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Aims and objectives. To examine the level of quality of life in individuals with schizophrenia and to test its association with
socio-demographic, clinical and psychosocial characteristics.
Background. Quality of life has been a focus of concern in mental health care, yet the level of quality of life and its determinants
for individuals with schizophrenia are not well known.
Design. Cross-sectional, descriptive design.
Methods. A total of 148 individuals with schizophrenia participated in the study. A demographic information sheet, the
18-item Brief Psychiatric Rating Scale, the Chinese Health Questionnaires, the Mutuality Scale and the World Health
Organization Quality of Life Scale, brief version, were used to collect data. Data were analysed with descriptive statistics,
Pearson productmoment correlation and stepwise multiple linear regression.
Results. Most of participants were single, unemployed, had a low education level and were supported financially by family.
Quality of life was positively correlated with age of mental illness onset, mutuality, employment status and monthly
household income, whereas it was negatively associated with the length of mental illness, symptom severity and health
status. Health status, mutuality, symptom severity, monthly household income and employment status were found to be key
significant predictors with mutuality having the greatest effect on quality of life.
Conclusions. The findings increase our understanding of socio-demographic, clinical and psychosocial characteristics
influencing the degree of quality of life in individuals with schizophrenia. Incorporation of families and communities into
the treatment programmes would enhance patients capabilities of social integration and satisfaction with their lives.
Relevance to clinical practice. Health care providers should make use of community-oriented intervention programmes that
aim to strengthen psychosocial functioning. Particularly, programmes that enhance health status and mutuality should be
identified and developed for both individuals with schizophrenia and their families.
Key words: community, nurses, nursing, quality of life, schizophrenia, Taiwan
Accepted for publication: 19 November 2011
2367
Introduction
Quality of life (QOL) is a worldwide matter of central concern
in schizophrenia research (Chan et al. 2007, Galuppi et al.
2010, Ho et al. 2010). Schizophrenia is a severe and persistent
mental illness affecting approximately 1% of the worlds
population (Mueser & McGurk 2004, Austin 2005). According to the Department of Health (2011), the prevalence of
schizophrenia in Taiwan affects 033% of the population.
Most patients with schizophrenia are often stigmatised and
discriminated against in Taiwanese society (Huang et al.
2008a,b, Hsiung et al. 2010, Kao et al. 2011). The clinical
characteristics of schizophrenia are often detrimental to
various aspects of life for those who are affected (Picardi et al.
2006, Eack & Newhill 2007, Meijer et al. 2009). In the
community mental health care system, a specific interest in the
QOL for patients with schizophrenia is emerging as a result of
patients continuous efforts to adapt to illness-related circumstances and other stressful daily life events.
Taiwan, along with the rest of the world, is making a
transition in mental health care from institutional to community-based health care services as part of a national policy of
deinstitutionalisation (Lin et al. 2008, Hsiao & Van Riper
2009, Huang et al. 2010). Unfortunately, most patients with
mental illness have often been discriminated against because of
negative public attitudes and have encountered difficulties in
their attempts to live in the community without sufficient
availability of adequate quality mental health care (Chan et al.
2007, Huang et al. 2008a,b; Lin et al. 2008). As a result of
reform in the mental health care system, assisting people with
schizophrenia to live in the community is an important
paradigm shift for community-oriented mental health care
(Lin et al. 2008, Galuppi et al. 2010). In addition to traditional
psychological or biological measures, it is imperative that
QOL is increasingly acknowledged as a critical outcome
measure for the effects of mental health care services on health
status in general and on schizophrenia in particular (Chan
et al. 2007, Galuppi et al. 2010). Although QOL has been
a focus of concern in mental health care, little is known
about the QOL of Taiwanese individuals with schizophrenia
living with their families in the community. Information on
QOL and its correlates is of particular importance to develop
evidence-based intervention programmes that can improve
satisfaction with multiple aspects of life for individuals with
schizophrenia.
