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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 105-113

Effects of group psychoeducation on knowledge of caregivers of people with schizophrenia


1 Assistant Professor, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
2 Staff Nurse, Department of Nursing, Christian Medical College, Vellore, Tamil Nadu, India
3 Social Worker, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
4 Lecturer in Occupational Therapy, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
5 Associate Professor, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
6 Department of Statistics, Christian Medical College, Vellore, Tamil Nadu, India
7 Professor and Head- Unit 2, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication21-Jan-2020

Correspondence Address:
Dr. Raviteja Innamuri
Department of Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IOPN.IOPN_2_19

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  Abstract 


Background: Several studies have documented poor knowledge of schizophrenia among caregivers and its negative influence on clinical outcomes such as treatment response and prognosis. The benefits of group psychoeducation of caregivers of patients suffering from schizophrenia have been well established. However, very few studies have explored the effectiveness of the group psychoeducation program in the Indian setting. Aims: This study aims to evaluate the effects of a group psychoeducation program on the knowledge of schizophrenia among caregivers. Settings and Design: The study was conducted at the department of psychiatry at a tertiary care hospital. The study design is a quasi-experimental, two-group pretest posttest design. Methods: Sixty-eight caregivers fulfilling the inclusion criteria were recruited consecutively from the inpatient wards. Their knowledge was assessed with a Knowledge About Schizophrenia Interview (KASI) questionnaire, within 1 week of admission and again during the week of discharge. Controls were caregivers who received psychoeducation through “standard care” alone. Cases were caregivers who received the “group psychoeducation program” in addition to the “standard care” during the course of their stay at the hospital. Their pretest and posttest scores were compared. Results: Fifty caregivers successfully completed the study. There was statistical difference between cases and controls in education (P = 0.007) and duration of stay (P ≤ 0.001). Comparing pretest and posttest scores of all the participants showed that psychoeducation received through various sources (standard care or standard care with group psychoeducation) from admission until discharge produced a significant change in knowledge (P = 0.001). On controlling for education and duration of inpatient stay using multivariate analysis, group psychoeducation further produced a significant improvement in KASI scores in subsections of management (B = 0.839, confidence interval [CI] = 0.301–1.377, P = 0.002) and course and prognosis (B = 1.366, CI = 0.095–2.637, P = 0.035). Conclusions: Group psychoeducation in the Indian setting is an effective and feasible option to improve the knowledge of schizophrenia among caregivers, especially with regard to management, course, and prognosis.

Keywords: Caregivers' knowledge, group psychoeducation, schizophrenia


How to cite this article:
Innamuri R, Palani K, Silas M, Samuel R, George DE, Peravali V, Ramaswamy D. Effects of group psychoeducation on knowledge of caregivers of people with schizophrenia. Indian J Psy Nsg 2019;16:105-13

How to cite this URL:
Innamuri R, Palani K, Silas M, Samuel R, George DE, Peravali V, Ramaswamy D. Effects of group psychoeducation on knowledge of caregivers of people with schizophrenia. Indian J Psy Nsg [serial online] 2019 [cited 2020 Jul 6];16:105-13. Available from: http://www.ijpn.in/text.asp?2019/16/2/105/276344




  Introduction Top


Schizophrenia is a serious and lifelong mental disorder with an incidence of 1.5 per 10,000 people and a prevalence of 1% worldwide.[1] Treatment of schizophrenia saw several breakthroughs in the last 100 years, especially with the introduction of antipsychotics in the 1950s.[2] Antipsychotics allowed better manageability, which eventually led to the advent of deinstitutionalization in 1955. This brought a shift in burden of care from hospital to families (caregivers) who have increasingly assumed greater responsibility for the care of their mentally ill relatives.[3],[4] Knowledge of schizophrenia among the caregivers of patients with schizophrenia is known to, directly and indirectly, influence the various outcomes of treatment.[5] It influences the explanatory models, belief systems, supervision of medication, compliance, expressed emotions, financial and social support offered, stigma, relapse prevention, and acceptance of the illness.[5] Studies have documented poor knowledge about schizophrenia among caregivers, with benefits of reduced hospitalization and relapse rates when psychoeducation and family therapy are incorporated in the management.[6]

