• Users Online: 233
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 331-344

Effect of psycho-educational program on families’ perception of burden and attitudes toward mental illness among caregivers of patients with schizophrenia


Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, Zagazig University, Zagazig, Egypt

Date of Submission30-Sep-2018
Date of Acceptance23-Oct-2018
Date of Web Publication28-Dec-2018

Correspondence Address:
Hanem Ahmed Abd Elkhalek Ahmed
Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, Zagazig University, Zagazig
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_25_18

Rights and Permissions
  Abstract 


Background In recent years, there has been increased interest in the role played by families in the treatment of patients with schizophrenia. Some family interventions may significantly reduce clinical difficulties and may have a positive effect, both emotionally and economically.
Aim The aim of this study is to investigate the effect of psycho-educational program on perception of burden and attitudes toward mental illness among caregivers of patients with schizophrenia.
Research design A quasi-experimental design was used in this study.
Setting This study was conducted at an outpatient clinic in El-Azazi Hospital for Mental Health in Abo-Hamad City.
Patients A convenient sample of 50 caregivers of patients with schizophrenia was included.
Tools of data collection Three tools were used for data collection: sociodemographic data sheets, Caregiver Burden Scale, and Opinions about Mental Illness Scale.
Procedure The sample was randomly divided into a control group (25 caregivers) and an experimental group (25 caregivers), who participated in a family psycho-educational program. The psycho-educational program consisted of thirteen 60-min sessions, held during a period of 2 months. Caregivers in the experimental group were evaluated at inclusion and at the end of the program. Caregivers in the control group were evaluated at inclusion and 2 months later.
Results Most caregivers experienced severe burden, and also significant percent of caregivers had negative attitudes toward mental illness before intervention. Compared with the control group, the experimental group showed significantly reduced caregivers’ burden and improved attitudes toward mental illness after intervention.
Conclusion The psycho-educational program for family members of patients with schizophrenia significantly reduced caregivers’ burden and improved caregivers’ attitudes toward mental illness.
Recommendations There is a need to facilitate access to psycho-educational programs in mental health centers and clinics and to integrate this intervention into the regular treatment plans for patients with schizophrenia.

Keywords: attitudes, caregivers, family burden, psycho-education, schizophrenia


How to cite this article:
Elkhalek Ahmed HA, Hady Ghaith RA. Effect of psycho-educational program on families’ perception of burden and attitudes toward mental illness among caregivers of patients with schizophrenia. Egypt Nurs J 2018;15:331-44

How to cite this URL:
Elkhalek Ahmed HA, Hady Ghaith RA. Effect of psycho-educational program on families’ perception of burden and attitudes toward mental illness among caregivers of patients with schizophrenia. Egypt Nurs J [serial online] 2018 [cited 2019 Jan 17];15:331-44. Available from: http://www.enj.eg.net/text.asp?2018/15/3/331/248967




  Introduction Top


Schizophrenia is one of the most serious psychiatric disorders (Varcarolis, 2012). According to the National Institute of Health, the prevalence rate of schizophrenia is between 0.6 and 1.9% of the population. It has a significant individual, social, and economic pressure on both patients and their families (Sadock et al., 2014). In developing countries, families have customarily been associated in the care of patients, and despite the difficulties forced on the families for the care of patients with schizophrenia, they prefer to deal with their patient at home instead of using long-term care services (Hjarthag et al., 2010; Lloyd et al., 2010).

Each disease, especially chronic diseases, has been associated with different family burden like economic and care burden. Chronic psychiatric disorders such as schizophrenia have been associated with more family burden (Khoshknab et al., 2014). The ‘caregiver burden’ concept includes all of the physical, mental, social, and economic problems experienced by the relatives of an individual with a chronic mental disease {World Federation of Mental Health (WFMH), 2010}.

The burden of care is more often defined by its effect on the caregivers. The concept of burden of care was divided into two separate areas − objective and subjective. Objective burden of care mentions the noticeable costs to the family that result from the disease, like taking care of daily tasks, whereas subjective burden indicates the psychological and emotional effects of mental illness on family members (including feelings of grief and worry). Living with a patient with schizophrenia can put substantial stress and limits on the rest of the family (Sharma et al., 2017). Precisely, the burden of caring for people with mental illness includes disturbance of everyday life routine, stigma and blame, dissatisfaction with family and relatives, economic problems, physical burden, troubles with patients’ adherence to treatment, and problems with health facilities and governmental support (Evensen et al., 2017).

Attitudes are defined as ‘predispositions to associate certain kinds of stimuli with certain kinds of responses’ (Stahlberg and Frey, 1994). Such responses are classified as affective, cognitive, and behavioral. Attitude towards mental illness shapes the way people with mental illness are treated in a society. Negative attitude obstructs social incorporation of these people, whereas positive attitude, believed by caregivers, offers support to the patient in prevention, early treatment, and rehabilitation (Högberg et al., 2008).

The attitude toward mental disorders plays an important role in the stigmatization of psychiatric patients. Caregivers encounter sigma as a negative consequence of mental illness, which is a powerful source of distress for families and raises the request for mental health professional support (Girma et al., 2014). Some families find it difficult to deal with the stigma linked with mental illness, and this negatively affects the families’ capability to cope with patients’ hardship from a mental illness (Karnieli-Miller et al., 2013).Families are a primary caregiving resource for person with schizophrenia, yet they often lack the knowledge and abilities needed to help their families. Studies show that families routinely seek information on basic facts about schizophrenia and its treatment, behavior management skills, and the mental health system so as to better cope with their relatives’ illness. It is well recognized that the maximum influence of a psychiatric disorder is borne by the family and often leads to a complete disruption in its functioning (Shinde and Anjum, 2014).

