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How Japanese public health nurses manage neighbors’ complaints toward mentally ill persons with problematic behaviors?

Despite enhancing deinstitutionalization since 2004, Japanese people do not have an adequate understanding of mental illness. As a result, they had more negative attitudes toward mentally ill persons than people of other nations. In addition, mental health care services have remained insufficient in Japan, and their readmission rate is still high. Relapse causes problematic behaviors in mentally ill persons. Neighbors often complain to public health nurses about it. However, no previous study has focused on managing neighbors’ complaints toward mentally ill persons, and improving the identification of the early warning signs of relapse of them is urgently required. The purpose of this study was to explore how public health nurses managed neighbors’ complaints toward mentally ill persons with problematic behaviors. In this multiple-case study, 11 Japanese public health nurses were interviewed in 2013. Based on the neighbors’ complaints, the public health nurses understood the association between the problematic behaviors of the mentally ill persons and their probability of relapse, and assessed their ability to live independently in the community. The public health nurses were able to change the role of the neighbors from a complainer to a key communicator for the mentally ill persons. To prevent hospitalization of the mentally ill persons, public health nurses managed neighbors’ complaints as useful clues to identify their probability of relapse, as well as to reduce neighbors’ stigma toward them. The findings will help to reduce neighbors’ misunderstanding of their mental illness, the readmission rate and medical costs of them.

PHNs are responsible for providing direct care to MIPs, their families, and community people 17,18) . The national license system ensured quality of Japanese PHNs' practices 19) . This background will contribute to explore the tacit knowledge of a situation when managing to neighbors' complaints related to the problematic behaviors of MIPs. Therefore, the purpose of this study was to explore how PHNs manage neighbors' complaints toward MIPs with problematic behaviors in the community.

Methods 1 Design and method of case study
We used the case study design to analyze the empirical knowledge of PHNs acquired through their everyday practice 20,21). We utilized Yin's multiple-case study design, which enables the collection of more robust evidence than that from a single-case study 22) .
In addition to snowball sampling, potential participants were identified from the information from 2 representative Japanese public health nursing journals regarding PHNs' practices, and municipal PHNs with experience in managing to neighbors' complaints toward MIPs were recruited by phone or e-mail between January and September 2013. We first recruited 5 PHNs with experience in managing to neighbors' complaints toward patients with schizophrenia. For theoretical sampling, we asked 7 PHNs with experiences in managing to neighbors' complaints toward persons with substance abuse who had not received psychiatric treatment. Six of them agreed to participate in this study. The final total number of participants was 11.
To obtain results with high reliability and validity, data collection should be based on a case study protocol, and a case study database should be created to organize all the data. Data should be collected from multiple sources, such as interviews and documents 22) . Our data fitted these criteria, as they were based on written materials, notes from the interviews and other information. We developed a case study protocol that included interview questions and documents to support the interview data, community demographic statistics, and the mental health policy of the municipality. To make the interview questions, we conducted a semi-structured interview with 1 PHN who met the criteria of the study participant. In the open-ended questions, we focused on the PHNs' experiences of managing neighbors' com-plaints toward MIPs.
With the participants' consent, interviews were recorded by a researcher in a private counseling room of the municipalities, between March 10 and July 14, 2013. The average time of the interviews was 77.7 minutes (SD = 22.4). To reduce recall bias, PHNs talked about their experiences with confirming the information recorded by the researcher, which was written in chronological order.

Analysis
To increase the reliability and validity of the findings, the results of the cases are compared to detect common patterns, and the study participants review the draft of the case study 22) . We performed longitudinal analysis based on time-lines, and organized the information from the PHNs. After making a transcript of the digitally recorded interview, it was read carefully and summarized in 2-3 lines. The summaries were coded based on the questions: 'How did PHNs use neighbors' complaints against the MIPs with problematic behaviors?' and 'Why did PHNs choose this approach?' The codes were combined in chronological order, and the commonalities were classified as a category, and named to reflect that classification. After identifying the approaches used by the PHNs, they were used to identify commonalities between the 11 participants.
To ensure the validity of the results, we confirmed the accuracy of the participants' comments and our interpretation with each participant, as well as with an expert in qualitative research methodology, and refined the categories as appropriate.

Ethics
Ethical approval was obtained through the Institutional Review Board of Tokyo Medical University (No.1, 2013). All study participants signed informed consent before participating in this study.