Psychoeducation may be defined as the education of a person with any psychiatric disorder in subject areas that serve the goals of treatment and rehabilitation.[7],[8] Psychoeducation may be done on a one-to-one basis or in groups. In may involve presentations, videos, role-plays, or pamphlets. However, the objectives in any setting remain to improve knowledge, thereby bring change in attitude and thereafter engage in effective behavior change that would, in turn, affect the various treatment outcomes. However, delivery of psychoeducation remains a challenge for resource-poor settings such as India, as it is a resource-intensive and time-intensive process. Therefore, group psychoeducation involving multiple families has been studied as a workable solution with the advantages of being able to address several caregivers at the same time, requiring lesser resource personnel than one-to-one sessions. Also, these groups permit greater size and strength of social support network, connect families that have similar problems, and build hope through mutual examples and experiences.[8] Several studies have demonstrated an increase in knowledge and better outcomes following various group psychoeducation programs for caregivers.[9],[10],[11] However, very few studies have explored the effectiveness of the group psychoeducation program in the Indian setting.[12]

Aim and objectives

The aim of the study is to evaluate the effects of a caregiver group psychoeducation program indigenously designed at a mental health center in South India, on the knowledge of schizophrenia. The objectives are (1) to assess knowledge of schizophrenia using the Knowledge About Schizophrenia Interview (KASI) questionnaire at the time of admission and discharge and (2) to evaluate the overall change in KASI score in the study population and compare the change between case group and control group.


  Methods Top


Design

Quasi-experimental, two group pretest posttest design. This design was adopted as randomization was not feasible and ethically possible.

Participants

In our study, caregivers were defined as accompanying family members of the patient admitted with a diagnosis of schizophrenia. The diagnosis of schizophrenia was made as per International Classification of Diseases – 10; ICD 10 (WHO, 1992) criteria. The study was approved by the institutional ethics committee and review board (IRB Min No 10463).

The inclusion criteria for the caregivers were willingness to participate and provide a written consent, caregivers of patients admitted with a diagnosis of schizophrenia, caregivers between the ages of 18 and 70, Tamil speaking, and the minimum duration of inpatient stay for the patients being at least 2 weeks. For the case group, caregivers were to attend a minimum of one group psychoeducation session. The exclusion criteria were severe language, hearing, or cognitive impairment and a diagnosis of major mental illness.

Study setting

This study was conducted at tertiary mental health care center that provides short-term care for patients with mental and behavioral disorders with an emphasis on a multidisciplinary approach and collaborative care using pharmacological and psychological therapies. The mental health care center has open wards and mandates stay of at least 1 caregiver during the inpatient stay. During the period of this study, there were two functioning adult units – units 1 and 2. The treatment protocols of both the units did not differ largely. These two units alternated their outpatient department (OPD) days (Unit 1 – Monday, Wednesday, and Friday and Unit 2 – Tuesday, Thursday, and Saturday), had equal beds allotted for their inpatients, and had the same postgraduates (primary therapists) circulated for postings for equal periods of time. The primary therapists are supervised by a consultant psychiatrist. A patient gets allotted to a unit based on the OPD day at their index presentation. The caregivers of the patient are considered to be under the same unit. Both units offered the “standard care” but only unit 2 offers the additional 'group psychoeducation program” for caregivers of inpatients.

Standard care

As part of the “standard care,” a multidisciplinary team of doctors, nurses, and occupational therapists provide psychoeducation to patients and their caregivers during the course of the stay. The standard care involves regular (thrice weekly) one-to-one sessions of the inpatients and caregivers, with the assigned primary therapist. Each session usually ranges from 30 to 60 min. The sessions are semi-structured and usually involve providing details about illness and treatment, providing ventilation and support. There is no protocol to these sessions. Sessions are modified based on the needs of the clients; focusing on psychoeducation and nonpharmacological strategies including psychosocial interventions. A fact sheet about schizophrenia (in the language understandable by the patient/caregivers) is provided in the first session. The standard care also involves regular informal interactions with nurses during ward rounds, while medications are dispensed. It also involves interactions with occupational therapists during daily occupational therapy sessions, which focus mostly on rehabilitation of patients.

