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Nursing and Health Sciences (2016) ,

Research Article

Predictors of quality of life among Chinese people with

schizophrenia
Xiao Qin Wang,1 Marcia A. Petrini1 and Donald E. Morisky2
1
HOPE School of Nursing, Wuhan University, Wuhan, China and 2Department of Community Health Sciences, UCLA Fielding
School of Public Health, Los Angeles, California, USA

Abstract This study was designed to investigate the association of quality of life, perceived stigma, and medication adher-
ence among Chinese patients with schizophrenia, and to ascertain the predictors of quality of life. A cross-
sectional correlation study was conducted with 146 participants. All participants completed self-report scales:
the Schizophrenia Quality of Life Scale, Links Stigma Scale, and the Morisky Medication Adherence Scale.
Pearson parametric correlations and stepwise multiple regressions were performed. The total quality of life score
and psychosocial subscale was signicantly positively correlated with perceived stigma, coping orientation of
withdrawal, and feelings of stigma, and negatively correlated with age and medication adherence. The means of
all subscale scores except perceived devaluation-discrimination and different/guilty feelings were signicantly
higher than the midpoint of 2.5. The best predictors of quality of life and psychosocial domains were stigma-
related feelings: feeling misunderstood, feeling different/shame, and age. Our ndings suggest that an individuals
negative emotional response may strengthen internalized stigma and decrease quality of life. As the best predictor,
age indicated that adaptation to mental illness may relieve perceived stigma and achieve favorable quality of life.

Key words China, medication adherence, quality of life, schizophrenia, stigma.

INTRODUCTION
Schizophrenia is a prevalent and severe mental disorder and
may severely impact an individuals quality of life (QOL)
(Kao et al. 2011). QOL is the most important measurement
for evaluating outcomes and treatment of people with schizo-
phrenia, a life-long mental condition, although QOL is a
multi-dimension concept and has no agreed denition (Awad
& Voruganti 2012; Boyer et al. 2013). QOL is based on the
individuals perception of their position in life in the context
of culture and value systems (World Health Organization
Quality of Life Group 1998 p551).
Previous studies have revealed multiple contributing factors,
such as unemployment and decient nancial resources (Chan
& Yu 2004; Chan et al. 2007); residual symptoms of illness
(Wetherell et al. 2003); public stigma (Lee et al. 2005); internal-
ized or perceived stigma (Livingston & Boyd 2010; Tang & Wu
2012); and side effects of medication and medication adherence
(McCann et al. 2008; Puschner et al. 2009). These interacting
factors affect QOL and may hinder recovery from illness. Cul-
tural context plays a critical part in evaluating its perception of
individuals life with schizophrenia. Predicting factors remain
understudied in Mainland China. Pioneering research has used
global scales to assess patients, which may ignore particular char-
acteristics; therefore, this study used a disease-specic instrument.
Correspondence address: Xiao Qin Wang, Faculty of HOPE School of Nursing, Wuhan
University, 115 Donghu Rd, Wuhan, 430071, China. Email: xiaoqin_wang78@163.com
Received 22 September 2015; revision 15 March 2016; accepted 19 March 2016
For 20 years, the effect of mental health on QOL has been
recognized in Mainland China. A community-based program
was developed to improve mental health, with mental health
hospitals remaining the main provider of care and treatment
(Phillips 2013; Wang et al. 2016). Patients who are clinically sta-
ble and scheduled for discharge may face new challenges, such
as discrimination and stigma from the public and their family,
self-perceived stigma, responsibility for self-medication, and re-
sidual symptoms and adverse side effects of the medication,
resulting in relapse or re-hospitalization. Despite these chal-
lenges, no current relevant research exists in Mainland China
related to the correlation of QOL, perceived stigma, and med-
ication adherence. The objective of this study was to investigate
(i) the relationship between QOL, perceived stigma, coping
strategies, demographic characteristics, and medication adher-
ence in people diagnosed with schizophrenia before discharge
from hospital, and (ii) to determine the predictors of QOL.
METHODS
DESIGN AND SAMPLE SIZE
This study was a cross-sectional correlational design. The sam-
ple size was computed using G* power 3.0 software (Faul et al.
2007). A correlational model was used with a medium effect
size= 0.30, power = 0.80, and alpha = 0.05, in which a total sam-
ple of 82 participants was needed. The actual sample size was
146 participants.

