School of Nursing, Peking Union Medical College, Beijing, China
School of Nursing, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
Correspondence: Professor David Arthur, School of Nursing, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. E-mail: hsarthur{at}inet.polyu.edu.hk
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To conduct a longitudinal experimental study examining the effect of patient and family education in a sample of Chinese people with schizophrenia.
Method A randomised controlled trial was conducted in a large hospital with a was conducted in a large hospital with a sample of 101 patients with schizophrenia and their families. Data were collected at admission and at discharge, and then at 3 and 9 months after discharge. The intervention group received family education, and data on their knowledge about schizophrenia, symptoms, functioning, psychosocial behaviour, relapse and medication adherence were collected and compared with the control group.
Results There was a significant improvement in knowledge about schizophrenia in the experimental group and a significant difference in symptom scores and functioning at 9 months after discharge. Patients who were nonadherent to medication regimens were more likely to relapse.
Conclusions Family education on schizophrenia by nurses in China was effective in improving knowledge and promoting improvement in patients symptoms.
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INTRODUCTION |
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Since the early observations by Brown et al (1958) that people with schizophrenia discharged to live in boarding-houses or with siblings fared better than those discharged to live with parents or spouses in terms of relapse, several landmark studies have demonstrated that there is now little doubt that family interventions in schizophrenia are effective in postponing psychotic relapse over periods of up to 2 years (Anderson & Reiss, 1982; Falloon et al, 1985; Leff et al, 1985; Hogarty et al, 1986; Tarrier et al, 1988; Pekkala & Merinder, 2003; Pharoah et al, 2003). Research on family management of schizophrenia is in its infancy in China, but several studies have focused on development of education programmes and choice of outcome measures (Xiong et al, 1994; Zhang et al, 1994, 1998, 2000). Briefly, all the studies were designed with control groups and used standard diagnostic criteria such as DSMIIIR (American Psychiatric Association, 1987), or the Chinese Classification of Mental Disorders (CCMDIIR) (Chinese Medical Association, 1995), which divides mental disorders into ten categories. These studies included either individual or group psychoeducation, often combined with antipsychotic drug treatment. There was marked reduction in relapse rates, rehospitalisation and the level of psychotic symptoms, and an enhancement of patients quality of life and social functioning, with an improvement in family relationships and social environment. The studies are not recent and none was conducted by nurses.
Our aim was to conduct a longitudinal experimental study that examined the effect of patient and family education on families knowledge about schizophrenia, and on patients symptoms, psychosocial functioning, adherence to medication regimens and relapse rates.
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METHOD |
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To avoid contamination between the two arms of the study, wards were selected rather than individuals. The hospital had ten wards that suited the inclusion criteria: eight general adult wards (four male wards and four female wards) were selected for the study, and by random assignment two male wards and two female wards were selected to be control wards and the other two male wards and two female wards to be experimental wards. When patients meeting the inclusion criteria were routinely admitted to the wards where the study was conducted, they and their families together were fully informed about the study and asked if they would agree to participate. One in five families (either patient or family members or both) refused to do so, and in these cases the patient was excluded from the study but remained in the ward. The purpose and the procedures of the study were described to those who agreed to take part, and their questions were answered. The rights of the participants were explained to them and their written consent was obtained.
Sample
Patients were included in the study on the basis of their
CCMDIIR diagnosis and two inclusion criteria: age 1665
years, and living with a family member at least 3 months prior to the current
hospital admission. Exclusion criteria were evidence of learning disability,
presence of known organic mental disorder and significant or habitual drug or
alcohol use.
According to the sample size estimate for differences in proportion with power of 0.80, and treatment group relapse rate around 12% and control group around 40% in previous studies (Birchwood & Spencer, 2000), the approximate sample size in each group should be 40. Finally, 101 patients with schizophrenia (and their families) were selected. There was no difference in the education level, working experience and professional position of physicians and nurses among the eight wards.
Outcome measures
Five outcome measures were used.
All the instruments have established reliability and validity and were selected carefully following review of their previous use. The Chinese versions of the BPRS, GAS and NOSIE measure psychotic symptoms, overall and psychosocial function of patients; they are reliable and valid, and have been widely used in China. The Chinese version of the KASI had rarely been used in mainland China, but its acceptable reliability and ease of administration and scoring led to its use in this study.
Following ethical approval from the university and hospital, a pilot study was conducted primarily to validate the intervention for use in the local culture and to assess the learning needs of patients and their families. The perceptions of patients families and nurses were assessed in the context of the international literature and related research to give validity to the intervention, the Comprehensive Patient/Family Education Guide (CP/FEG) (Li, 2003).