Group psychoeducation program

The “group psychoeducation” for caregivers is conducted by a Tamil-speaking social worker in a separate chamber. These sessions are held on Wednesdays of every alternate week. The caregivers under unit 2 are invited to participate on voluntary basis, at no charge. The duration of each session ranges from 30 to 45 min. The session has a structured and an unstructured segment. The structured segment involves a 20–30 min presentation on details about schizophrenia (symptoms, course, prognosis, treatment options, and compliance) assisted by a 31-slide PowerPoint presentation. This is followed by a discussion and clarification of queries posed by the participants for another 10–15 min. The discussion and clarification are not structured and are based on the queries from the audience. Each session is usually attended by 5–10 caregivers of several inpatients. A caregiver could choose to attend the session multiple times.

Outcomes

The outcomes were change in knowledge scores and its relationship with other sociodemographic and clinical variables. These were assessed through the following tools:

  1. Pro forma for sociodemographic and clinical variables. This pro forma was designed by the investigators
  2. KASI is a clinician-assisted self-report questionnaire which has been shown to be a feasible and effective tool in the assessment and evaluation of the knowledge about schizophrenia.[11] It was introduced by Barrowclough et al. in 1987. It places emphasis on functional value of reported knowledge, than on the recall of information, and can be rated reliably and has face validity for the relative.


KASI assesses responses based on allocation of values on a 1–4 scale as negative, neutral, positive value, and positive value and additional correct information. KASI has 6 subsections including diagnosis (4 questions), symptomatology (5 questions), etiology (4 questions), medication (7 questions), course and prognosis (3 questions), and management (4 questions).

Sample size

Sample size was calculated using the hypothesis testing for two means based on Barrowclough et al., 1987. Power (80%) and alpha error (5%) were kept constant. The mean difference between both the groups was assumed to be 2.5 with an effect size of 0.83. The sample size obtained was 23 in each group with a total of 46.

Procedure

The primary investigator (PI) identified 70 caregivers of patients admitted with a diagnosis of schizophrenia in the ward and were invited to participate in the study. Written informed consent was obtained, and 68 consenting caregivers were recruited. The PI collected their sociodemographic variables and then assessed their knowledge of schizophrenia using the KASI questionnaire during the 1st week of admission (pretest). During the period of inpatient stay, all caregivers received “standard care.” Caregivers of patients admitted under unit 2, additionally received the “group psychoeducation,” as per the unit protocol.

During the week of discharge, all participants, both attending (cases) and not attending (controls) the group psychoeducation program were re-administered the KASI questionnaire (as posttest) by the PI. To minimize investigator bias, the PI was not involved in the psychoeducation. There was no blinding involved in the study.

Statistical methods

We used EpiData, version 3.1, for data entry and SPSS, version 16.1, for statistical analysis. To avoid bias, a combination of numbers was used to code data to mask identification during statistical analysis. Categorical variables were analyzed using Chi-square test, and continuous variables were analyzed using Mann–Whitney U test, Wilcoxon signed-rank test, and t-test. Multilinear regression analysis was utilized to control for various parameters.


  Results Top


The participants flow has been shown in [Flow Chart 1]. Of the 68 caregivers, 50 (25 in each group) caregivers successfully completed the study. Six of the caregivers (3 in each group) dropped out of the study due to inadequate duration of stay, 11 were not available for posttest due to various reasons such as unplanned discharges, unavailability during the week of discharge, and 1 withdrew consent. As described in [Table 1.1] and [Table 1.2], majority of the caregivers were middle aged male (mean age of 52.26 years, range 18–70 years), married (n = 46, 92%), Hindu (n = 43, 86%), literate (n = 48, 96%), employed (n = 49, 98%) from a rural (n = 34, 68%), lower socioeconomic status (n = 32, 64%), and were first degree relatives (n = 43, 86%) to the patients. On multiple linear regression, the study population with higher education status and those living as a nuclear family had higher posttest KASI scores, as described in [Table 2.1]. There was a statistical difference between cases and controls in education (P = 0.007) and duration of stay (P ≤ 0.001). All other parameters were similar. Mann–Whitney U test was performed which revealed no significant difference in the duration of illness of patients in both cases and controls.