Over the past decade, emphasis on the family environment has been increased. It is supposed that the family environment plays a vital role in the development and prognosis of the illness (Carr, 2012). Family members can be a precious resource for serious mentally ill individuals. By learning more about the illness, they can support their loved one through diagnosis and beyond. A significant method of changing the attitude toward a phenomenon is giving information about it {Sun et al., 2014}.

Psycho-educational interventions, generally defined as information provided to patient and family about a condition and its management, adjusting to mental illness, and communicating and facilitating problem solving skills, are proven to be effective for improving compliance in psychosis, and in reducing relapse {Xia et al., 2011; National Institute for Clinical Excellence (NICE), 2014}.

On the same line, El-Ghamry et al. (2010) found that providing a family psycho-educational program to a sample of Egyptian families of patients with schizophrenia appears to have had a positive effect on patients with schizophrenia and their caregivers. This is confirmed by the fact that caregivers in the experimental group showed an overall significant improvement in attitudes and gain in knowledge, which were not detected in controls. Moreover, Rahmani et al. (2015) found that most of the families in the experimental group had positive attitudes toward mental disorder after intervention in comparison with the control group.

Nasr and Kausar (2009) found that psycho-educational family programs constructed to improve attitudes toward mental illness have been effective. Specifically, its effectiveness has been obvious on medication compliance, positive coping with stressors, and reducing the risk of relapse in the first year following hospital discharge. Several other studies have also showed the efficacy of family psycho-educational interventions in reducing family burden of patients with schizophrenia (Macleod et al., 2011; Navidian et al., 2012).


  Significance of the study Top


Based on El-Azazi medical record (2017), the outpatient clinic received monthly from 650 to 700 patients with schizophrenia with their caregivers for follow-up. Moreover, recent researches recorded that between 50 and 80% of patients with this disorder either live with their family or are regularly in touch with their family members. In Arab countries, most patients with schizophrenia live with their families. These patients require financial and psychological support from their families. Psycho-educational programs for these families can have a major effect on their knowledge and attitude, and consequently, on the way they care for and interact with these patients, and ultimately lead to decreased burden and an improved quality of life for the patients and their families. This study aimed to examine the effect of group psycho-educational program on burden and attitudes toward mental illness in families of patients with schizophrenia.


  Aim Top


This study was designed to investigate the effect of psycho-educational program on perception of burden and attitudes toward mental illness among caregivers of patients with schizophrenia through the following objectives:
  1. Assessing the perception of burden, and attitudes toward mental illness among caregivers of patients with schizophrenia.
  2. Developing and implementing a psycho-educational program for caregivers of patients with schizophrenia to decrease perception of burden and improve attitudes toward mental illness


Hypothesis

The psycho-educational program has positive influence on perception of burden and attitudes toward mental illness among caregivers of patients with schizophrenia.


  Patients and methods Top


Research design

A quasi-experimental design was utilized to accomplish the aim of this study.

Sample and setting

A convenient sample of 50 caregivers of patients with schizophrenia was selected from caregivers of patients with schizophrenia who attended ‘outpatient clinics’ in El-Azazi Hospital for Mental Health at Abo-Hamad City. The families were selected based on the inclusion criteria that were as follows: (a) readiness to participate in the study; (b) chief caregiver, a person who is the main responsible person for patient care like a parent, spouse, or sibling; and (c) having no psychiatric problems. The inclusion criteria for patients were as follows: (a) being diagnosed as a schizophrenia disorder based on DSM-V; (b) having no comorbidity disorders; and (c) having no mental retardation.

Those who agreed were randomly assigned as 25 for the experimental group and 25 for the control group. All names of caregivers were written in a small piece of paper individually, and then the paper was folded. They were selected as 25 for experimental group and 25 for control group.

Tools of data collection

Three tools were used to collect data.

Tool I: sociodemographic data

This sheet was designed by the researchers after revising of related literature and opinions of expertise for content validity and included the following:
  1. Sociodemographic data of caregivers, such as age, sex, marital status degree of relation to the patient, occupation, educational level, family type, and income.
  2. Personal data of the patient such as age, sex, duration of disease, age at onset, and occupation.


Tool II: Caregiver Burden Scale

This scale was developed by Zarit et al. (1980). It is a self-administered questionnaire to assess the experience of burden. It was divided by Abd El-Salam (2002) into four categories: physical (eight items), social (five items), psychological and financial (six items), and dissatisfaction burden (three items). The scale was translated into Arabic by the researchers.

Scoring system: a five-point Likert scale was used, where 0=never, 1=rarely, 2=sometimes, 3=frequently, and 4=always. The total score ranged from 0 to 88 points. A higher score means greater level of burden.

Level of Caregiver Burden Scale was as follows:
  • Burden mild (0–29): 33%.
  • Burden moderate (30–58): 66%.
  • Burden severe (59–88): 67–100%.


Tool III: Opinions about Mental Illness Scale

This scale was developed by Cohen and Struening (1962) to measure beliefs and attitudes toward the etiology, treatment, and prognosis of mental illness. The original tool is a self-report scale composed of 51 items and based on five attitudinal dimensions. The scale was translated into Arabic and modified by the researchers. The modified Arabic version of this tool consisted of 42 items and the same attitudinal dimensions. Nine items have been omitted to avoid repetition of items and also owing to difference in culture.

