Psychosocial well-being needs of alcohol/drug sufferers and therapeutic architectural solutions in rehabilitation centre, Nigeria: a cross-sectional study

Bias control in research

Research bias can develop during the research process, from the initial planning stage, theory development, data collection and analysis. Therefore, for this study, the effort to control potential sources of bias included: the researchers created a thorough research plan, used an appropriate statistical method, defined a target population and a sampling frame, employed simple random sampling for data collection, avoided convenience sampling, accounted for dropouts or missing data, obtained complete data, avoided generalisation, placed interview or survey topics into separate categories, created data analyst blinding, intention-to-treat analysis, maintained detailed records, completed reporting of all prespecified outcomes.

Introduction

The issues guiding research method selection included the topic investigated, the aim and objectives of the study, the research problem, and philosophy. Considering the above, the mixed-method research was determined to be most appropriate for this study. A mixed analysis involves using quantitative and qualitative data analysis techniques within the same study, as shown in Figure 1. A mixed method entails gathering and measuring data using parallel constructs for both data types, separately analysing both data types, and relating results through a side-by-side contrast in a discussion, converting the qualitative data set into quantitative scores, or equally displaying both data (Wisdom and Creswell, 2013). This method is adequate for understanding gaps between both data, reflecting participants’ views and promoting scholarly interaction by improving data validity and reliability. Since psychosocial well-being and therapeutic architectural solutions are multi-faceted issues, this article employed the sequential explanatory mixed-method approach to investigate the psychosocial well-being needs of users in an ADRC that requires TASs to promote a healing environment through design. The research philosophy is pragmatism which adopts both the positivist and interpretivist paradigms. The research strategy is a case study of four selected rehabilitation facilities in four cities (Lagos, Abuja, Port Harcourt, and Enugu) in Nigeria.

Figure 1. Structure of the research methodology.

Data collection

The authors extracted data from both primary and secondary sources. The primary data collection instruments consisted of survey questionnaires, an in-depth interview guide, an observation guide, and a checklist of TACs in a rehabilitation facility. The authors distributed 100 questionnaires among the users of four rehabilitation centres and industry specialists within the study areas, as shown in Table 1. Of the 100 questionnaires distributed, the researchers retrieved 77. The authors interviewed twelve selected sufferers and specialists from the four rehabilitation centres, and 3 interviewees from each of the rehabilitation facilities. The 12 participants were purposely selected from the four randomly selected rehabilitation facilities in the four busiest cities (Lagos, Abuja, Port-Harcourt and Enugu) across four (south-west, north-central, south-south and south-east) of the six geopolitical zones in Nigeria. The authors selected 3 out of the 12 participants from the four facilities. The three participants comprised: 1. the chief consultant, 2. a specialist nurse and 3. an alcohol drug sufferer (ADS). Therefore, three from ADRS-RC, Lagos, 3 from NLSHRC, Abuja, 3 from 180DC, Port Harcourt and 3 from NPHS, Enugu making a total of 12 participants. Also, the study used observation guides and checklists to record data on the available TACs in the four facilities that influence the patient’s psychosocial well-being. The authors used a semi-structured questionnaire to identify the psychosocial well-being needs (PWNs) of ADSs. The breakdown of the number of questionnaires administered and the responses are in Table 1. These questionnaires were designed to be completed by the patients (ADSs). Four research assistants undertook the data gathering process for twelve weeks during the morning and evening, during weekends (Fridays to Sundays). Data collection started on July 15 and ended on September 30, 2022.

According to Table 1, The National Psychiatric Hospital Service, Enugu had a 100% response rate, 180 Degrees Centre Agip Estate, Port-Harcourt, Rivers returned 75% of the questionnaires. The New Life Specialist Hospital and Rehabilitation Centre, Kurudu, Abuja, had a 60% response rate, and the A&D Referral Services - Rehabilitation Centre, Surulere, Lagos, returned only 50% of the questionnaires.