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As shown in [Table 2.2], The median of differences between pretest and posttest KASI scores of all participants, using the related samples Wilcoxon Signed Rank Test is significant with a value of 0.001. Using multiple linear regression, it was found that education and family type were significantly associated with posttest scores. Caregivers with higher education status and living in nuclear families had higher posttest scores, as shown in [Table 2.2].

Since both groups were not comparable and showed significant difference with regard to the level of education and duration of stay (exposure to psychoeducation), multiple linear regression was done to adjust statistically. [Table 3] demonstrates significant change in KASI in the subsections of management, course, and prognosis when education status and duration of stay were controlled.
Table 3: Multivariate analysis (on adjusting for education and duration of inpatient stay) showing associations between differences of Knowledge About Schizophrenia Interview scores for cases group

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Therefore, this study shows that psychoeducation received through various sources (including doctors, nurses, social workers, other patients, and families) from admission until discharge has produced significant improvement in knowledge among the study population. When educational status and duration of stay of the cases and controls were controlled, group psychoeducation produced a further improvement in KASI scores in subsections of management, course, and prognosis.


  Discussion Top


The findings of the study are generalizable to routine clinical practice as the participant described in the study population is similar to a typical caregiver.[13] It suggests that psychoeducation of caregivers of inpatients admitted could be considered as a valuable opportunity and might prove beneficial, especially in developing nations where separate psychoeducation as part of outpatient consultation is not always a feasible option.

Several other interpretations have also been possible. Several studies have compared different modalities of psychoeducation in their effectiveness to influence clinical outcomes such as relapse rate, reduction in rating scale scores, and expressed emotion.[5] However, very few studies measured improvement in knowledge. The scales used for the assessment largely differed with very few studies using KASI as an assessment tool. Therefore, direct comparisons with studies could not be made.

With regard to gender of caregivers, our study shows that approximately 60% of the caregivers were males. This is similar to the study done by Shinde et al., 2014[13] in Maharashtra that might indicate that male caregivers played a leading role when compared to women. With regard to sources of information for caregivers, our study showed that all the caregivers that were recruited in the study had some knowledge about schizophrenia. 58% of the caregivers learned through friends and family and 24% from medical professional. In a similar study on caregivers in Maharashtra,[13] nearly 30% had no prior knowledge of schizophrenia and learnt through experience of caregiving to the patient. In their study, medical health professionals were source of information to 30% of the sample, 10% acquired from friends, and 3% from newspapers. This discrepancy is perhaps due to the reason that the study setting is a tertiary care center and nearly 44% of the caregivers in our study already served as caregivers in the past.

Barrowclough et al., 1987[11] used KASI and demonstrated significant change in knowledge after a brief intervention, among all 6 subsections of KASI except medication. In a study by Sota et al., 2008[9] a modified version of KASI known as m KASI was used for comparing small group with two sessions, large group with five and nine sessions to demonstrate similar results of increase in knowledge. However, our study was able to demonstrate significant change in knowledge scores of KASI only on management, course, and prognosis sections. There could be several factors influencing this result, which are analyzed below:

In the diagnosis section, relatives were expected to mention the name of the illness as schizophrenia for scores 3 and above. Most of the caregivers did not know English and found it difficult to pronounce the word “Schizophrenia” or its translation in native Tamil. This could have reflected as lower scores in this section.

In the symptomatology section, caregivers were expected to know the symptoms of schizophrenia and common presentations. In the study population, the answers to this subset were given as per the presentation of their relative currently admitted as inpatient and not as per the description in the fact sheet or psychoeducation. This was also reflected in the answers in posttest KASI when a few caregivers described the side effects of the antipsychotic medication as part of the illness symptomatology. Lower educational and poor understanding could have contributed to low scores in this section.

In the etiology subsection, participants were expected to accept the biological basis of schizophrenia. However, as majority of the caregivers were educated up to primary school, they found it difficult to understand the concept of neurotransmitters and brain function. Academic and marital stressors, which occurred temporally, were reported as etiological and precipitating factors during interview. Multiple explanatory models were commonly seen among caregivers. Our psychoeducation was not directed towards replacing their existing model with a biological model, but only attempted to incorporate the biological model into their existing model.