Background
With increasing progress towards holistic care, the improvement of QOL has been recognised by health care providers as
2368
Quality of life
Methods
Study design and sampling
A cross-sectional, correlational research design was used to
recruit subjects. A convenience sample of 148 individuals with
schizophrenia was recruited from a psychiatric outpatient
department (OPD) in central Taiwan. This sample size can
detect correlations between variables with a medium effect size
at the power of 080, a of 005 and a p-value of 005 (Cohen
1992). Inclusion criteria were: (1) diagnosis of schizophrenia
according to DSM-IV criteria (American Psychiatric Association 2000), (2) aged 20 years or above, (3) outpatients living
with their families in the community have been clinically stable
for at least three months before recruitment [Clinical stability
was defined as an increase in the dose of drug(s) not more than
50% over the past three months (Lobana et al. 2001), and (4)
able to understand or speak a Taiwanese and Mandarin
language. Exclusion criteria included: (1) neuro-cognitive
impairment (e.g. dementia) or known organic disorders, (2)
current inpatient treatment, and (3) presence of visual,
language or communication difficulties.
Data collection
Data were collected between 2009 and 2010. Prior to
commencing the study, ethics approval for this study was
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Measures
Socio-demographic data
All participants completed a demographic information sheet,
which included data on gender, education, marital status,
employment status, monthly household income, age of
mental illness onset, length of mental illness and number of
previous hospitalisations.
Symptom severity
The 18-item Brief Psychiatric Rating Scale (BPRS; Overall &
Gorham 1962) was used to assess the presence and severity of
psychiatric symptoms. It is a seven-point Likert-type scale
from 0 (not present) to 6 (extremely severe). Higher scores
indicated a higher level of mental symptoms (total score
range of 0108). Cronbachs alpha has been reported, ranging from 062 to 087 (Overall & Gorham 1962, Huang et al.
2008a,b). In this study, the Cronbachs alpha was 073.
Health status
Heath status was assessed with the Chinese Health Questionnaire (CHQ; Cheng et al. 1990). It is a 12-item questionnaire and scored via the 0-0-1-1 method, with higher
scores indicating poor health status. The CHQ has been
shown to have acceptable criterion validity and satisfactory
internal consistency with a Cronbachs alpha of 084 and 083
in the community and hospital groups, respectively (Cheng
et al. 1990). Cronbachs alpha for the present sample was
084.
Mutuality
The Chinese version of the Mutuality Scale (Shyu et al. 2010)
was used to assess the quality of relationship between the
caregiver and the care recipient. The scale is composed of 15
2370
Data analysis
Data were analysed using the Statistical Package for the
Social Sciences (SPSS ) version 17.0 for Windows (SPSS,
Chicago, IL, USA). Statistical significance was determined
at p < 005. Descriptive statistics such as frequency, mean
value and standard deviation were used to analyse sociodemographic, clinical and psychosocial characteristics. The
Pearson productmoment correlation test was used to examine the association of QOL with socio-demographic, clinical
and psychosocial characteristics. Stepwise multiple linear
regression was carried out to test variables that had significant correlations with QOL to determine the relative
importance of the variables in contributing to variation in
QOL.
Results
Characteristics of participants and main study variables
The characteristics of participants and the mean and standard
deviation of main study variables are summarised in Tables 1
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 23672376
Quality of life
69
79
466
534
109
15
24
736
101
163
51
97
345
655
47
72
29
318
486
196
63
85
426
574
133
15
899
101
%
3865 1043
248 602
7
141
47
953
133
6
1
8
898
41
07
54
139 978
Predictors of QOL
Variables
SD
Range
Possible
range
Symptom severity
Health status
Mutuality
Total quality of life (QOL)
Physical health
Psychological health
Social relationships
Environmental features
380
530
3393
9030
1328
1243
1279
1297
383
306
1572
1857
279
298
322
307
023
012
060
32132
420
519
420
420
0108
012
060
28140
420
420
420
420
Pearson productmoment correlation coefficients were calculated to examine the association of QOL with sociodemographic, clinical and psychosocial characteristics. All
variables were considered as continuous except gender,
education, marital and employment status and monthly
household income, which were dichotomous. QOL was
positively and statistically significantly correlated with age
of mental illness onset (r = 025, p < 001), mutuality
(r = 0508, p < 001), employment status (r = 0229,
p < 001) and monthly household income (r = 0303,
p < 001) and negatively correlated with the length of
mental illness (r = 0285, p < 001), symptom severity
(r = 0306, p < 001) and health status (r = 0194,
p < 005). Patients with early onset of schizophrenia, greater
mutuality with their family caregivers, employment and
greater monthly household income perceived greater satisfaction with their QOL. Likewise, patients who perceived less
satisfaction with their QOL were those who had longer
duration of schizophrenia, severe psychiatric symptoms and
worse health status. There was no significant relationship of
QOL with gender, number of previous hospitalisations,
marital status and education.