Socio-demographic analysis

Figure 2 shows the respondents’ percentile from the analysed data, of which 46.8% are male and 53.2% female. The respondents ranged across different age groups. Youths aged 18–29 years were the largest group, accounting for 70.1% of responses, whilst the smallest group was those under 18 years old (5.2%). The composition of rehabilitation centre users in Nigeria shows that 75.3% of respondents were medical staff, and 7.8% were missing (7.8% of the questionnaires from medical staff were not recovered). The remaining 16.9% were patients, particularly in the treatment planning and administration phase. Hence most of the responses obtained were from medical staff, validating the expert opinion required for the study. Of the respondents, 74.0% were single, 22.1% were married, 2.6% were widows, and 1.3% were divorced. Degree/Higher National Diploma (HND) holders made up 58.4% of the respondents, while 27.3% were postgraduate degree holders, 7.8% were National Certificate on Education- (NCE)/Ordinary National Diploma (OND) holders, 5.2% held other educational qualifications, and 1.3% had no formal education. The figure reveals that 49.4% were employed, 14.3% were self-employed, 18.2% were students, and 6.5% were retired. The 5,000–50,000 NGN income bracket was the most common (46.8% of respondents), 18.2% of participants fell within the 50,000–100,000 bracket, and 24.7% earnt between 100,000–200,000, while 6.5% of respondents fell within the 200,000–300,000 bracket, and 2.6% earnt between 300,000–500,000.

Figure 2. Stacked column chart on socio-demographic characteristics of the respondents.

Figure 3. Psychosocial well-being needs in an alcohol and drug rehabilitation centre.

Data analysis

The study used the explanatory sequential mixed approach in the analysis (i.e., collecting quantitative data first, then using qualitative data to explain the quantitative findings). The psychosocial well-being needs were analysed using descriptive statistical analysis of the 7-point Likert scale, and the result was illustrated in charts, screen plots, and graphs. The questionnaire survey employed four volunteering staff of the selected facilities. SPSS version 21 (RRID: SCR_002865) was used to code and analyse the data. The study ascertained the TACs of an ADRC through observation guides and checklists (checklist obtained from literature and personal experience and observation and adapted for this study. Following objective two of the study, which is to identify the therapeutic architectural components (TACs) of an ADRC, a TACs checklist would be vital in explaining and creating a prototype healing environment. The search for a TACs checklist led us to review the following literature (Davies, 2020; DuBose, MacAllister, Hadi, & Sakallaris, 2018; Iyendo, Uwajeh & Ikenna, 2016; Youssef, 2014; Thompson, Robinson, Dietrich, Farris & Sinclair, 1996).

Davies (2020) was very helpful in identifying the TACs in ADRC. Thompson et al. (1996) provided the table format used as a checklist. In the sample table, the researchers retained the three columns, but the researcher replaced the content in each column with the TACs and TASs items. The authors used Figure 2 content in Youssef (2014), Figures 1 and 2 contents in Iyendo, Uwajeh and Ikenna (2016), and Figure 4 content in DuBose, MacAllister, Hadi, and Sakallaris (2018).

Figure 4. TACs in a healing rehabilitation environment.

Based on the observations recorded in the four (4) rehabilitation facilities, column 3 of the table, the authors assessed the rehabilitation facilities on the scale of “A” – applicable; “NA” – not applicable; “SA” – slightly applicable.) to record the components in the selected rehabilitation facilities. In analysing the effect of TASs on the recovery process of substance abuse patients, content analysis on data collected through previous literature (books, academic journals, periodicals, and reports) and interviews with addiction therapists and specialist doctors from the four Nigerian case studies were carried out to ensure an optimum result.

Results of identifying the psychosocial well-being needs of alcohol and drug sufferers in the selected rehabilitation centres

In an interview, the Chief Consultant of the National Psychiatric Hospital Service, Enugu, said “psychosocial is a combination of psychological and social behaviour”. He further stated, “psychosocial studies the link between fears and how people relate to others in a social setting”. Thus psychosocial well-being encompasses the mental, emotional, social, and spiritual dimensions of being healthy. Accordingly, Ekhaese and Hussain (2022) believe that psychosocial well-being and substance abuse in the Sustainable Development Agenda is a historical turning point. Psychosocial well-being is a complex interaction between history, thoughts, and interpretations of the past and what it means to the present. However, identifying the PWNs of ADSs in the selected rehabilitation centres would require understanding PWNs. Below are the words of a specialist nurse in A&D Referral Services - Rehabilitation Centre, Surulere Lagos, “PWNs are any need essential to mental health and generated through interactions between the individual and the environment, such as the need for satisfaction, social approval, or justice. Consequently, psychosocial well-being needs to correlate with mental health disorders such as depression, worry, dementia, and hallucination”. She added, “psychosocial well-being needs are a dynamic experience that influences capability, social connections and support systems (including access to basic services), and cultural norms and value systems as validated by the psychosocial well-being as a conceptual framework”.

From the literature, psychosocial well-being needs (PWNs) are at the bottom level of Maslow’s hierarchy of needs. Psychosocial well-being integrates among others mental, social, emotional, spiritual and cultural determinants of health. According to Vansteenkiste, Ryan and Soenens (2020), there are 8 PWNs: 1. affiliation (relatedness), 2. power, 3. cognitive, 4. achievement, 5. autonomy, 6. competence, 7. meaning, and 8. closure.

