The effect of self-management with family participation on ... › journal › file › 96file2733.pdfpatients with schizophrenia in Indonesia: A pilot study Sri Padma Sari*, Wandee

12 Songklanagarind Journal of NursingVol. 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***

Abstract

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 with schizophrenia.

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 participation

* Student, Master of Nursing Science (International Program), Faculty of Nursing, Prince of Songkla University, Thailand** 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

Introduction

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).


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.

Purpose

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.

Methods

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.

Recruiting process 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 control group.


Intervention 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.

Table 1The description of self-management with family participation program

Week Content Nurse activities


Measurements 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 questions used to assess the subject’s prior knowledge on medication. It was developed by the researcher and the results of this questionnaire are used to guide the researcher in designing the content of the educational session. The questionnaire has 10 items with true/false answers. Possibles score range from 0 to 10, with higher scores indicating better prior knowledge.

Medication Adherence Behavior Questionnaire (MABQ) measures medication adherence behavior and was developed by researcher. It has 10 items using a Likert-type rating scale (4 = all the time, 3 = usually, 2 = sometimes, 1 = never). Total scores range from 10 to 40. Higher scores indicate higher medication adherence behavior.

Drug Attitude Inventory (DAI) is a self-reported questionnaire that evaluates subjective affect of antipsychotic drugs among schizophrenia patients. It was developed by Hogan et al. The internal consistency was .93 and test-retest reliability was .82 (Sajatovic, Velligan, Weiden, Valenstein & Ogedegbe, 2010). The item has 30 items with true and false answers (+1 and -1). The scale has 15 items that are scored as true and 15 items that are scored as false. Correct answers are scored as +1 and incorrect answers are scored as -1. The final score is the sum of the total of pluses and minuses. The positive total score indicates positive subjective responses.


Validity of the instruments The content validity of the instruments including intervention program, teaching plan and booklet, prior knowledge medication questionnaire and medication adherence behavior questionnaire were validated by three experts; two lecturers from the Faculty of Nursing, PSU, Thailand and one lecturer from Faculty of Nursing, Indonesia University. The researcher modified the instrument based on recommendations from the experts. All instruments had good content validity ( .9 - 1.0).

Translation of the instruments DAI and BCIS were translated using back-translation.

Reliability The instruments of the prior knowledge to medication, MABQ, and Indonesia version of BCIS and DAI were tested with 20 outpatients with schizophrenia. The Chronbach’s alpha of the instruments showed low reliability. Therefore, the researcher tested those instruments with 20 outpatients with schizophrenia by using test-retest reliability with the result were the prior knowledge to medication = .71, MABQ = .78, BCIS = .74 and DAI = .88.

Data analysis The data were analysed using a statistical program. The demographic data, patient clinical information and care giver information were analyzed and described in frequency, mean and standard deviation. Chi-square, the Fisher’s exact test and Mann-Whitney U test were applied to test the difference in demographic characteristics and mean scores of medication adherence behavior and attitude toward medication between the experimental group and control group.

Results

The results of this study showed that the two groups (6 subjects in both experimental and control groups) were not significantly different in patients characteristics (Table 2). Similarly, the results revealed that there were no significant differences in caregivers characteristics (Table 3).

Table 2Frequencies of patients characteristics of the experimental group and control group (N=12)


Table 2 (continue)


Table 3Frequencies of caregivers characteristics of the experimental group and control group (N=12)

Table 2 (continue)


This study also revealed that knowledge regarding medication, medication adherence behavior and attitude toward medication for both groups before the intervention were not significantly different (Table 4).

After receiving self-management with family participation, subjects in the experimental group reported significant improvement on medication adherence behavior (U = 2, p = .01) and a positive attitude toward medication (U = 3, p = .02) as compared with the control group (Table 5).

Table 4Comparison of knowledge regarding medication, medication adherence behavior and attitude toward medication between two groups before intervention

Table 5Comparison of medication adherence behavior and attitude toward medication between two groups after intervention

Discussion

Self-management is an individual’s ability to manage the symptoms, medication and the consequent condition of the illness which needs to be done in conjunction with family, community and health care professionals (Wilkinson & Whitehead, 2009). The self-management program is associated with many outcomes, such as increased use of medication, self-efficacy, self-management behavior, and enhancing health behavior change (Richard & Shea, 2011; Ryan & Sawin, 2009). The present study revealed that subjects receiving self-management with family participation had higher medication adherence behavior and attitude toward medication than subjects in the control group. There are several reasons underpinning the positive outcomes of this study.


This study used patient-tailoring in the intervention. Self-tailoring is based on principles of learning for behavior change and self-management skills as well as decision-making and problem solving skills which are part of the self-management program (Lorig & Holman, 2003). The findings in this study was consistent with other studies which found that patient-tailoring can enhance medication compliance in schizophrenia patients (Barkhof et al., 2012; Hudson, Owen, Thrush, Armitage & Thapa, 2008).

This present study involved family in the intervention (family participation). In this study, family participated in the self-management process: self-monitoring, self-evaluation and self-reinforcement because self-management not only requiresindividual’s ability but also needs his/her family to control health condition (Wilkinson & Whitehead, 2009; Richard & Shea, 2011). The patient needs support from the environment to accomplish self-management tasks (Kanfer & Gaelick- Buys, 1991). In patient’s self-management, the role of family is to facilitate, remind and motivate patient to perform self-management tasks, to be a partner in problem solving and decision making and also help the patient to cope with emotional stress because of having chronic illness (Rosland, 2009). Studies showed that family support can influence medication adherence among schizophrenia patients. The findings of this study were consistent with previous studies involving family member or patients care givers in the intervention which had significant improvement in positive attitude toward medication (Chaiyajan, Sitthimongkol, Yuttatri & Klainin, 2009). and improved in adherence to medication (Shon & Park, 2002; Chan, Yip, Tso, Cheng & Tame, 2009).

