12 Songklanagarind Journal of Nursing
Vol. 34, Supplement, January - April 2014
The effect of self-management with family
participation on medication adherence among
patients with schizophrenia in Indonesia:
A pilot study
Sri Padma Sari*, Wandee Suttharangsee**, Weena Chanchong***
Purpose: Medication adherence is essential for schizophrenia patients to
prevent relapse and re-hospitalization. This study showed that self-management
can enhance medication adherence among patients with schizophrenia. In addition,
the role of family is very important for treating schizophrenic patients. This study
aimed to examine the effect of self-management with family participation on
medication adherence behaviors and attitude toward medication among patients
Methods: Twelve patients diagnosed with schizophrenia and their families
were assigned into control and experimental groups. Self-management with family
participation is a one-month program which involved patients and their families
to perform self-management method and included education and counseling
sessions with follow up using telephone and face-to-face meetings every week. The
pretest and posttest data were collected using the medication adherence behavior
questionnaire and Drug Attitude Inventory (DAI-30 items). Mann-Whitney U test
was used to determine the difference between the two groups.
Results: The results showed that subjects receiving self-management with
family participation reported significant improvement in medication adherence
behavior (U = 2, p < .05, p = .01) and positive attitude toward medication (U = 3,
p < .05, p = .02) than those receiving the usual care.
Conclusion: This study revealed that self-management with family
participation could enhance medication adherence behaviors and attitude toward
medication among patients with schizophrenia.
Keywords: schizophrenia; medication adherence; self-management; family
* Student, Master of Nursing Science (International Program), Faculty of Nursing, Prince of Songkla
** Associate Professor, Faculty of Nursing, Prince of Songkla University, Thailand.
*** Lecturer, Faculty of Nursing, Prince of Songkla University, Thailand.
13Songklanagarind Journal of NursingVol. 34, Supplement, January - April 2014
Schizophrenia is a common mental illness with high prevalence around
the world. It is a serious mental disorder characterized by impairments in
thought process that influence their behaviors (Thorson, Matson, Rojahn &
Dixon, 2008). Presently, pharmacotherapy is central in treating patients with
psychotic disorder, including schizophrenia (Shon & Park, 2002). However,
many people with schizophrenia do not comply with taking their medication.
In schizophrenia, non-adherence is a major issue since it has several
impacts such as relapse, hospitalization, difficulty in achieving remission,
suicide attempt and clinical burden and cost (Patel & David, 2007). Several
factors are identified as influencing medication adherence among schizophrenia
patients and the important one is attitude towards medication. Several studies
revealed that antipsychotic side effects can influence patient’s attitude and lead to
medication adherence (Mutsatsa et al., 2003; Rungruangsiripan, Sitthimongkol,
Maneesriwongul, Talley & Vorapongsathorn, 2011).
Self-management is one method that help patients to be able to manage
their chronic condition. A meta-analysis study found that patient-tailoring strategy
can enhance medication compliance in patients with schizophrenia (Barkhof, Meijer,
Sonneville, Linszen & Haan, 2012). It is based on principles of learning for
behavior change and self-management skills. It contributes to several significant
outcomes for schizophrenia patients such as managing their symptoms, adhering
to medication and having a sense of well-being or quality of life.
Self-management also needs to occur in conjunction with family (Wilkinson
& Whitehead, 2009). Meta-analysis study showed that educational programs
which included family members have better outcomes in reducing symptoms and
preventing relapse than if given only for patients (Lincoln, Wilhelm & Nestoriuc,
2007). Therefore, educating both schizophrenia patients and their family is needed
in managing medication.
In Indonesia, the number of relapse on schizophrenia patients was reported.
The number of relapsed patients had a significant correlation with non-adherence
with medication. The common problems of non-adherence to medication among
schizophrenia patients in Indonesia were socio-economic, attitudes, memory, and
family (Tarleni, 2009). The role of family is important in patient’s medication
adherence because schizophrenia patients usually do not have knowledge in taking
medication. The family need to remind and assist the patient to take the medication
continuously (Tarleni, 2009).
14 Songklanagarind Journal of Nursing
Vol. 34, Supplement, January - April 2014
Self-management has been reported very beneficial for patients with
chronic illnesses including schizophrenia. In Indonesia, studies were conducted
with other chronic diseases such as diabetes and hypertension. Therefore,
this study proposed to examine the effect of self-management with family
participation on medication adherence among patients with schizophrenia.
The purpose of this study was to compare medication adherence and
attitude toward medication of schizophrenia patients receiving self-management
with family participation and those receiving the usual care.
Sample and setting
The subjects in this study were outpatients who had been diagnosed with
schizophrenia based on ICD-10 and their family. The inclusion criteria were
including (1) age 18-60 years old, (2) being clinically stable (BPRS < 36), (3) able
to communicate verbally, (4) can be contacted by phone, (5) subject consent to
participate in the study and (6) have family member or relative who can be involved
in the program. The researcher excluded patients who have (1) severe complications
that may cause them unable to participate in the study, (2) hospitalized, or (3)
comorbid organic disorder/ disability, depressive disorder, substance dependence
and cognition problem. The inclusion criteria of family members were (1)
spouse, parent, sibling or other family member, (2) responsible for caring for the
schizophrenia patient for at least six months, (3) living together with the patient,
(4) be able to communicate verbally and (5) willing to participate in the study. This
study was conducted in the patient’s home.
The researcher got patient data from mental health community hospital and
a total of 18 were assessed for eligibility after obtaining approval from the Ethics
Committee of Faculty of Nursing, Prince of Songkla University and community
local health department where the study took place. Six patients were excluded
because most of them (5 patients) had unstable condition and 1 patient did not want
to join the program. Twelve patients met the inclusion criteria and participated in
this study after the researcher obtained written informed consent from patients and
their family. The patients and their family were randomized. There were 6 patients
and their family in the experimental group and 6 patients and their family in the
15Songklanagarind Journal of NursingVol. 34, Supplement, January - April 2014
The self-management with family participation study was a one-month
program based on self-management method by Kanfer and Gaelick-Buys (1991)
which involves the patient and his/her family performing self-monitoring, self-
evaluation and self-reinforcement (Kanfer & Gaelick-Buys, 1991). This program
assisted the patient and family to reflect on patient’s behavior regarding medica-
tion management, evaluate patient’s behavior, assist patient to develop goal and
action plan and provide self-reinforcement. The program was conducted weekly
and using telephone and face-to-face follow up. The description of the program is
included in Table 1.
The description of self-management with family participation program
Week Content Nurse activities
16 Songklanagarind Journal of Nursing
Vol. 34, Supplement, January - April 2014
The measurements in this study were as follows:
Demographic Data Questionnaire (DDQ) consisted general data for patients,
clinical information (age of onset, length of illness, number of hospitalizations,
type of medication, barriers and side effect, BPRS score, and insight) and general
data on family.
Brief Psychiatric Rating Scale (BPRS) is a widely used instrument for
assessing the positive, negative and affective symptoms of psychotic people
especially schizophrenia. It consists of 18 symptoms, with scores ranging from 1
(not present) to 7 (extremely severe). The total score is a sum score from 18 items
with higher total scores indicating severe problems.
Beck Cognitive Insight Scale (BCIS) was used to measure cognitive insight.
It is a 15-item self-report instrument with two subscales, self-reflectiveness and
self-certainty. Answers are givenas a Likert scale from 0 (do not agree at all) to
3 (agree completely). The total score is self-reflectiveness minus self-certainty.
Lower total score means poorer cognitive insight.
Prior Knowledge Regarding Medication Questionnaire consisted of 10