2371
b
0495
0315
0247
8014***
5087***
3941***
0153
1328
0116
0083
0106
2437***
279
1741
1227
1565
Discussion
This is one of the few studies that has investigated QOL and
its correlates (i.e. socio-demographic, clinical and psychosocial characteristics) in individuals with schizophrenia living
with their families in the community. Although these are
critical variables in the care of people with mental illness,
prior research has primarily focused on socio-demographic
and clinical factors as predictors (Chan et al. 2007, Xiang
et al. 2008, Meijer et al. 2009). Knowing the relative
contributions of multiple factors that influence QOL in
people diagnosed with schizophrenia can help provide insight
for preventions as well as interventions for improving
satisfaction with various aspects of life.
The mean scores for QOL and its four domains (i.e.
physical health, psychological health, social relationships and
environmental factors) in this study were lower than those for
the general population in Western countries (Bobes &
Carcia-Portilla 2006, Picardi et al. 2006, Evans et al. 2007)
and Eastern countries (Kunikata et al. 2005, Xiang et al.
2007, Yen et al. 2008). Further, our respondents reported
less satisfaction with their psychological and social relationships compared with other aspects of life, which is consistent
2372
Quality of life
Limitations
The results of this study should be interpreted with caution
because of several methodological limitations. First, the study
was cross-sectional; therefore, the results cannot be used to
infer causality. Given that the degree of mutuality and QOL
may change over time, the extent of QOL and its determinants need to be investigated longitudinally, to show subtle
changes throughout the course of schizophrenia. Secondly,
the study only recruited outpatients with schizophrenia living
with their families in the community, precluding generalisation to all patients with schizophrenia. Therefore, replication
of the current findings with inpatients is necessary. Finally, a
potential limitation of the study was the use of WHOQOLBREF, a generic questionnaire that may not have been
sensitive enough to detect subtle changes of QOL in persons
with schizophrenia. More specific instruments with sensitive
gradations such as the Schizophrenia Quality of Life Scale
Revision 4 (SQLS-R4; Kuo et al. 2007) should be used for
future studies.
Conclusion
Schizophrenia is a taxing and demanding illness that interrupts the QOL in affected individuals and their families. The
findings of this study underline the deleterious effect of low
mutuality, high symptom severity, low monthly household
income and unemployment status on QOL in patients
with schizophrenia living with their families in Taiwan.
2373
Additionally, this study further expands the existing caregiving literature on the importance of patients mutuality with
their family caregivers and its impact on the satisfaction of
QOL in schizophrenia. Apparently, the emphasis on holistic
care needs to go further by looking at information not only
on the psychopathological symptoms but also on psychosocial characteristics. Knowledge gained from this study is
critical for health care professionals to incorporate families
and communities into treatment programmes and, in turn,
enhance patients capabilities of social integration and
satisfaction with their lives.
Acknowledgements
We would like to express our sincere appreciation to the
research participants for their corporation. Sincere thanks to
Chung Shan Medical University Hospital, Taiwan for funding this study (CSH-2010-A-011).
Contributions
Study design: CYH, CCC; data collection and analysis: CYH,
MHH CJT, SHC, CCC and manuscript preparation: CYH,
MHH, CJT, SHC, CCC.
Conflict of interest
No conflicts of interest.
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