Procedure
The education programme commenced in hospital for both patients and their
families, but family members were able to choose whether to receive the
intervention in hospital or at home subsequent to the patients
discharge. Both the experimental group and the control group were rated on the
first four outcome measures on admission and at discharge, and then assessed
again on all five measures 3 months and 9 months after discharge. Most studies
have indicated that a programme that covers a 9-month to 12-month period
following hospital discharge is acceptable to both patients and their
relatives. In view of the evidence of relapse rate changes during the first 9
months after discharge, it was decided to adopt two assessment points, one
short-term (3 months after discharge) and one 9 months after discharge
(Leff et al, 1985;
Tarrier et al,
1988).
Intervention
The programme duration was 8 h with the patient and 36 h with the family in
hospital, and then 2 h per month for 3 months after discharge for patient and
family together. A nurse with experience in family intervention (L.Z.)
provided the intervention, with the aid of registered nurse research
assistants who had either a diploma or a degree and had worked in psychiatric
nursing for at least 10 years. The research assistants were given direct
supervision and 12 h training in the intervention, and to ensure consistency
were observed and critiqued in a pilot situation before the main study. The
control group received usual standard treatment and care, in which there was
no organised education programme, but patients and families could seek
information from staff, and educational pamphlets and materials were available
in a ward library. The intervention given to the experimental group was in
addition to the standard treatment and care received by the control group.
L.Z. and the research assistants were not masked to the participants
intervention status when completing the assessments.
In the pilot study a random sample of 15 head nurses were asked their opinions on what should be included in the programme, and 51 family members were interviewed to identify their understanding and learning needs. The responses were subjected to content analysis (Li, 2003). On the basis of the pilot study results and a synthesis of the major findings from international research in the area, our education programme was designed primarily to educate families and patients about schizophrenia and its treatment, and to teach skills to help patients and families cope more effectively, particularly with the disruptive consequences of the illness (Birchwood & Spencer, 2000). The intervention comprised five phases.
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RESULTS |
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Knowledge about schizophrenia |
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Brief Psychiatric Rating Scale
A t-test revealed no significant difference between the two groups
on the total BPRS score at admission, and both groups were therefore
considered compatible for the purposes of further inferential analysis. At
discharge and at 3 months after discharge ANCOVA revealed no significant
difference between the two groups on the total BPRS score. At 9 months after
discharge, however, there was a significantly lower score for the experimental
group on the BPRS. Interestingly, the mean scores for the somatic concern and
motor retardation items were also significantly higher in the experimental
group.
Repeated measures ANCOVA adjusted for baseline outcomes was calculated to compare the differences between the groups at the different time points. There were significant differences for both groups on the BPRS score between admission and before discharge, between admission and 3 months after discharge, and between admission and 9 months after discharge. Internal consistency was estimated by Cronbachs a at 0.7.
Global functioning and psychosocial behaviour
There was no significant difference for the GAS scores between the two
groups at admission and ANCOVA revealed no significant difference between the
two groups before discharge and at 3 months after after discharge, but there
was a significantly higher mean in the experimental group at 9 months after
discharge (Table 2). We used
ANCOVA to compare the mean scores between admission (baseline) and the three
assessment points. There were significant differences in the GAS mean scores
between admission and before discharge, between admission and 3 months after
discharge and between admission and 9 months after discharge for both the
experimental and control groups (Table
2). The scores of the experimental group continued to increase
from admission to discharge, whereas the highest score for the control group
was before discharge.
There was no significant difference for the NOSIE scores between the two groups at admission, and ANCOVA revealed no significant difference between the two groups at 3 months after discharge, but there was a significantly higher mean in the experimental group at discharge and at 9 months after discharge (Table 2). Scores for both groups were significantly different between admission (baseline) and the three time points. Internal consistency of the NOSIE was estimated by Cronbachs a at 0.65.
Relapse and medication adherence
Of the 89 people who completed the study, 4 were readmitted to hospital
within 3 months of their discharge, a further 16 were readmitted within 9
months and 4 relapsed according to the BPRS criteria within 9 months of their
discharge. There was no significant difference between the experimental and
control group in the number of people who relapsed (16% v. 37%),
using Fishers exact test. At 3 months after discharge, 91 participants
(excluding the 10 people who had withdrawn at that time) were asked whether
they were adhering to their medication regimen. Fishers exact test
revealed no significant difference in medication adherence between the
experimental group (30 adherent and 14 not adherent) and the control group (27
adherent and 20 not adherent).
To compare relapse and adherence after discharge, 89 patients (excluding the 12 who had withdrawn) were separated into medication adherent and not adherent groups. Fishers exact test revealed a significant correlation between medication adherence and relapse. Clearly, the patients who did not adhere to medication regimens were more likely to relapse (Table 3). No significant difference was found between male and female patient groups and relapse rate. The relapse rate for females was 31% (17/55) and for males 21% (7/34). Because the sample size is small, these are exploratory findings only and need to be treated with caution.