The dimensions include the following:
  1. Authoritarianism (eight items): the opinion that people with a mental illness cannot be held accountable for their acts and they should be controlled by society.
  2. Benevolence (12 items): an attitude that could be placed between tolerance and pity/compassion (attitudes that are encouraging of patients but still acknowledge society view of persons with mental illness).
  3. Mental hygiene etiology (eight items): the opinion that mental illness is similar to other illnesses and should be treated adequately by specialists.
  4. Social restrictiveness (10 items): the opinion that mentally ill persons should be restricted in some social domains.
  5. Interpersonal etiology (four items): the belief that the real cause of a mental illness is the problematic interpersonal relations.


Scoring system

The scale was measured on a five-point Likert scale (1=strongly agree to 5=strongly disagree). The total score ranged from 42 to 210 points. In general, higher scores to a subscale reflect a more positive attitude towards mental illness. The scale has 15 reversed sentences (No. 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, and 38).

Cutoff points of Opinion about Mental Illness (OMI) Scale were as follows:
  • Opinion negative (42–125): less than 60%.
  • Opinion positive (126–210): more than 60%.


Content validity and reliability

The validity of the tools was ascertained through the process of translation retranslation and reviewed by experts. A panel of three experts in nursing, one professor from the Psychiatric Nursing Department at the Faculty of Nursing, Cairo University, and two professors of community Health Nursing Department at the Faculty of Nursing, Zagazig University, reviewed the tools for face and content validity and tested for relevance and comprehensiveness, as well as clarity, applicability, and ease for implementation. Reliability of the tools was assessed by Cronbach’s alpha test in statistical package for the social sciences, version 20 (SPSS Inc., Chicago, Illinois, USA). In this study, researchers collected two standardized scales: OMI Scale and Caregiver Burden Scale. Cronbach’s alpha of scales in the current study is as follow: OMI Scale 0.73 and Caregiver Burden Scale 0.86.

Ethical clearance

An official permission was obtained, for conducting the study, from the Director of El-Azazi Hospital for Mental Health. The aim of the study was clarified to caregivers before seeking their contribution in the study. They were given a chance to refuse to contribute in the study. They were informed that they could withdraw at any phase of the research study. Finally, they were secured that their information would be treated confidentially and will be used for the research purpose only.

Pilot study

A pilot study was carried on 10% of the sample of caregivers from other outpatient clinics’ caregivers to assess the content of the tools, in addition to assess the time needed for filling in the tools, and clearness of the tools; the essential changes were done, namely, restating, using simpler semantic for the statements.

Data collection procedure

Psycho-educational program description

Psycho-education refers to the process of providing education and information to those seeking or receiving mental health services such as people diagnosed with mental health conditions and their family members to help people better understand and become accustomed to living with mental health conditions.

Objectives of the program

  1. To understand the meaning of schizophrenia and its causes, symptoms, and its effect on the patient and his/her family.
  2. To understand different treatment modalities for schizophrenia.
  3. To discuss the importance of treatment compliance, signs of relapse in patients with schizophrenia, and explain family role in preventing relapse.
  4. To understand the importance of effective communication skills in the family and with patients with schizophrenia.
  5. To gain skills in coping strategies with stressors arising from patient symptoms.
  6. To explain cognitive and behavioral techniques for managing patient′s symptoms.
  7. To understand the importance of stress management in the family and identify different ways of stress reduction.


The study program was designed to be 13 sessions implemented in four phases, where the first two sessions were for assessment, 10 sessions for intervention program, and the final session for evaluation.
  1. Preparatory phase:
    1. Preparation of the content:
      • A review of the current, past, local, and international related literature was done for preparation of the intervention program. The planning phase includes the program strategy (time table, teaching methods, and participant assignments based on each skill).
      • The content of the program includes meaning, symptoms, and causes of schizophrenia; the effect of disease symptoms on the family of patients with schizophrenia; different treatment modalities for schizophrenia; negative effects of antipsychotic drugs and methods of management; nonpharmacological treatment for schizophrenia; importance of treatment compliance, signs of relapse, and family role in preventing relapse; importance of effective communication skills in the family and with the patient with schizophrenia; different coping strategies with stressors arising from patient symptoms; cognitive and behavioral techniques for managing patient’s symptoms; expressed emotion and emotional environment in the family; stress management in the family; and different ways of stress reduction

        The researchers used lecture, group discussion, question and answer methods, and demonstrations for participants to practice new skills.
    2. Recruitment and group allocation:
      • The study population included the families of the patients with schizophrenia disorder who along with their patients were regularly attending the outpatient of El-Azazi Hospital for mental health for follow-up.
      • The researchers contacted the caregivers to explain the purpose and procedure of the study. The experimental group then was divided into two subgroups (12 and 13 family caregivers). This study occurred through twice weekly for each subgroup.
    3. Assessment and data collection (pretest):
      • Participants from the study groups were asked to complete a baseline questionnaire, which was 1 week before the intervention.
  2. Introductory phase (two sessions):
    • An associate between researchers and caregivers was made, and brief clarification was given on meaning of schizophrenia, symptoms of schizophrenia (positive symptoms, negative symptoms, cognitive symptoms, and insight disturbance), and causes of schizophrenia.
  3. Intervention program (10 sessions):
    • The psycho-educational program was conducted in 10 sessions of 60 min each twice weekly for the study subgroups. Researchers started by easy and widely accepted more difficult contents. Lecture, group discussion, question and answer, and demonstrations with participants to practice new skills methods were used to attain sessions. At the start of each session, the researchers clarified the topic designated for that session for 5 min. Then, contributors were asked to discuss about their experience in 10 min. The researchers taught the families about the selected topic in 40 min. In the remaining 5 min, a conclusion from the discussion was made by the participants. During program implementation, the researchers distribute the health education program booklets on the caregivers.
    • The content of the psycho-education program sessions was as follows: (a) effect of disease symptoms on the family of patients with schizophrenia and different treatment modalities for schizophrenia; (b) pharmacological treatment for schizophrenia and negative effects of antipsychotic drugs and methods of management; (c) nonpharmacological treatment for schizophrenia (electroconvulsive therapy, psychotherapy, rehabilitation therapy, and role of caregiver in rehabilitation therapy); (d) importance of treatment compliance, signs of relapse in schizophrenic patient, and family role in preventing relapse of patients with schizophrenia; (e) importance of effective communication skills in the family and with the patient with schizophrenia; (f) different coping strategies with stressors arising from patient symptoms; (g) cognitive and behavioral techniques for managing patient’s symptoms [impaired thought process, disturbed sensory perception, impaired verbal communication, self-care deficit, sleep pattern disturbance, inability to cope, other directed violence, and self-directed violence (risk of suicide)]; (h) expressed emotion and emotional environment in the family; (i) importance of stress management in the family and different ways of stress reduction (deep breathing, relaxation of muscles, visualization, and meditation); and (j) last session of psycho-education program that focused on identifying caregivers’ opinion about the sessions’ benefit.
    • Each session lasted 60 min, two sessions per week for each subgroup, and the implementation of the psycho-education program was covered. The researchers complied with the distribution of the health education program booklet and handouts on the program sessions; the duration of study was 2 months, started from beginning of January to the last of February 2018.
  4. Evaluation phase (last session):
    • Participants were reassessed by using the same tools of pretest, and comparison was done to determine the effectiveness of the program evaluation.


