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  • 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*** 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).

  • 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.

    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.

  • 15Songklanagarind Journal of NursingVol. 34, Supplement, January - April 2014

    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 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

    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 que