Results 1 Characteristics of the study participants, neighbors, and MIPs
All PHNs were women and worked at public sectors in urban areas. Their average years of experience as a PHN was 16.9 years (SD = 6.8). Among the 11 MIPs, 5 had schizophrenia, 3 were of unknown diagnosis, and 1 each had an adjustment disorder, alcoholism, or substance abuse. The most common request of the neighbors was to hospitalize the MIPs for psychiatric treatment (Table 1).

Management of neighbors' complaints towards MIPs with problematic behaviors by PHNs to support their living in the community
We identified common 6 approaches of management of neighbors' complaints toward MIPs with problematic behaviors by the PHNs.

Understanding the association between the problematic behaviors of the MIPs reported by the neighbors and their probability of relapse
Neighbors complained about the MIPs with problematic behaviors living in their community by either phone or by visiting the public health center. They were angry and embarrassed about it. These complaints were important clues to identify MIPs in the community. PHNs learned the association between the problematic behaviors of the MIPs reported by the neighbors and early warning signs of relapse.
''If the neighbors had not contacted the PHN, we would not have known about the MIP living in the community. The neighbors' complaints were meaningful information. We could identify the MIP living alone with a risk of relapse.'' (Case 4) PHNs were concerned about the relationship of the neighbors and MIPs. In situations in which the neighbors and the MIPs had lived in the same community for many years and knew each other well, the neighbors often had some level of understanding of the MIP's disabilities and character. However, in cases in which the MIPs had lived in the community for only a short time, the neighbors tended to be less understanding. PHNs carefully assessed the past troubles among them.
''The neighbor said that the MIP went out to bars and joined community activities with neighbors. However, he became unable to care for himself because of his worsening condition. At first, the neighbors cleaned his room and served him meals with alcohol. Owing to poor sanitary conditions, the neighbors helped him to move from upstairs to downstairs. However, his room repeatedly became unsanitary.'' (Case 6) Furthermore, PHNs considered whether the problematic behaviors of the MIPs met the criteria of selfharm or assault. PHNs predicted the outcome of neglecting the neighbors' complaints and future situations that may occur in the community, to identify the seriousness of the MIPs' mental health condition.
''She spread garbage and spilled vinegar into the neighbors' houses. If we had ignored this problem, her problematic behavior would have escalated into serious conflicts with the neighbors.'' (Case 3)

Recognizing the necessity of reducing neighbors' stigma against MIPs and providing correct knowledge of mental illness to neighbors
Through consultations, PHNs gradually recognized that the neighbors' complaints were related to stigma toward mental illness. The neighbors requested for the PHNs to recommend the MIPs for psychiatric hospitalization. They were unaware of the trend of deinstitutionalization of MIPs. Some neighbors believed that MIPs spent their entire life in a psychiatric hospital. The PHNs tried to identify the neighbors' level of knowledge of mental illness and the reason why they had negative perspectives of MIPs.
''The neighbor said that the patient was discarding her excreta out of her front door since June, and said 'I cannot stand it anymore! You should involuntarily hospitalize her in a psychiatric ward. If you cannot force her into a psychiatric ward, I will start legal proceedings.''' (Case 7) PHNs have the responsibility to protect the rights of all community residents, and recognized the necessity to improve the neighbors' prejudices toward MIPs. To increase the neighbors' knowledge of mental illness, PHNs explained to them that problematic behaviors were caused by a worsening of the mental illness, that patients could not be involuntarily hospitalized in a psychiatric ward.
''I explained to the neighbors that there were several kinds of rules for the admission of MIPs to a psychiatric ward. The MIP and his/her family must agree to the hospitalization. Furthermore, the primary doctor has to recognize the need of psychiatric admission.'' (Case 10)