Examples of PWNs in an ADRC include the need for symptom control, the need to maintain poise and self-esteem, to prevent rejection and isolation, to provide a comfortable and serene environment, to promote spiritual comfort, and the need for therapeutic communication. These needs require psychosocial well-being treatment and the appropriate setting. These include 1. assertive community treatment (ACT) such as a counselling room, treatment room, and community halls; 2. self-help and support groups, which can be in an indoor or outdoor space, including open spaces, parks and recreational spaces, multipurpose halls and conference rooms; 3. individual placement and support (IPS) supported employment in indoor and outdoor spaces (recovery room, worship spaces, and open spaces); 4. psychotherapy needs an indoor area such as a treatment room, sleeping room, common room/lounges, consultation rooms, lecture room, counselling room; 5. psychosocial rehabilitation in an indoor or outdoor space (meeting rooms, treatment spaces, open spaces, green gardens, and counselling room), 6. psychoeducation can be carried out in indoor or outdoor areas, such as lecture spaces, seminal rooms, multipurpose halls, workshop spaces, and open spaces for sports; 7. vocational rehabilitation (VR) requires indoor spaces such as training spaces, conference halls, seminar rooms, classrooms, and workshops; and 8. clubhouses need an indoor space (dance halls, lounges/bars and restaurants). Therefore, Olawande, Ajayi, Amoo and Iruonagbe (2019) agree that psychosocial interference and services for the reintegration of mentally ill patients into a rehabilitation centre are factors in relieving their caregivers’ burdens.

Result of examining the TACs of an ADRC

A psychosocial environment can be positive or negative. A positive psychosocial environment should be friendly, sweet, warm, caring, supporting, pleasing, and encouraging. In contrast, a negative one can be cold, uncaring, cluttered, harsh, punitive, aloof, sarcastic, and threatening. However, the study has made some adjustments to help keep the therapeutic experience positive for all categories of users, especially ADSs. The built environment represents a flexible feature, which supports mental health service delivery if we engage in intelligent and sensitive design practice, as shown in Figure 4.

The rehabilitation facility comprises three drivers: people, place, and process. For the therapeutic architect to create a design that is effective for people, they must understand user behaviour. It may require working with data (information) to actualise an efficient process and utilise sustainable built environment strategies to create a healthy place. However, between people (user-behaviour) and the built environment, there is the engagement of building applications through therapeutic architecture, which may affect the built environment’s impact on the people. The flow from the built environment (place) to the process needs design competence for green building technology, and the resultant effect is the impact of the built environment (place) on the process. Ultimately, the process for the people requires the execution of the healthcare procedure that can initiate the process impact on the people through engaging the healthcare requirements. Therefore, the knowledge and manipulation of this therapeutic concept, properties, practice, and components may produce a healing rehabilitation environment required for a smooth and comfortable recovery rate for ADSs in an ADRC.

Checklist of therapeutic architecture components/elements

From Table 2, nine TACs/elements were identified from the literature and interviewed experts/professionals in four selected rehabilitation centres in Nigeria. These nine elements comprise the checklist of TAC in healthcare facilities. These include:

Table 2. Checklist based on the therapeutic architecture components (TACs).