Statistical analysis

All data were collected, tabulated, and statistically analyzed using the statistical package for the social sciences (version 20.0) for Windows (SPSS Inc.). Quantitative data were expressed as the mean±SD and median (range), and qualitative data were expressed as number and percentage. Continuous data were checked for normality by using Shapiro–Wilk test. Student’s test (t) was used to compare between two independent groups of normally distributed variables. Mann–Whitney U test was used for two independent non-normally distributed variables. Repeated measure paired t test was used to compare between two independent groups of normally distributed variables. Wilcoxon’s signed rank test was used to compare between two dependent groups of non-normally distributed variables. Percent of categorical variables was compared using χ2 test or Fisher’s exact test when indicated. McNemar test was used to compare between two independent groups of categorical data. All tests were two sided. Spearman’s rank correlation coefficient was calculated to assess relationship between various study variables; + sign indicates direct correlation and−sign indicates inverse correlation. Moreover, values near to 1 indicate strong correlation and values near 0 indicate weak correlation. P value less than 0.05 was considered statistically significant, whereas P value less than 0.001 was considered highly significant, and P value more than or equal to 0.05 was considered statistically insignificant.


  Results Top


[Table 1] shows that the mean age of caregivers in the study and control groups was 50.3±13.9 years, and 60% of them were female caregivers. Moreover, 72% of caregivers were married, 32% of them were illiterate, and 20% had basic education only.
Table 1 Sociodemographic characteristics of caregiver groups

Click here to view


The table also reveals that 40% of caregivers were unemployed and 24% were retired. As for degree of relation, 50% of the sample was parent caregivers. Moreover, 84% of the sample came from single families and 76% of them had insufficient income. The table also indicates that there are statistically insignificant differences between the study caregivers’ and control groups regarding sociodemographic characteristics (P>0.05).

[Table 2] indicates that the mean age of the patients in both groups was 34.2±10.2 years. Overall, 66% of them were males and 60% of them were unemployed. Moreover, the mean duration of disease was 11±10.4 years. The table also shows that there are statistically insignificant difference between the experimental and control groups regarding demographic characteristics and disease characteristics (P>0.05).
Table 2 Characteristics of patientgroup and control group

Click here to view


[Table 3] shows that the total mean score of caregiver burden for the experimental group is 64.4±20.2 compared with 68±4.2 for the control group, and there are statistically insignificant differences between both groups regarding total caregiver burden and also caregivers’ burden subitems before psycho-educational program (P>0.05).
Table 3 Comparison of Caregivers’ Burden Scale items and total burden for the studied caregivers before and after psycho-educational program

Click here to view


However, after psycho-educational program, the total caregivers’ burden for the study group is 30±12.3 compared with 68.4±5.1 for the control group, and there are statistically significant differences between both groups regarding total caregivers’ burden and also caregivers’ burden subitems (P<0.05).

The table also reveals that, physical burden at pre-program phase represents the highest mean scores for both groups, followed by psychological-financial, and social burden and the least mean was dissatisfaction burden.

[Figure 1] illustrates that 68% of the study caregivers’ group and 84% of control group experienced severe burden before the program. However, at postprogram phase, only 4% of the study caregivers’ group versus 88% of control group experienced severe burden.
Figure 1 Comparison of caregivers’ pre–post program scores of total caregiver burden for the experimental and control groups.

Click here to view


[Table 4] shows that the total mean score of caregivers’ OMI for the study group is 111.8±23.5 compared with 120±14.8 for the control group, and there are statistically insignificant differences between both groups regarding total OMI and also OMI subitems before psycho-educational program (P>0.05).
Table 4 Comparison of Opinion about Mental Illness Scale items and total Opinions about Mental Illness for the studied caregivers before and after psycho-educational program

Click here to view


However, after psycho-educational program, the total OMI for the experimental group is 173.6±12.5 compared with 125±14.2 for the control group, and there are statistically significant differences between both groups regarding total OMI and also OMI subitems (P<0.05).

The table also indicates that interpersonal etiology at preprogram phase represents the lowest mean scores for both groups, followed by authoritarianism, then by social restrictiveness, and mental hygiene, and the least benevolence.

