Drug Attitude and Medication Adherence Behavior among Schizophrenic Patients

Introduction

 Schizophrenia is one of the most serious psychiatric disorders. It carries a lifetime risk for approximately 1% of the population. The symptoms of schizophrenia remain perhaps the most mysterious form of human psychological experience. Early onset of the disease, most often occurs between the age 15 and 30 years old (1). Schizophrenia is a combination of disordered thinking, perception, behavior, affect, and impaired social competency; which means that a schizophrenic patient has difficulty thinking clearly, knowing what real, managing feelings, making decisions, and relating to others (2)

Knowing the attitude of patients towards drugs is very important in patients suffering from psychiatric disorder as schizophrenia. Negative attitude of patient towards psychiatric medication is the foremost cause for nonadherence to medications(3).Additionally, certain study has also found that attitudes of family members and their knowledge of the patient’s illness contribute to adherence and that attitudes of the family toward psychotropic medications can influence the attitudes of patients toward these medications(4).

Non-adherence to medication is widely agreed to be one of the most important factors limiting the success of treatment. Additionally, it may constitute a determinant factor affecting the magnitude of health care costs and the cost effectiveness of antipsychotic medications, since high adherence levels can greatly reduce the risk of relapse and subsequent hospitalization costs (5).

The effectiveness of nursing interventions in schizophrenia depends not only on patient performance, but also on the involvement of the entire family and society. This is extremely important in the recovery process. For this, a multidisciplinary and networked effort is crucial. Thus, the nurse’s capacity for teamwork is also one of the essential characteristics (6). As educators and advisers, psychiatric nurses can collaborate with schizophrenic patients to improve medication adherence and other outcomes using shared decision-making techniques and tools that engage and empower clients to actively participate in decisions about their treatment (7).

Significance of the study

A variety of research found that, adherence to the medication regimen was the main factor of success in treating patients with schizophrenia. Thus, non-adherence to treatment means patients do not follow the treatment recommendations and regimen. Non-adherence to medications is a complicated and multidimensional health problem since it is considered a major hindrance in making treatment efficacy, increase the risk of relapse and subsequent re-hospitalization. On the other hand, through clinical experience; the researcher noticed that a great number of schizophrenic patients have been re-hospitalized. According to Minia Hospital for Mental Health and Addiction treatment statistics was done every 3 months, about half of schizophrenic patients (50%) were re-hospitalized and have relapse of their disorders.

Aim of the Study:

The aim of this study was to assess drug attitude, and medication adherence behavior among schizophrenic patients.

Research Questions:

Is there a relationship between drug attitude and medication adherence behavior among schizophrenic patients?

Subjects and Method:

Research Design:

A descriptive correlational research design was used in this study.

Research Setting:

This study was conducted at Minia Hospital for Mental Health and Addiction treatment. This hospital is affiliated to Ministry of Health located at New Minia City. It consists of two floors; the first floor for the Outpatient clinics, Pharmacy and Female inpatient unit. The second floor includes Department of Administration, Department of Addiction treatment, Inpatient male unit and the Nursing office. The hospital capacity is 53 beds for both genders and serves all Minia governorates.

Study subjects:

 A purposive sample consisted of 50 male and female schizophrenic patients were participating in this study.

Inclusion criteria

• Patients between the ages of 18 and 55 years.
• The patient should be in treatment for at least three months prior to inclusion in the study.

Exclusion criteria

• Mental retardation.
• Co-morbid diagnosis of substance dependence.
• Organic brain disease.

Tools of Data Collection

Data were collected through using of the following tools:

Personal demographic and clinical data questionnaire:

The researcher developed an interview questionnaire and covered the following items: Personal data, date of admission, duration of illness, history of hospitalization, number of previous hospitalization, and total duration time of hospitalization.

Drug Attitude Inventory scale (DAI-30):

Drug attitude inventory was developed by Hogan et al, (1983) (8). .This scale, developed to measure patient's subjective responses and attitudes towards maintenance of antipsychotic drug therapy. It consisted of 30 items ;15 items for patient who is fully adherent to his/ her prescribed medication (and so would be expected to have a ‘positive’ subjective response to medication) would answer as ‘True’, and 15 items such a patient would answer as ‘False'. To calculate the score from a set of answers, each ‘positive’ answer is given a score of plus one, and each ‘negative’ answer is given a score of minus one. The total score for each patient is calculated as the sum of the pluses and minuses items. A positive total score indicates a positive subjective response and a negative total score indicates a negative subjective response.