2016 John Wiley & Sons Australia, Ltd. doi: 10.1111/nhs.12286

2 X. Q. Wang et al.
Participants and ethical consideration
Approval was obtained from the ethics committee of Wuhan
University and two psychiatric hospitals in central China. A to-
tal of 161 potential participants met the inclusion criteria: aged
1865; clinically diagnosed with schizophrenia based on Diag-
nostic and Statistical Manual of Mental Disorders (DSM-IV;
American Psychiatric Association 1994) criteria; and clinically
stable and ready to be discharged to their home or community.
Patients were excluded from the study if they were co-morbid
with dementia or substance abusers. The purpose of the study
was explained to all participants, and they were informed of
their right to withdraw at any time without consequence. After
signing the consent forms, potential participants were provided
with self-report scales and questionnaires. Nine refused and six
dropped out of the study, leaving a nal sample of 146; the re-
sponse rate was 90.7%. From October 2011 to February 2013,
the researcher collected data, providing questionnaires to be
answered independently. If a participant needed assistance,
could not read, or had blurred vision, the researcher read out
the items to be answered.
Instruments
The Schizophrenia Quality of Life Scale (SQLS) developed by
Wilkinson et al. (2000) is a disease-specic measurement for
people with schizophrenia to evaluate how their lives are im-
pacted. It contains 30 items in three subscales: psychosocial dys-
function (15 items), symptom/side effects (8 items), and
dysfunction of motivation and energy (7 items). Each item is
scored using a ve-point Likert format (0 = never to 4 = al-
ways). Four items (Nos. 12, 13, 15 and 20) are reverse coded
(0 = always to 4 = never). Responses to scales range from 100
reecting the worst QOL to 0 reecting the best. SQLS has
been reported as having acceptable reliability and validity (Wil-
kinson et al. 2000). The original scale was translated and back-
translated by psychiatric professionals. The back-translated
version was sent to the editor of Oxford Outcomes Ltd, who
suggested changes for some of the items. For example, in item
1, I lack of energy while working was changed to I lack en-
ergy while doing things; in item 9, I feel hopeless was
changed to I feel desperate; in item 14, I am always doing
things in the way that people think it is wrong was changed
to I misinterpret what people say; in item 20, I feel I can deal
with some things was changed to I think I can cope; in item
25, I get muscle cramp was changed to I get muscle
twitches; and in item 29, I feel uneasy whenever thinking
about the past was changed to I feel upset whenever thinking
about the past. These six items were translated and back-
translated once more, at which time it was agreed that no mis-
interpretation remained. Oxford Outcomes Ltd. approved the
Chinese version. Cronbachs alpha of the SQLS was 0.89 for
this study, and subscales were: psychosocial dysfunction
= 0.90, symptom/side effect = 0.80, and dysfunction of moti-
vation and energy = 0.73.