[Figure 2] indicates that only 28% of caregivers in the experimental group and 48% of the control group had positive attitude toward mental illness before the program. However, postprogram, all caregivers (100%) in the experimental group in comparison with 72% of the control group had positive attitudes toward mental illness.
Figure 2 Comparison of caregivers’ pre–post program scores of total Opinion about Mental Illness (OMI) for the study and control groups.

Click here to view


[Table 5] reveals no statistically significant relations between Caregivers’ Burden Scale and OMI Scale among the experimental group before implementation of psycho-educational program (r=−0.23 at P>0.05).
Table 5 Correlation of Caregivers’ Burden Scale and Opinion about Mental Illness Scale of studied groups before and after psycho-educational program

Click here to view


The same table illustrates no statistically significant relations between Caregivers’ Burden Scale and OMI Scale among the experimental group after implementation of psycho-educational program (r=−0.13 at P>0.05).

Moreover, this table shows no statistically significant relations between Caregivers’ Burden Scale and OMI Scale among the control group before implementation of psycho-educational program (r=−0.05 at P>0.05).

The same table reveals no statistically significant relations between Caregivers’ Burden Scale and OMI Scale among the control group after implementation of psycho-educational program (r=−0.11 at P>0.05).


  Discussion Top


Severe mental illnesses have a significant effect on patients’ and families’ quality of life. The outcomes of living with a mentally ill patient can include family burden, fear of mental illness signs and symptoms, doubt about causes of the disease, lack of social support, and stigma (Rahmani et al., 2015). This study aimed to investigate the effect of psycho-educational program on burden and attitudes toward mental illness among caregivers of patients with schizophrenia.

Regarding caregivers’ characteristics, the results revealed that the mean age of caregivers was about 50 years and the majority of caregivers were married. This elevated mean age and marriage rate might be owing to the dominance of parents’ caregivers in the study. These results agree with those of Kate et al. (2013), who studied caregiver burden among caregivers of schizophrenia and found that the mean age of the caregivers was about 46 years and the majority of caregivers were married.

The present study results revealed that less than two-thirds of caregivers were females. The higher percentage of female over male caregivers indicates the women by nature of their position and characteristics are taking the major responsibility of caring for their ill relative. This result agrees with that of Metwaly (2007), who studied the effect of stigma of mental illness and burden of caregiven of families of patients with schizophrenia on their level of expressed emotion and indicated that the majority of caregivers were females. Moreover, Navidian et al. (2012) in their study about the effectiveness of a group psycho-educational program on family caregiver burden of patients with mental disorders found that most caregivers in their study were women who also were housewives.

This result was supported by Abd El-Aziz (2002), who studied problems and coping methods among family caregivers of mentally ill patients and reported that the sex of the caregiver has a role in perception of caring burden, and he found that the primary responsibility of caregiving falls on wives, daughters, daughters in law, and grand daughters. They commonly become at high risk for becoming secondary victims of illness.

In this respect, Navidian and Bahari (2008), in their study about burden experienced by family caregivers of patients with mental disorders, stated that in Iranian family circle, girls or women are dependable for taking care of children, patients, elderly, and disabled people in the family as a part of their daily family tasks. However, contradictory findings were found in a similar study, carried out by Kate et al. (2013), who reported that most caregivers were males.

The current study revealed that, exactly half of caregivers were parents, more than two-fifths were brothers and sisters, and minorities were spouses or siblings. The highest percent was from parent which can be explained as the early onset of mental illness hinder the patient from marriage and establishing his/her own family, so parents become the main caregivers. In this regards, Aggarwal et al. (2011), in their study about experience of caregiving in schizophrenia found that about half of the caregivers were parents, whereas less than one-fourth were spouses and one-fifth were siblings.

Regarding patients’ characteristics, the present study results revealed that, the mean age of the patients was 34.2±10.2 years. This low mean age may be related to the early onset of mental illness in late adolescence or early adulthood. This result agrees with that of Metwaly (2007), who reported that the mean age of patients was 32 years.

The current study results found that three-fifths of patients were unemployed. This can be related to the early onset of disease and chronicity of the illness that prevent the patient to maintain work. This result is consistent with that of Aggarwal et al. (2011), who found that, a significant percentage of the patients were unmarried and unemployed.

Considering caregiver burden, the current study revealed that most caregivers (both experimental and control groups) experienced severe burden at preprogram phase. This high level of burden might be owing to the physical and emotional drain and exhaustion of caregiving process that leads to this burden.

In congruence with the previous finding, Khoshknab et al. (2014) in their study about the effects of group psycho-educational program on family burden in caregivers of Iranian patients with schizophrenia found that family burden in Iranian households with a patient with schizophrenia is significantly high before intervention (over 40 in a scale of up to 48), and nearly all families confront a severe burden. This goes in line with the result of Kaur (2014), who studied caregiving burden and social support among caregivers of schizophrenic patients and reported that majority of caregivers had moderate and sever burden.

On the contrary, the previous results contradicted with those of Gupta et al. (2015), who studied psychological well-being and burden in caregivers of patients with schizophrenia and found that most caregivers experienced moderate burden, whereas one-fifth of them experienced severe burden and distress.

All categories of Caregiver Burden Scale for both the experimental and control groups, in the present study, showed high mean scores before implementation of the program, including physical, social, psychological and financial, and dissatisfaction burden. Physical burden represented the highest mean scores. This means that objective burden was higher than subjective burden before implementation of the program. This might be owing to that the more help than needed that the patient asks from his/her relative, the higher the expectations from the patient that this relative is the only person he/she can depend on; therefore, these demands and dependency from the patient make the caregiver feel physical exhaustion and burden more than any other burden.

