or complete lack of knowledge about how to behave with a sick relative; • hopelessness in hospitalization in state psychiatric hospitals, which is a great trauma for their sick relatives (life in a "cage" without hopes for the best and personal unrealization); • decreased self-esteem because long-term care of their sick relatives [1].
In European countries, constant attention is paid to stigmatization of patients with mental disorders, so such patients find support not only from government agencies (medical, social), but also from NGOs, various denominations, community volunteers and more. The main approaches to the mentally ill abroad use the following principles: balanced care, treatment and rehabilitation, which are the basis for a measured approach to health [17]. According to Nie J. B. et al. [14] in China, with the participation of 107 doctors and nurses, they examined medical professionalism through interviews. The analysis revealed distrust, escalation of conflicts, disputes between patients and their relatives and doctors. The vicious circle pointed not only to the crisis of the patient-physician relationship, but also to the crisis of medicine as a profession and institution, which seriously jeopardized the basic principle of medical professionalism that characterizes the traditional Chinese ideal of "medicine as an art of mankind".
According to the results of recent studies, the possibility of signs of somatic disease, anxiety and depression, as well as predictors of emotional burnout was established [8,19,22]. The study by Ruiz-Fern?ndez M. D. et al. [18] showed a direct relationship between the degree and severity of the disease in patients with mental disorders on the percentage of somatic diseases in healthy individuals who cared for these patients. Also, caregivers of patients with mild Alzheimer's disease were found to have 46.3 % of somatic diseases, and those who cared for patients with moderate Alzheimer's disease had 61.9 % of mental health disorders.
According to Skoda K. V. [20], women who cared for sick relatives with mental illness at the Kharkiv Regional Psychoneurological Dispensary from 2012 to 2016 were found to have: depressive syndrome in 64.5 % of wives and 74.0 % of mothers of mentally ill people; anxietydepressive syndrome in 80.1 % of wives and 70.8 % of mothers of mentally ill; vegetative-somatic complaints in 37.3 % of wives and 48.1 % of mothers of mentally ill; signs of anxiety-phobic syndrome in 21.7 % of wives and 11.0 % of mothers of mentally ill. Therefore, psychoneurological hospitals should not only treat patients in crisis, but also conduct psycho-correctional and psycho-educational activities for relatives of patients with mental disorders due to the fact that medical psychological centers for rehabilitation of relatives of patients have not yet been established, but there are only such centers for ATO/JFO soldiers in Ukraine.

Conclusions
1. State building codes "Health care facilities" must be implemented in accordance with European requirements, to avoid the feeling of hopelessness when hospitalized in public psychoneurological hospitals, which are a great trauma for patients and their relatives.
2. To prevent stigmatization of relatives of patients in psychoneurological hospitals there is need to conduct their training, post-training interviews to determine the degree of stigmatization and subsequent preventive measures.
3. For relatives of the mentally ill on the basis of psychoneurological hospitals it is necessary to equip rooms for psychodiagnostics and further psychocorrection.
4. It is necessary to develop and implement educational and psychological training in psychiatric hospitals, as well as the development of affordable correctional programs for relatives of the patient to reduce maladaptation and improve life satisfaction.