Link et al. (2002) developed Links Stigma Scales, consisting
of three subscales: perceived devaluation-discrimination
(PDD), stigma-coping orientation, and stigma-related feeling.
The scales range from 1 (strongly disagree) to 4 (strongly
2016 John Wiley & Sons Australia, Ltd.
agree); higher scores indicate greater stigma perception. The
stigma-coping orientation scale included secrecy, withdrawal,
challenging, distancing, and educating (Link et al. 2002).
Stigma-related feelings evaluate the individuals perception of
being misunderstood and different from others and ashamed
about illness ( = 0.62 and 0.70, respectively; Link et al. 2002,
2004). In this study, Cronbachs alpha of PDD, stigma-related
feeling, and stigma coping scales were 0.89, 0.73, and 0.88,
respectively.
The Morisky Medication Adherence Scale (MMAS-8) is a
universal adherence scale, in which the medication name in
each item can be replaced (Morisky et al. 2008). The total
scores ranged from 0 to 8 and were ranked as low (< 6), me-
dium (6 to < 8) and high adherence (=8). Cronbachs alpha
of MMAS is 0.71 in this study.
The social-demographic questionnaire included gender, age,
educational level, marital status, employment status, household
income per month, age of the initial onset, and duration of
schizophrenia.
Pilot study
A pilot study to test the reliability of the scale was conducted
before the main study. Thirty participants were eligible based
on the same inclusion criteria. The internal consistency for
the 30-item SQLS was = 0.85. The subscales of SQLS had
the following values: psychosocial dysfunction = 0.89,
symptom/side effect = 0.79, and dysfunction of
motivation/energy = 0.69. The internal consistency for the
46-item Link Stigma Scale was = 0.90. The subscales had the
following values: PDD = 0.88, and stigma coping orientation
scale = 0.87. The MMAS-8 had an internal consistency of
= 0.74. Data collected in the pilot study were not included in
the main study.
Data analysis
SPSS version 17.0 (IBM Corporation, Chicago, IL, USA) was
used for data analysis. Descriptive statistics were calculated
for the demographic information. Pearson parametric correla-
tions were performed to explore the relationships between
QOL, perceived-stigma, coping orientations, medication ad-
herence, and demographic characteristics. Stepwise multiple
regressions were performed to identify the best predictors of
QOL. P < 0.05 was regarded as statistically signicant.
RESULTS
The MMAS socio-demographic information and means and
standard deviation (SD) are presented in Table 1; 47.3% of par-
ticipants were men, 52.7% women. Almost 70% of participants
were aged between 21 and 40 years; and 68.5% (n = 146) had
no higher education. The age of initial onset ranged from 14
to 25 years, accounting for 65%; 71.3% of the participants were
single, divorced, and widowed.
Factors included in the PDD and coping orientation sub-
scales are presented in Table 2. According to Link et al.
(2002), the mean of each subscale was compared with the 2.5
midpoints to assess the level of perceived stigma. The means
Quality of life for people with schizophrenia 3