In this respect, Khoshknab et al. (2014) reported that all sides of burden were considered in their study at elevated level before intervention comprising financial sides, every day activities, recreations, and family relations in addition to physical and psychological health. The high level of financial burden is a result of work loss by both the patients and their caregivers. Relatively high monthly expenses on medication and care costs would be an addition to this financial difficulty.

The implementation of group psycho-educational program to the caregivers of the current study led to considerable reduction in the total mean score of burden of the experimental group compared with the control group (30±12.3 and 68.4±5.1 at P<0.001, respectively) at postprogram phase. In all four categories of the Caregiver Burden Scale and total caregiver burden, the experimental group demonstrated significant lower mean scores compared with the control group. This indicates that the program was most successful where gaps of skills about managing symptoms and difficult situations in mental illness were present that may lead to burden. This requires that any psycho-educational program should be custom-tailored and must be based on real identified needs of the target attendants.

In agreement with the present study findings, Khoshknab et al. (2014) found that a 1-month group psycho-educational program made a considerable decrease in family burden of the intervention group in comparison with the control group (27.87 vs. 37.82; P<0.001). In all six categories of Family Burden Interview Scale and total family burden, the intervention group displayed lower scores compared with the controls.

Similarly, Sharif et al. (2012), who studied the effect of a psycho-educational intervention for family members on caregivers’ burden and psychiatric symptoms in patients with schizophrenia in Shiraz, Iran, found that the family psycho-education in their study showed positive effects in diminution of family burden and patients’ symptoms in the experimental group immediately and 1 month after the intervention. In this respect, Navidian et al. (2012) reported that burden is one of the most commonly used instruments to assess the effect of intervention.

Navidian et al. (2012) added that the intervention, particularly based for caregivers for patients with schizophrenia and mood disorder, in Iran, positively can affect burden. In the same line, decline in family burden, following psycho-education programs, has been found to be efficient psychologically and clinically (Rummel-Kluge and Kissling, 2008; Giron et al., 2010).

In this respect, Nasr and Kausar (2009) clarified that, the accurate procedure by which group psycho-education minimizes the level of family burden is not until now totally understood. Enhancing knowledge regarding the disease and changes in attitudes and consequent changes in behaviors of the caregivers, all may cause this decline.

Regarding caregivers’ attitudes, the results of the present study showed that, majority of caregivers in the experimental group and more than half of caregivers in the control group had negative attitudes toward mental illness at preprogram phase. This negative attitude might be owing to the low level of education among caregivers, as slightly more than half of them were either illiterate or had basic education only. This low educational level makes caregivers more liable to have negative attitude toward mental illness, as attitude differs among caregivers of various educational level. Probably, educated caregivers are better exposed to mass media and are more aware of myths about mental illness compared with their less-educated counterparts.

These results are in agreement with those of Rahmani et al. (2015), who studied the effects of group psycho-educational program on attitude toward mental illness in families of patients with schizophrenia, and showed that nearly all of families in the experimental and control groups had negative attitude toward mental illness before implementation of the program. This result also agrees with those of Caqueo-Urízar et al. (2011), who studied attitudes and burden in relatives of patients with schizophrenia in a middle income country and found that attitudes tend to be negative in the entire sample. In this regard, Namdar et al. (2008) claimed that families of the mentally ill patients feel ashamed of their mentally ill patients.

All dimensions of OMI Scale in the present study showed decreased mean scores before implementation of the program, including authoritarianism, benevolence, mental hygiene etiology, social restrictiveness, and interpersonal etiology. Interpersonal etiology represented the lowest mean scores in the pretest of both groups. This reflects the role of culture in formulating a distorted belief about mental illness, that it results from bad interpersonal experiences such as lack of deprivation of parental love and concern during childhood, and as such minimizes biomedical causes of serious mental illness.

In this respect, Rahmani et al. (2015) divided OMI Scale into six dimensions, including separation, stereotyping, restrictiveness, benevolence, pessimistic prediction, and stigmatization. They also showed that the mean scores of the separation, stereotyping, and restrictiveness dimensions were lower in the pretest of both groups and concluded that the families tended to neglect their patients and apply restricted procedures against them.

At postprogram phase, the result of the present study revealed that the implementation of the psycho-educational program to the caregivers led to significant increase in the total mean score of OMI of the experimental group compared with the control one (173.6±12.5 and 125±14.2, respectively), with P value less than 0.001. In all five dimensions of OMI Scale and total OMI, the experimental group showed significant higher mean scores compared with the control group. This means that caregivers have learned how to act, feel, and think in a more positive and flexible way with respect to the illness. This more positive attitude has immediate effects on the relationship with the patient, as well as on caregivers themselves, who will thus have better and major control over the diverse situations which occur when living with a patient with schizophrenia.

The high positive attitude at postprogram phase can also be explained as the caregivers in the present study had not been exposed to any preceding psycho-educational programs, and had been living with their condition for many years, so they may have been more responsive to the intervention and thus show better readiness to modify their attitudes. Additionally, the exposure to, and exchange of experiences with other relatives is a highly worthy stimulus, which may inspire caregivers to change their attitudes. In this regard, the entire experimental group had positive attitude toward mental illness at postprogram phase. This finding related to the cutoff point of OMI Scale which is considered negative at less than 60%, and any score equal or above 60% is considered positive attitude.

Similarly, Rahmani et al. (2015) showed in their study results that the mean score of OMI in post-test have been improved and family psycho-educational intervention has been effective on improving family attitude toward mental illness. Furthermore, Gutierrez-Maldonado et al. (2009) in their study about effects of a psycho-educational intervention program on the attitudes and health perceptions of relatives of patients with schizophrenia reported that psycho-educational program created an enhancement in the attitudes of relatives toward schizophrenia.