The self-management method was used in this study involved three processes: self-monitoring or self-observation, self-evaluation and self-reinforcement. The researcher assisted the patients and families to monitor the patient’s behavior in taking medication. Then, they were assisted to decide whether their current behavior congruent with ideal behavior or not after giving the educational session. Then the patients were assisted to set the goal, action plan and to do self-reinforcement when they can achieve their goal. All of these processes were based on self-management method (Kanfer & Gaelick-Buys, 1991).

Giving education about disease and treatment was also included in this study since it is one of important factor to medication adherence. This study provided educational and discussion sessions regarding the disease and medication for both patients and their family. The knowledge about illness and medication may help patients and family to understand how medication can control the symptoms and behaviors thus changing their attitude and improving their adherence to medi-cation. This findings was consistent with other studies providing psycho-education intervention showed significant effect on medication adherent (Shon & Park, 2002, Chan et al., 2009).


Follow-up session by phone call and face-to-face meetings was also important for achieving the outcome. The researcher evaluated the implementation of goals, action plan and self-reward by phone call follow up at the second and third week and face-to-face follow up at the fourth week. The researcher also discussed factors/ barriers identified each week and help them to find alternative strategies to overcome them. Studies have shown that motivational interviewing has had little impact on medication adherence because of lack of monitoring during the intervention (Drymalski & Campbell, 2009). Therefore, follow up is very important to monitor the patient’s condition after the intervention. Other studies also showed significant effects on medication adherence when using follow up (Shon & Park, 2002; Chan et al., 2009).

However, there were some limitations in this study. This study conducted in the community where the subject in the experimental and control group live in the same area and there may have been interaction between the subjects. The generalization of the findings of this study may be limited by the small number of patients and the short-term of follow up. Therefore, further study with longer follow up and a different setting is needed.

Conclusion

In conclusion, this study was a quasi-experimental study that was undertaken to evaluate the effectiveness of self-management with family participation thus adding to our knowledge the impact of this intervention. These findings showed that self-management with family participation had positive influence on medication adherence behavior and attitude toward medication on schizophrenia patients.

Implications

This study provides evidence that self-management with family participation may be essential to enhance medication adherence behavior and attitude toward medication. The program contains clear intervention guideline and methods to be applied by nurses to promote medication adherence and could be used for nurses either in the hospital or community and also health volunteers. This program may be considered by health policymakers in increasing the quality of care to schizophrenia patients.

References

Barkhof, E., Meijer, C. J., Sonneville, L. M. J., Linszen, D. H., & Haan, L. (2012). Interventions to improve adherence to antipsychotic medication in patients with schizophrenia: A review of the past decade. European Psychiatry, 27, 9–18.


Chaiyajan, W., Sitthimongkol, P., Yuttatri, P., & Klainin, P. (2009). Effects of psychoeducational Program on Attitude toward Medication and Compliance with First Appointment after Discharge in Schizophrenic Patients. Journal of Nursing Science, 27(3), 73-81.Chan, S. W., Yip, B., Tso, S., Cheng, B., & Tame, W. (2009). Evaluation of a psycho education program for Chinese clients with schizophrenia and their family caregivers. Patient Education and Counseling, 75, 67–76. Hudson, T. J., Owen, R. R., Thrush, C. R., Armitage, T. L., & Thapa, P. (2008). Guideline implementation and patient-tailoring strategies to improve medication adherence in Schizophrenia. Journal Clinical Psychiatry, 69, 74-80. Kanfer, F. H., & Gaelick-Buys, L. (1991). Self-management methods. In F. H. Kanfer., & A. P. Goldstein (Eds.). Helping people change: A textbook of methods (4th ed., pp. 305-359). New York: Pergamon.Lorig, K. R., & Holman, H. R. (2003). Self-management education: History, definition, outcomes and mechanism. The Society of Behavioral Medicine, 26(1), 1–7.Lincoln, T. M., Wilhelm, K., & Nestoriuc. (2007). Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: A meta-analysis. Schizophrenia Research, 96, 232–245.Mutsatsa, S. H., Joyce, E. M., Hutton, S. B., Webb, E., Gibbins, H., Paul, S., & Barnes, T. R. E. (2003). Clinical correlates of early medication adherence: West London first episode schizophrenia study. Acta Psychiatrica Scandinavica, 108, 439-446.Patel, M. X., & David, A. S. (2007). Medication adherence: Predictive factors and enhancement strategies. Psychiatry, 6, 357-361.Richard, A. A., & Shea, K. (2011). Delineation of self-care and associated concepts. Journal of Nursing Scholarship, 43, 255-264.Rosland, A-M. (2009). Sharing the care: The role of family in chronic illness. California Health Care Foundation, 1-27.Rungruangsiripan, M., Sitthimongkol, Y., Maneesriwongul, W., Talley, S., & Vorapongsathorn, T. (2011). Medicating role of illness representation among social support, therapeutic alliance, experience of medication side effects and medication adherence in persons with schizophrenia. Archives of Psychiatric Nursing, 25, 269-283.Ryan, P., & Sawin, K. J. (2009). The individual and family self-management theory: background and perspective on context, process and outcomes. Nursing Outlook, 57, 217-225.Shon, K., & Park, S. (2002). Medication and symptom management education program for rehabilitation of psychiatric patients in Korea: The effect of promoting schedule on self-efficacy theory. Yonsei Medical Journal, 43, 579-589.


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The effect of self-management with family participation on ... › journal › file › 96file2733.pdfpatients with schizophrenia in Indonesia: A pilot study Sri Padma Sari*, Wandee