S/N	Therapeutic Architectural Components (TACs)	Therapeutic architectural solutions (TASs)	Level of applicability
			ADRS-RC	NLSHRC	180DC	NPHS
1.	Nature	1. Landscape and therapeutic garden 2. Access to views and nature (Views of nature scenes, indoor plants and contact with the outside environment)	NA	SA	SA	A
			NA	SA	SA	A
2	Colour	1. Colour and its impact on the rehabilitation environment	NA	A	A	A
3.	Healthy Buildings	1. Architectural design impact on rehabilitation centre users especially the alcohol and drug suffers 2. Room Layout (single rooms and a combination of multi-bedded and single assigned based on patients' preference 3. Home-like environment (designing of patients' lounge into a “healing sanctuary”	NA	SA	SA	A
			A	A	A	A
			NA	A	SA	A
4.	Healthy Lighting	1. Optimising environmental light and views in the rehabilitation environment 2. Easy-facing windows. 3. Large openable windows 4. Sensory stimulations - aroma, sound, and touch 5. Lighting hardware and software - low-cost, and user-friendly	NA	A	SA	A
			SA	A	A	A
			SA	A	A	A
			NA	SA	SA	A
			A	A	A	A
5.	Cultural Responsiveness	1. Access to social support 2. Communication of cultural identity occurs through language, texture, design, colour, expectations, norms, and values.	SA	A	A	A
			SA	A	A	A
6.	Physical Security	1. Environment providing deep attachment (providing personal reliable and intimate space, aesthetics experience, and secure atmosphere). 2. A threat assessment, a risk assessment, and a vulnerability assessment. 3. Intrusive and visually offensive solutions	NA	SA	SA	A
			SA	SA	SA	SA
			NA	SA	SA	SA
7.	Wayfinding and Privacy	1. Personal Control and Access to privacy 2. Environment to accommodate a declining visual, auditory and kinesthetic sense	SA	A	A	A
			NA	SA	SA	SA
8.	Materials	1. Rehabilitation centre auditory environment 2. Incorporating Musical Sounds for therapy 3. Cleanliness and Ease of Maintenance 4. Natural floor, walls and furniture materials	SA	A	SA	A
			NA	A	SA	A
			A	A	A	A
			A	A	A	A
9.	Positive Distraction - Furniture & Seating	1. Artwork and Healing Process 2. Presence of home mobility barriers 3. Prepared environment (elevated toilet seats, a soothing tabletop fountain, soft and age-appropriate furniture, uncluttered highways, large clock, calendars, handrails)	SA	A	A	A
			NA	SA	SA	SA
			SA	SA	A	A

The analysis shows the patients’ PWNs in a rehabilitation centre that requires therapeutic architecture solutions. The results reveal that the patient PWNs, that the selected rehabilitation caters for, may guide the research in determining what aspects need more focus. Using the TACs/elements as a benchmark, Table 2 presents elements assessed in the facility. For instance, in A&D Referral Services - Rehabilitation Centre (ADRS-RC), Surulere Lagos, the only applicable TACs are the ease of maintenance under materials. All of the other TACs are either not applicable or slightly applicable. This means that the ADRS-RC environment cannot support most PWNs, so there is a need for the centre to focus on all TACs. In New life Specialist Hospital and Rehabilitation Centre, Kurudu, Abuja (NLSHRC), all nine of the TACs were identified, only healthy lighting (sensory stimulation) and positive distraction (artwork and healing process and home mobility barriers) elements are not applicable, with the remaining seven TACs either applicable or slightly applicable. This means that in NLSHRC at Abuja, the PWNs of ADSs are adequately provided for. Consequently, the patients here are likely to enjoy a speedy recovery process. In 180 Degrees Centre Agip Estate, Port-Harcourt, Rivers (180DC) the situation is very similar to the NLSHRC at Abuja. Thus, the ADSs’ recovery rate here is also high. However, in the National Psychiatric Hospital Service, Enugu (NPHS), the facility meets all nine TACs in all the observation guide lists and inventories taken. The researchers recorded only applicable and slightly applicable. It is only in positive distraction that the researchers observed components that were considered not applicable. Thus, it is clear that the PWNs of ADSs are provided for, implying a high recovery rate in NPHS.

Result of analysing the effect of TACs on the recovery process of substance abuse patients

The study result analysed the effect of nine TACs on the recovery process of substance abuse patients using the survey results. Figure 5 indicates that 5.2% of the respondents considered the air quality within and around the rehabilitation facility poor, 24.7% as fair, 32.5% indicated average, 24.7% described it as good, 3.9% as very good and 9.1% as excellent. The survey results revealed that a larger percentage of people considered the air quality in the rehabilitation facility adequate. On water quality served within the rehabilitation facility, 6.5% of respondents considered it as very poor, 7.8% as poor, and 28.9% indicated that it was average. Meanwhile, 9.1% described it as good, 13.0% as very good, and 6.5% as excellent. The result requires more consideration given the water quality in rehabilitation centres today. Regarding the thermal comfort within the rehabilitation facility, 2.6% of respondents stated that it was very poor, 5.2% considered it poor, 32.5% as fair, and 35.1% as average. In contrast, 13.0% indicated that it was good, 5.2% very good, and 6.5% excellent. The quality of sleep while in the facility varied with 1.3% of respondents indicating that it was poor, 14.3% considered it fair, and 37.7% average. Conversely, 36.4% indicated that it was good, 2.6% stated that it was very good, and 7.8% considered it excellent. Thirteen per cent of respondents considered the facility poor in providing an intimate atmosphere, 9.1% stated that it was poor, 20.8% described it as average, 18.2% considered it good and 3.9% thought it was excellent. Furthermore, 5.2% of respondents described the security/sense of safety within the rehabilitation facility as very poor, 3.9% thought it was poor, 9.1% considered it fair, 31.2% indicated that it was average, 26.0% described it as good, 18.2% thought it was very good and 6.5% stated that it was excellent. The data on orderliness within the facility revealed that 1.3% of respondents considered it very poor, 13.0% poor, 14.3% fair, 26.0% indicated average, 33.8% good, 5.2% very good, and 6.5% excellent. This study indicates that orderliness is a concern in rehabilitation centres, therefore, should be a priority in the design.