In our study, we noted that there was a greater change in KASI scores in subsections of diagnosis and symptomatology in comparison to etiology. This correlates with a similar study done by Das et al., 2006[14] on 100 outpatients which found that psychoeducation could not produce significant changes in explanatory models.

In the medication section, caregivers were expected to know the name, prophylactic need, and that medication has to be continued as long as prescribed by the doctor. Psychoeducation at our hospital places emphasis on these aspects, and usually, participants are well aware of this, even if they disagree. However, it may be possible that due to the lower level of education in the sample population, very few knew the names of the medication, which was required for the additional scoring on medication subsection of KASI.

In the management, course, and prognosis sections, caregivers are expected to know actions that could be damaging to the process of recovery. As a family-oriented setting, the caregiver is in contact with the patient for a majority of time, and ways to approach and manage patients are usually learnt during the course of their stay under supervision of mental health personnel including occupational therapists. This could have been responsible for good scores on these sections. Group dynamics could have also positively contributed to better understanding among cases. In addition, participants in the question and answer session following their group psychoeducation program have a special opportunity to clarify several aspects regarding management, marriage, and job which could have been responsible for the higher scores among cases in comparison to the controls.


  Conclusion Top


The study showed an increase in knowledge of schizophrenia among caregivers in all subsections of KASI with routine psychoeducation using “standard care.” However, certain aspects of psychoeducation can be addressed more effectively in groups. The study demonstrated that group psychoeducation to be an effective and feasible tool in the Indian setting (resource poor and culturally diverse) to further increase knowledge of schizophrenia, especially with regard to practical aspects such as management, course, and prognosis.

Limitations of the study

The KASI questionnaire used in our study assesses knowledge about schizophrenia in specific subsections. However, the group psychoeducation program covers several aspects of care of patients with schizophrenia, which need not have reflected completely in the KASI scores. Other factors such as relationship with patient, caregiver characteristics, duration of illness and length of stay, number of previous hospital admissions, existing knowledge about schizophrenia, severity scores on psychiatry rating scales and their association could have been studied. A small sample size is another limitation of the study. A higher effect size could have been obtained with higher sample sizes.

Though the PI was not involved in the administration of the psychoeducation, the PI was being rotated among both the units during the study and was aware of the patients in cases and controls. Since the scoring criteria were based on relative answers, PI involved in scoring could have unknowingly been biased in giving greater scores to participants in the cases group.

In comparison to other studies,[12] our group psychoeducation program was less structured with number of sessions ranging from one to four sessions. Several studies including Thara et al., 2005[12] in a study done at SCARF, Chennai had a recommendation of a minimum of two sessions. The psychoeducation program was spaced once every 2 weeks to allow adequate time for understanding of the information and discussion of their queries. KASI pretest and posttest were also adequately spaced to assess long-term retention and not immediate recall following the psychoeducation program. More than one relative per patient was allowed to attend the same psychoeducation session but were treated as separate cases. Several studies[6],[11] including Barrowclough et al., 1987, utilized a psychoeducation booklet for reference between sessions and further clarification of doubts. We supplemented the same using fact sheets written in simple and vernacular terms.

Financial support and sponsorship

This study has been funded by fluid grant, Christian Medical College, Vellore.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Thara R, Padmavati R, Lakshmi A, Karpagavalli P. Family education in schizophrenia: A comparison of two approaches. Indian J Psychiatry 2005;47:218-21.  Back to cited text no. 12
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13.
Shinde M, Desai A, Pawar S. Knowledge, attitudes and practices among caregivers of patients with schizophrenia in Western Maharashtra. Int J Sci Res 2014;3:516-22.  Back to cited text no. 13
    
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Das S, Saravanan B, Karunakaran KP, Manoranjitham S, Ezhilarasu P, Jacob KS. Effect of a structured educational intervention on explanatory models of relatives of patients with schizophrenia: Randomised controlled trial. Br J Psychiatry 2006;188:286-7.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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