Collecting information about the MIPs and assessing their ability to live independently in the community
PHNs have no evidence of the MIPs' problematic behaviors other than the neighbors' complaints. The PHNs tried to collect information on the MIPs, such as past consultation records and the application form for psychiatric medical aid, as evidence of his/her mental illness, and the MIP's residence certificate as evidence of his/her residency in the community.
''According to the past consultation records, the police contacted the PHN regarding the MIP's problematic behaviors. His parents also consulted the PHN about his problematic behaviors in 2002.'' (Case 11) In a few cases, there was no evidence of mental illness other than the neighbors' complaints. Before contacting the individual, PHNs tried to collect information about their consultation history from the relevant departments, such as the police and welfare office.
''The policeman told me that the neighbors often called the police about the trouble between the MIP and them, and that the MIP had a history of psychiatric treatment.'' (Case 2) Through collecting information on the MIPs, PHNs tried to find evidence supporting the neighbors' complaints. To prevent hospitalization, PHNs also collected information about the MIPs' mental health condition and treatment status, and comprehensively assessed whether they could live independently in the community or not.
''She discontinued her psychiatric treatment, and her condition got worse. However, she continued living in the community.'' (Case 9)

Identifying key family members for the care of the MIPs and assessing their ability of problem solving
Through collecting information from relevant professionals, PHNs confirmed that the presence of key family members of the MIPs. This is because a large amount of family support is necessary to enable MIPs to continue living in the community. Among the 11 MIPs, 3 did not have any living family members. Therefore, the PHNs of 8 MIPs tried to clarify their family relationships. Family members of 4 MIPs did not want to become involved with the MIPs. The MIPs had repeatedly caused problems with their neighbors over the years, and their families had to support them, resulting in worsened family relations.
''He got into enormous debts and was persecuted by an insistent creditor. His wife committed suicide after suffering from his debts. His son and daughter have little contact with him. Although his son did not respond to our calls, his daughter understood his situation and tried to meet with him.'' (Case 6) In addition, health conditions of the family members and their abilities of problem solving varied greatly. Some parents of MIPs had declined cognitive function and lived in facilities for the elderly. They were unable to support the MIPs. PHNs encountered a difficulty in obtaining family support.
''His father could not understand my explanation about his son's worsening condition, because of his hearing impairment. The father could not support his son due to old age.'' (Case 8)

Building trustful relationships with the MIPs and their family without threatening their safety
As PHNs have the responsibility to support MIPs for long periods of time, building trustful relationships with them is important for providing adequate care. However, it is unknown whether the MIPs actually want to receive professional help. To be able to meet the MIPs without threatening their safety, PHNs would often write a letter to the MIPs stating their concern.
''I understood that he required long-term support. If I visited him without an appointment, he would appear scared. That is why I tried to send him a letter first.'' (Case 11) The MIPs and their families were uncomfortable with PHNs who suddenly visited them. PHNs understood their negative attitudes. If they wanted to reschedule the appointment, PHNs accepted their requests and carefully approached them to build a trustful relationship with them and to collect information about them.
''I visited her home and met her father. However, he gave me a pointblank refusal. He said to me 'What is the purpose of your visit?' I explained to him 'I want to talk to you about your daughter's health.' However, I was an unwanted guest for him. He wanted to end my home visit as soon as possible.'' (Case 1)

Consulting with mental health care professionals regarding how to support the MIPs and sharing information with neighbors to gain their support
Based on the collected information, PHNs assessed the conditions of the MIPs and whether they were capable of living independently in the community. PHNs discussed with the MIPs' primary doctor, psychiatrists, and related staffs about how to assess their conditions and to support their life in the community, as public servants. The continuation of medical treatment was a key to reduce the problematic behaviors of the MIPs. Of the 11 MIPs, only 2 continued their psychiatric treatment. To prevent hospitalization of the MIPs and to enable them to continue living in the community, PHNs discussed about the necessity of psychiatric treatment with the mental health care professionals.
''I received advice regarding my assessment from the contract psychiatrist. She said that the MIP who is at highest risk of becoming the target of neighbors are those with schizophrenia, because of her hallucinations and delusions of poisoning, and she is in the most need of psychiatric treatment.'' (Case 5) As the health conditions of the MIPs changed, PHNs had many discussions with professionals regarding their care. When MIPs did not require acute psychiatric care, the PHNs and relevant professionals monitored their health conditions.
In addition, PHNs thought that neighbors would continue to complain about the MIPs if they could not see an improvement in the care for the MIPs. Furthermore, PHNs thought that if neighbors complained about the MIPs again, it would give them another chance to understand the current condition of the MIPs. PHNs tried to share the information with the neighbors, to receive their support. The role of the neighbors changed from a complainer to a key communicator for the MIPs within the community.
''We routinely visited the home of the MIP because a neighbor repeatedly complained about the problematic behaviors of the MIP. I explained to the neighbor that we visit the MIP's home routinely, and that we also shared the information she gave us with the police. I appreciated receiving the neighbor's complaints because we could not monitor the MIP as constantly as she could.'' (Case 7)