Figure 5. (A) Clustered column chart on the quality of impact on the built environment on patient recovery rate. (B) Line chart on the quality of impact on the built environment on patient recovery rate.

Figure 6 indicates that 2.6% of respondents considered the facility’s sense of trust and acceptance as very poor, 3.9% as poor, 11.7% as fair, 55.8% as average, 13.0% as good, 5.2% as very good, and 7.8% indicated it as excellent. Similarly, 5.2% of respondents described the value of lasting friendships within the facility as very poor, 9.1% as poor, 24.7% as fair, 31.2% as average, 18.2% as good, 10.4% as very good, and 1.3% as excellent. The results indicate that rehabilitation facilities should provide more spaces and activities that foster social interaction and improve the value of lasting friendships as a TAC for patients’ healing process. The result on elements (available amenity) that meets patient’ status/needs reveal that 5.2% considered it as very poor, 9.1% as poor, 24.7% as fair, 31.2% as average, 18.2% as good, 10.4% as very good, and 1.3% as excellent. Likewise, 2.6% of respondents indicated that the facility poorly boosted their self-esteem psychologically. In contrast, 16.9% stated that its ability to boost their self-esteem was fair, 20.8% as average, 28.6% as good, 13.0% as very good, and 18.2% as excellent. For a sense of belongingness, 2.6% of respondents considered it very poor, 3.9% as poor, 23.4% as fair, 36.4% as average, 23.4% as good, 5.2% as very good, and 5.2% as excellent.

Figure 6. Stacked column on the impact of the human health environment on PWNs.

Figure 7 indicates that 5.2% of respondents strongly disagreed that the rehabilitation centres convey a sense of home. Meanwhile, 7.8% disagreed, 11.7% somewhat disagreed, 11.7% neither agreed nor disagreed, 23.4% somewhat agreed, 31.2% agreed, and 9.1% strongly agreed. This study indicated that most rehabilitation centres convey a sense of home to their users. On rehabilitation centres boosting social ties, relationships, and the ability to work in groups, 5.2% of respondents strongly disagreed, 5.2% disagreed, 20.8% somewhat disagreed, 14.3% neither disagreed nor agreed, 18.2% somewhat agreed, 28.6% agreed, and 7.8% strongly agreed. Regarding the sense of place and privacy, 2.6% of respondents strongly disagreed, 3.9% disagreed, 16.9% somewhat disagreed, 16.9% neither agreed nor disagreed, 23.4% somewhat agreed, 19.5% agreed, and 16.9% strongly agreed. The result indicates that most people considered rehabilitation centres today to convey a sense of place and privacy.

Figure 7. (A) Clustered bar chat on the impact of social connectedness between the built environment and patient well-being. (B) Scatter chart with smooth lines and markers on the impact of social connectedness between the built environment and patient well-being.

As shown in Figure 8, almost half of the respondents are satisfied with the treatment options in the rehabilitation centre (44.2%), 28.6% are neutral, and 26.0% as not satisfied with the treatment options in the rehabilitation centre.

Figure 8. Clustered bar chart on satisfaction with the treatment option in an ADRC.

Based on the importance of rehabilitation centres and their facilities in our communities today, 5.2% see their availability as very unimportant, while 3.9% consider them unimportant. Meanwhile, 14.3% are uncertain, 18.2% view them as important, and 57.1% describe them as very important, as shown in Figure 9. The summary of these findings proves that for 75.3% of rehabilitation centre users and experienced medical practitioners, the availability of rehabilitation centres is vital in our communities today.

Figure 9. Clustered bar chart on the importance of rehabilitation centres in a communities.

Ethics

The ethical approval was granted by the institutional review committee at Covenant University, Canaan Land, Nigeria known as Covenant University Health and Research Ethics Committee (CUHREC). The Certificate of Project Approval from the CUHREC (No.: CU/HREC/EE/162/22) was issued before the data collection. All the procedures performed in this study were under the 1964 Helsinki declaration and its later amendments. Written Informed consent was taken from all the respondents of the study.

Informed consent

Written informed consent was obtained from all the participants through specialist nurses in the facilities.