 The studied sample total scores were divided into 4 groups on the following basis:

• From – 30 to 0:  No attitude
• From  0 to 10  : Poor attitude
• From 10 to 20 : Partial attitude
• From 20 to 30 :Good attitude

Reliability:

The reliability of the tool was done by the statistician and revised by the supervisors. The internal consistencies of the questionnaire were calculated using Cronbach's alpha coefficients test. The Cronbach’s alpha of the questionnaires was 0.84, indicate good reliability.

Medication adherence behavior tool:

Medication adherence behavior tool was developed by the researchers; it consisted of 16 items. It was designed to facilitate the recognition of adherence behavior to psychotropic medications. Response choices were 'yes’’ or ‘‘no’’ for all items except item 8 has a five-point Likert response scale from (0-4). Each ‘‘no’’ response was rated as (1) and each ‘‘yes’’ response was rated as (0) except for item 5 in which each ‘‘yes’’ response is rated as 1 and each ‘‘no’ ’response is rated as 0 (reverse score). The studied sample was grouped into 3 categories:

• From 4-8 : poor adherence,
• From 9-12 : partial adherence
• From 13-17: good adherence.

Reliability:

The reliability of the tool were done by the statistician and revised by the supervisors. The internal consistencies of the questionnaire were calculated using Cronbach's alpha coefficients test. The Cronbach’s alpha of the questionnaires was 0.85, indicate good reliability.

Content Validity:

The tools were submitted to three experts in psychiatric mental health nursing to test their validity (Minia, Assuit and Cairo Universities, Faculty of Nursing, Psychiatric Nursing department) and the necessary modifications were done.

Procedure:

A review of the related literature which covering various aspects of the problem was done, using available books and journals, to get acquainted with the research problem and to implement the study.

Tools of the study were translated into Arabic by the researchers and were revised by the supervisors.

An official permission was obtained from the research ethical committee of Faculty of Nursing and the director of Minia Hospital for Mental Health and Addiction treatment at Minia governorate to conduct the study.  Data of the studied sample were obtained and recorded by the researchers. At the beginning of the interview the researchers greeted each participant, explained the purpose and duration of this study and informed oral consent was taken. The researchers went to the hospital for two days/ week (Saturday, Sunday) from 10 a.m. to 1 p.m. to meet with the studied sample after finishing their breakfast and taking their medications.

Pilot study:

Pilot study was done to evaluate the tools clarity and applicability as well as the time needed to complete each questionnaire. It was carried out on 10 patients; this number was excluded from the total sample. All sample recruited in the pilot study met the inclusion criteria.

Statistical Analysis:

The collected data were coded, categorized, tabulated, and analyzed using the Statistical Package for the Social Science (SPSS 24). Quantitative data were expressed as frequency and percentage. Relations between different numerical variables were tested by using Pearson correlation. Probability (p-value) less than 0.05 was considered significant.

Ethical consideration:

A written initial approval was obtained from the Research Ethical Committee of the Faculty of Nursing,   Minia University, there is no risk for study sample during application of this research, the study followed common ethical issues for participation in the clinical research, privacy was provided during data collection. Anonymity and confidentiality were assured through coding the data; each patient has the right to refuse to participate in the study without any rationale. Informed oral consent to participate in the study was obtained from educated and uneducated studied sample. A written consent was also obtained from the Patients’ Rights Committee in Minia hospital.

Results

Table (1): Frequency distribution of the studied sample personal demographic data (n= 50).

Table (1) shows that, 40% of the studied sample are in age range of 28 <38years old. While more than half of them are males, 46% are married and have a secondary school education, while more than half of the studied sample is unemployed.

Table (2): Frequency distribution of the studied sample clinical data (n= 50).

Table (2) shows that, 40 % of the studied sample suffered schizophrenia for more than three years, while the majority of them were previously hospitalized. Regarding duration of hospitalization, more than half of the studied sample stayed in the hospital for < 2 months and 40% of them were admitted once to the hospital.

Table (3): Frequency distributions of Drug Attitude Inventory (n= 50).

Table (3) showed that, more than three quarters of the studied sample had no attitude, while 22% of them had poor attitude.

Table (4): Frequency distributions of Medication Adherence Behavior (n= 50).

Table (4) revealed that, about three quarters of the studied sample had poor adherence, while 26% of them had partial Medication Adherence

Table (5): Correlations among drug attitude inventory in relation to personal demographic and clinical data (n=50):

Table (5) shows correlations between Drug Attitude Inventory in relation to personal demographic and clinical data. Significant positive correlations are found between Drug Attitude Inventory, education and duration of hospitalization (r=.031 at p= 0.007, r=.009at p=0.04 respectively).

Table (6): Correlations between Medication Adherence Behavior and different Personal demographic and clinical data (n=50).

Table (6) reveals only one significant positive correlation between Medication Adherence Behavior and Marital status (r=.025 at p= 0.03) only.