Association between the purposes of the PHNs in caring for the MIPs and in managing neighbors' complaints toward MIPs with problematic behaviors
The 6 approaches which were used by PHNs for management of neighbors' complaints toward MIPs with problematic behaviors are shown in Fig. 1.
The approach used by PHNs to understand the association between the problematic behaviors of the MIPs reported by the neighbors and their probability of relapse was unknown to the neighbors. The PHNs recognized the importance of improving neighbors' stigma against MIPs, and of providing them with the correct knowledge of mental illness. This approach contributed to reduce the stigmatized attitude of the neighbors toward MIPs and to improve it. The vertical axis represents the purpose of managing to the neighbors' complaints about the PHNs' activities.
In parallel, the PHNs tried to detect the MIPs who required care at an early stage, and to gather evidence to confirm the relapse of mental illness based on neighbors' complaints. In addition, to prevent the hospitalization of MIPs, PHNs discussed with mental health care professionals about the care they required. The horizontal axis shows the purpose of the care for the MIPs in the use of each approach. Each approach contributed to detect of early warning signs of relapse, to prevent of the hospitalization of the MIPs, and to support their stable life in the community.
The diagonal line shows the boundary of care by PHNs for MIPs and their neighbors. The first and last categories were across this boundary because they were associated with care for both the neighbors and MIPs.

Discussion
To the best of our knowledge, this is the first study to explore how PHNs managed neighbors' complaints toward MIPs with problematic behaviors. The principal finding of this study was that PHNs managed neigh-bors' complaints toward MIPs as useful clues to identify the early warning signs of relapse and to reduce neighbors' stigmatized attitudes toward them. In addition, regardless of the varying levels of experience of the PHNs and the different nature of their situations, all PHNs used the same approaches. This is a new effective and efficient approaches of detecting the MIPs who need help at an early stage and for reducing the stigma towards MIPs. Our finding will also contribute to prevent hospitalization for the MIPs, to reduce their length of hospital stay, as well as medical cost. Furthermore, PHNs in charge of mental health care have high risk of burnout because of facing the dilemma between supporting MIPs' life and keeping community safety 23) . Managing neighbors' complaints toward MIPs will be the key to protecting MIPs' well-being and to keeping public good. Our finding will contribute to prevent burnout and turnover among PHNs.
We also found that the PHNs assessed the information of MIPs, identified key family members to care for the MIPs, and assessed their ability of problem solving. Our findings support a previous study which showed that PHNs utilized multiple sources of data for identifying an individual's health condition 18) . Additionally, in Japan, many families live with MIPs and play an important role in caring for them 24,13) . Previous studies showed that the level of caregiver burden is related to the severity of illness of the MIPs 25) . Our results sug-gested that the importance to develop more social resources for MIPs to keep a stable life in the community and to reduce family care burden.
Furthermore, the PHNs could change the role of the neighbors from a complainer to a key communicator for them. Previous study focused on professional care and did not mention about the neighbors' voices 26) . MIPs faced 2 main problems; one was managing their disorder and symptoms, and the other was facing misinterpretation of their mental illness by the public, resulting in stigma 27) . Our present findings should contribute to improving these 2 major problems at once, to develop a socially inclusive community based on managing the neighbors' complaints by PHNs in their daily practices. The results should also help novice PHNs to understand the role of PHNs who must protect the rights of people, whether or not they are mentally ill.
Limitations This study has 2 main limitations. First, the results represent the experiences of PHNs in Japan. The generalization of these results to other countries would be difficult. Second, the researcher could not access internal documents of the municipal public health centers for reasons of confidentiality. In the future, nation-wide studies should be performed to confirm the usefulness of neighbors' voices to identify early signs of relapse MIPs: mentally ill persons PHNs: public health nurses and to develop a socially inclusive community. Developing an educational program for PHNs to effectively manage neighbors' complaints for the care of MIPs is also required.
Conclusions Despite these limitations, this is the first study to explore how PHNs managed neighbors' complaint toward MIPs with problematic behaviors in the community. Our findings will be the key to promoting the deinstitutionalization of and to reduce public stigma toward MIPs.