Regarding correlations among the studied variables, the current study results showed that there were no significant correlations between burden in caregivers and their attitudes toward mental illness before and after implementation of the program for both experimental and control groups. However, Caqueo-Urízar et al. (2011) found in their study that apparent burden in the caregiving role is extensively correlated with global attitude. The poorer the attitude toward the patient, the more concerned the caregiver is about his/her capability in the role. They added that psycho-educational programs can make a precious contribution. By giving them the tools, they need to control the disorder, and it would be possible to improve caregivers’ attitudes, decrease their burden, and finally, facilitate a better relationship between patient and caregiver.

In a similar study, Desousa et al. (2012) concluded that family psycho-education is an essential part of schizophrenia treatment programs. Latest shifts to brief hospitalization and a focus on community care have confirmed the significance of relative education in this stage of treatment.


  Conclusion Top


The findings showed the efficacy of a family psycho-educational program both in decreasing the family caregivers’ burden and in improving the caregivers’ attitudes toward mental illness. No significant correlation was found between caregivers’ burden and caregivers’ attitudes toward mental illness.

Recommendations

Based upon the current study results, the following recommendations are suggested:
  1. Facilitating access to psycho-educational programs in mental health centers and clinics and to integrate this intervention into the regular treatment plans for patients with schizophrenia.
  2. Longer follow-up periods are recommended to decide the long-term effects of family psycho-educational intervention on outcomes for patients and their families.
  3. Further studies are needed to examine the effects of family psycho-educational programs on the other outcomes such as relapse rate, patient functioning, and medication compliance after hospital discharge.
  4. Future investigations should concentrate on obtaining more accurate =evaluations of the contributions of particular components of these programs to lowering burden and modifying attitudes toward mental illness.
  5. As intervention was successful in changing attitudes and declining the burden of family caregivers for patients with schizophrenia, it is also likely that this program will be applicable to other mental disorders.
[39]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interesting.



 
  References Top

1.
Abd El-Aziz EM (2002). Problems and coping methods among family caregivers of mentally ill patient [unpublished master thesis]. Cairo, Egypt: Faculty of Nursing. Cairo University.  Back to cited text no. 1
    
2.
Abd El-Salam E (2002). The impact of elderly health problems on the caregiver’s health [master thesis].Menoufyia, Egypt: Faculty of Nursing, Menoufyia University.  Back to cited text no. 2
    
3.
Aggarwal M, Avasthi A, Kumar S, Grover S (2011). Experience of caregiving in schizophrenia: study from India. Int J Soc Psychiatry 57:224–236.  Back to cited text no. 3
    
4.
Caqueo-Urízar A, Gutiérrez-Maldonado J, Ferrer-García M, Peñaloza-Salazar C, Richards-Araya D, Cuadra-Peralta A (2011). Attitudes and burden in relatives of patients with schizophrenia in a middle income country. BMC Fam Pract 12:101.  Back to cited text no. 4
    
5.
Carr A (2012). Family therapy: concepts, process and practice. 3rd ed. New York: John Wiley & Sons.  Back to cited text no. 5
    
6.
Cohen J, Struening EL (1962). Opinions about mental illness in the personnel of two large mental health hospitals. J Abnorm Soc Psychol 64:349–360.  Back to cited text no. 6
    
7.
Desousa A, Kurvey A, Sonavane S (2012). Family psycho-education for schizophrenia: a clinical review. Malays J Psychiatry 21:0.  Back to cited text no. 7
    
8.
El-Ghamry R, Khalil A, El-Nahas G, Ramy H, Hussein H (2010). Familypsycho-education and outcome of schizophrenia: an Egyptian study [MD thesis]. Cairo, Egyot: Ain Shams University, Faculty of Medicine.  Back to cited text no. 8
    
9.
Evensen S, Ueland T, Lystad JU, Bul LH, Klungsoyr O, Martinsen EW (2017). Employment outcome and predictors of competitive employment at 2-year follow-up of a vocational rehabilitation program for individuals with schizophrenia in a high-income welfare society. Nord J Psychiatry 71:180–187.  Back to cited text no. 9
    
10.
Girma E, Möller-Leimkühler AM, Müller N, Dehning S, Froeschl G, Tesfaye M (2014). Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia. BMC Int Health Hum Rights 14:1.  Back to cited text no. 10
    
11.
Giron M, Fernandez-Yanez A, Mana-Alvarenga S, Molina-Habas A, Nolasco A, Gomez-Beneyto M (2010). Efficacy and effectiveness of individual family intervention on social and clinical functioning and family burden in severe schizophrenia: a 2-year randomized controlled study. Psychol Med 40:73–84.  Back to cited text no. 11
    
12.
Gupta A, Solanki RK, Koolwal GD, Gehlot S (2015). Psychological well-being and burden in caregivers of patients with schizophrenia. Int J Med Sci Public Health 4:70–76.  Back to cited text no. 12
    
13.
Gutierrez-Maldonado J, Caqueo-Urızar A, FerrerGarcıa M (2009). Effects of a psycho-educational intervention program on the attitudes and health perceptions of relatives of patients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 44:343–348.  Back to cited text no. 13
    
14.
Hjarthag F, Helldin L, Karilampi U, Norlander T (2010). Illness-related components for the family burden of relatives to patients with psychotic illness. Soc Psychiatry Psychiatr Epidemiol 45:275–283.  Back to cited text no. 14
    