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DISCUSSION |
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Symptoms of patients
Our study confirmed that patient and family education in addition to
routine hospital treatment was as effective as the routine hospital treatment
alone for schizophrenia in the early admission period. Clearly, over the
period from admission to discharge, the medication regimens and other
treatments such as occupational and recreational treatment in the hospital
have a good effect on the symptoms. This period is one of marked improvement
as patients are medicated, relieved of stress and pressure and given
intensive treatment. Three months after discharge, BPRS scores
(including hostilesuspicious symptoms) in the experimental group were
significantly lower than in the control group. This interesting and reassuring
finding continued at 9 months after discharge, when thinking disturbance,
hostilesuspicious symptoms and the overall symptoms in the experimental
group were significantly lower than in the control group. This was consistent
with the findings of two other Chinese studies
(Xiong et al, 1994;
Zhang et al, 1994)
using the BPRS.
An interesting and unexpected finding was that the somatic concern of the experimental group was higher than that of the control group before discharge and at 3 and 9 months after discharge. Similar findings were not reported in other studies. The tendency of somatic presentation among Chinese patients, and the nurses and families tendency to reinforce these symptoms in people with mental disorders, has been frequently examined and discussed (Lin et al, 1995). These behaviours might reinforce the patients role and encourage somatic expression of symptoms, or patients might believe that the more intervention they received, the more severe or complex their symptoms were.
Psychosocial functioning of patients
The overall psychosocial functioning of patients in both groups was
significantly improved before discharge and at 3 months and 9 months after
discharge, compared with their function at admission. However, importantly
and in line with symptom improvement the overall functioning
of the experimental group kept improving, and at 9 months after discharge
there was a significant difference between the two groups on the GAS score.
These findings support those of Rund et al
(1994) and Barrowclough et
al (1999), but not those
of Merinder et al
(1999) in their community
study, and reinforced the findings of the Chinese studies
(Xiong et al, 1994;
Zhang et al, 1994,
1998;
Song et al, 1998),
particularly in terms of return to work.
The outcomes of symptoms and psychosocial functioning in this study demonstrated that the effect of the patient and family education programme may be overshadowed by other factors around discharge, and that it may start to exert its influence only 39 months after discharge. One explanation is that it takes time for patients and families to integrate new knowledge and skills into their daily life, and as symptoms and problems with living reappear people are able to change their coping behaviour or modify their relationships and interactions to influence their coping.
This study has reinforced the findings of local Chinese studies of the positive effect of family education on global assessment of functioning. In this study those in the experimental group were healthier at the 9-month measurement point, as it seems that the effects of our education programme become apparent at a point after hospitalisation when symptoms begin to reappear. This confirms similar findings in overseas studies (Barrowclough et al, 1999).
Medication adherence
The lack of significant difference between the intervention and control
groups may be due to the long period of hospitalisation, family factors and/or
cultural factors. This finding did help to isolate the notion that medication
adherence did not necessarily affect deterioration in symptoms. Caution needs
to be exercised with these results, as the sample size was small, the
reliability of assessing adherence by patients selfreport is
questionable and other extraneous variables may be operating. More research
needs to be done to identify whether (and why) Chinese people seem to be more
adherent than those in overseas studies.
Relapse rate
Nine months after discharge the relapse rate of the experimental group
(16%) was lower than that of the control group (37%), but this was not
statistically significant. Zhang et al
(1998) also reported that
compared with the control group (from 26% reduced to 23%), the experimental
group (from 32% reduced to 18%) showed a reduction in annual relapse rates at
2-year follow-up. These findings were supported by Song et al
(1998), Xiong et al
(1994) and Chen et al
(2000).
This study is important because the Chinese government is beginning to increase the numbers of nurses in China and to expand their role, and the societal and legal expectations are that the family members will care for disabled individuals indefinitely, regardless of the emotional and economic burden. Moreover, given the limited housing availability and the complete absence of half-way houses, neither patients nor families have the option of choosing to live separately. Chinese families and patients need help to adapt to this difficult situation (Zhang et al, 1994), as the financial consequences of the government accepting responsibility for housing mentally ill persons would be daunting. People with schizophrenia and their families in China therefore should have the chance to obtain an educational intervention in hospital and also after discharge. The success of our education programme, and the needs of the patients and families revealed during the education process, should stimulate nursing managers and nursing staff to realise their own responsibility and be confident to take on the educator role. The Chinese government recognises the need for more nurses of a higher quality, and future studies and practice could be enhanced by the findings of this study. Some of the challenges facing nurses include having to develop interventions that are culturally sensitive and appropriate for environments where patients and their families are hesitant about sharing their feelings and experiences.
This study was the first of its kind to be conducted by nurses in mainland China. Its positive findings provide much impetus for the development of research and independent evidence-based practice in a branch of nursing and healthcare that is in much need of stimulation. Through the rigour of the research process, decades of valuable research was synthesised into a culturally valid intervention, adapted to a unique healthcare environment and successfully applied to a culturally unique sample of patients and their families, by their culturally unique nurses.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication December 10, 2003. Revision received December 16, 2004. Accepted for publication December 23, 2004.
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