15.
Högberg T, Magnusson A, Ewertzon M, Lützén K (2008). Attitudes towards mental illness in Sweden: adaptation and development of the community attitudes towards mental illness questionnaire. Int J Ment Health Nurs 17:302–310.  Back to cited text no. 15
    
16.
Karnieli-Miller O, Perlick DA, Nelson A, Mattias K, Corrigan P, Roe D (2013). Family members of persons living with a serious mental illness: experiences and efforts to cope with stigma. J Ment Health 22:254–262.  Back to cited text no. 16
    
17.
Kate N, Grover S, Kulhara P, Nehra R (2013). Relationship of caregiver burden with coping strategies, social support, psychological morbidity, and quality of life in the caregivers of schizophrenia. Asian J Psychiatry 6:380–388.  Back to cited text no. 17
    
18.
Kaur N (2014). Caregivers’ burden and social support among caregivers of schizophrenic patients. Delhi Psychiatry J 17:337–341.  Back to cited text no. 18
    
19.
Khoshknab MF, Sheikhona M, Rahgouy A, Rahgozar M, Sodagari F (2014). The effects of group psycho-educational program on family burden in caregivers of Iranian patients with schizophrenia. J Psychiatr Ment Health Nurs 21:438–446.  Back to cited text no. 19
    
20.
Lloyd H, Singh P, Merritt R, Shetty A, Yiend J, Singh S, Burns T (2010). A comparison of levels of burden in Indian and White parents with a son or daughter with schizophrenia. Int J Soc Psychiatry 57: 300–311.  Back to cited text no. 20
    
21.
Macleod SH, Elliot L, Brown R (2011). What support can community mental health nurses deliver to carers of people diagnosed with schizophrenia? Findings from a review of the literature. Int J Nurs Stud 48:100–120.  Back to cited text no. 21
    
22.
Metwaly SM (2007). The effect of stigma of mental illness and burden of care-given of families of schizophrenic patients on their level of expressed emotion [master thesis]. Zagazig, Egypt: Faculty of Nursing, Zagazig University.  Back to cited text no. 22
    
23.
Namdar H, Arshadi M, Ebrahimi H, Sahebi HM (2008). Nursing student’s attitude toward mental illness. Iran J Nurs Res 3:15–21.  Back to cited text no. 23
    
24.
Nasr T, Kausar R (2009). Psycho-education and the family burden in schizophrenia: a randomized controlled trial. Ann Gen Psychiatry 8:17.  Back to cited text no. 24
    
25.
National Institute for Clinical Excellence (NICE) (2014). Psychosis and schizophrenia in adults: treatment and management (National Clinical Guideline No. 178). London: National Collaborating Centre for Mental Health.  Back to cited text no. 25
    
26.
Navidian A, Bahari F (2008). Burden experienced by family caregivers of patients with mental disorders. Pak J Psychol Res 23:19–28.  Back to cited text no. 26
    
27.
Navidian A, Kermansaravi F, Rigi SN (2012). The effectiveness of a group psycho-educational program on family caregiver burden of patients with mental disorders. BMC Res Notes 5:399.  Back to cited text no. 27
    
28.
Rahmani F, Ranjbar F, Ebrahimi H, Hosseinzadeh M (2015). The effects of group psycho-educational program on attitude toward mental illness in families of patients with schizophrenia. J Caring Sci 4:243–251.  Back to cited text no. 28
    
29.
Rummel-Kluge C, Kissling W (2008). Psycho-education for patients with schizophrenia and their families. Expert Rev Neurother 8:1067–1077.  Back to cited text no. 29
    
30.
Sadock BJ, Sadock V, Ruiz P (2014). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins.  Back to cited text no. 30
    
31.
Sharif F, Shaygan M, Mani A (2012). Effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patients with schizophrenia in Shiraz, Iran. BMC Psychiatry 12:48.  Back to cited text no. 31
    
32.
Sharma H, Sharma B, Sharma DB (2017). Burden, perceived stigma and coping style of caregivers of patients with schizophrenia and bipolar disorder. Int J Health Sci Res 7:84–94.  Back to cited text no. 32
    
33.
Shinde M, Anjum S (2014). Effectiveness of demonstration regarding feeding of hemiplegia patient among caregivers. Int J Sci Res 3:20–27.  Back to cited text no. 33
    
34.
Stahlberg D, Frey D (1994). Attitudes I: Structure, measurement and functions. In Hewstone W, Stroebe J, Condol M, Stepherson GM eds. Introduction to social psychology. Barcelona: Ariel; 149–170.  Back to cited text no. 34
    
35.
Sun B, Fan N, Nie S, Zhang M, Huang X, He H (2014). Attitudes towards people with mental illness among psychiatrists, psychiatric nurses, involved family members and the general population in a large city in Guangzhou, China. Int J Ment Health Syst 8:26.  Back to cited text no. 35
    
36.
Varcarolis EM (2012). Manual of psychiatric nursing care planning. Translated by Abdolahian E, Soltanifar A, Sodmand P.; Tehran, Iran: AndisheRafie Publications [in Persian].  Back to cited text no. 36
    
37.
World Federation of Mental Health (WFMH) (2010). Caring for the caregiver: why your mental health matters when you are caring for others. Woodbridge, VA: WFMH.  Back to cited text no. 37
    
38.
Xia J, Merinder LB, Belgamwar MR (2011). Psycho-education for schizophrenia. Cochrane Database of Systematic Reviews. Publication no. Issue 6. Art no.:CD002831).  Back to cited text no. 38
    
39.
Zarit SH, Reever KE, Bach-Peterson J (1980). Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist 20:649–655.  Back to cited text no. 39
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Significance of ...
Aim
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed37    
    Printed0    
    Emailed0    
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]