Table 1. Social-demographic characteristics of participants and Table 2. Means and standard deviations of stigma scores and t-test
MMAS (n = 146) compared with 2.5 midpoint (n = 146)

Frequency Percent (%) t-test comparing mean to

2.5 midpoint
Gender
Male 69 47.3 Variables Mean SD t P
Female 77 52.7
Age (years) PDD 2.53 0.43 0.81 0.42
1820 16 11.0 Stigma-coping orientation
2130 61 41.7 Secrecy 2.95 0.48 11.38 0.000**
3140 42 28.8 Withdrawal 2.63 0.37 4.11 0.000**
> 40 27 18.5 Educating 2.83 0.48 8.17 0.000**
Educational level Challenging 2.88 0.44 10.52 0.000**
None or Primary school 10 6.8 Distancing 2.72 0.44 5.96 0.000**
Junior high school 49 33.6 Stigma-related feeling
Senior high school 41 28.1 Misunderstood 2.81 0.44 8.51 0.000**
Technical school/bachelor degree 46 31.5 Different and ashamed 2.32 0.50 -4.48 0.000**
Marital status *
P < 0.05;
Single 82 56.2
**P < 0.01. PDD, perceived devaluation-discrimination; SD, standard
Married/remarried 42 28.7
deviation.
Divorced 19 13.0
Widowed 3 2.1
Employment status before hospitalization correlated with PDD (r = 0.189, P < 0.05; r = 0.193, P < 0.05);
Full-time employment/study 68 46.6
coping orientation of withdrawal (r = 0.197, P < 0.05; r = 0.179,
Part-time employment 14 9.6
Unemployment/ no study 55 37.7
P < 0.05); different and ashamed stigma-related feelings
Retired 9 6.2 (r = 0.243, P < 0.01; r = 0.219, P < 0.01); and misunderstood
Household income per month stigma-related feelings (r = 0.258, P < 0.01; r = 0.284, P < 0.05).
< 1000 Yuan 14 9.6 SQLS and the psychosocial domain were signicantly and neg-
10002000 Yuan 59 40.4 atively correlated with age (r = 0.192, P < 0.05; r = 0.183,
20003000 Yuan 41 28.1 P < 0.05, respectively), and medication adherence (r = 0.185,
> 3000 Yuan 32 21.9 P < 0.05; r = 0.196, P < 0.05, respectively).
Age of initial onset The best predictors of QOL among the variables are pre-
1419 years 37 25.3 sented in Table 4. For SQLS, stigma-related feelings of being
2025 years 58 39.7
misunderstood, difference/shame, and age entered the equa-
2635 years 33 22.6
3645 years 13 8.9
tion at the rst, second, and third steps, respectively, and
45 years and above 5 3.4 accounted for 14.1% (P = 0.000) of the variance. For the psy-
Duration of schizophrenia chosocial domain, misunderstood stigma-related feelings, age,
First episode 16 11.0 and difference/shame stigma-related feeling accounted for
< 1 year 22 15.1 16.1% (P = 0.000) of the variance. For the symptom/side effect
13 years 26 17.8 domain, difference and shame stigma-related feeling explained
35 years 19 13.0 4.2% (P = 0.014) of the variance.
510 years 33 22.6
1015 years 15 10.3
15 years and above 15 10.3 DISCUSSION
MMAS
According to Wilkinson et al. (2000) the means of total SQLS
Low adherence (< 6) 70 47.9
Medium adherence (6 to < 8) 46 31.5
and three subscales are below 40, which implies that patients
High adherence (= 8) 30 20.5 with schizophrenia have a comparatively good QOL before dis-
charge. A plausible explanation for this may be that partici-
MMAS, Morisky Medication Adherence Scale. pants have lower symptom levels and a stable mental status
prior to discharge, indicated by high SQLS scores: 92.5% of
of all subscale scores, except the PDD and different/shame feel- participants reported always or often able to carry out
ing scales, were signicantly higher than the 2.5 midpoint, sug- my day to day activities; over 54.1% feel that I can cope;
gesting that most individuals struggled to cope in various ways and 45.2% take part in enjoyable activities. A possible inter-
to relieve perceived stigma. The coping orientations most fre- pretation of these ndings is that individuals were provided
quently used in this study were secrecy (2.95 0.48) and chal- with opportunities to interact with others in the hospital envi-
lenging (2.88 0.44). ronment and received supportive and therapeutic care from
Correlations between QOL, perceived stigma, coping strate- psychiatric professionals; participation was encouraged in a va-
gies, demographic characteristics, and medication adherence riety of activities provided by nurses or therapists. All of these
are shown in Table 3. SQLS and the psychosocial domain, the factors could facilitate self-evaluation and consequently pro-
dependent variables, were signicantly and positively mote QOL. However, new challenges or difculties awaited

2016 John Wiley & Sons Australia, Ltd.

4 X. Q. Wang et al.

Table 3. Correlations among demographic characteristics, SQLS, PDD, coping orientations, and medication adherence (n = 146)

Variables X1 X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X12 X13 X14 X15

Age (X1) 1 0.597** -0.192* -0.183* -0.108 0.045 0.206* 0.033 0.112 -0.085 -0.209* 0.034 0.071 0.227** -0.051
Duration of 1 -0.076 -0.110 -0.028 0.020 0.280** 0.117 0.200* -0.081 -0.233** 0.047 0.007 0.120 -0.195*
schizophrenia (X2)
SQLS (X3) 1 0.939** 0.721** 0.765** 0.189* 0.081 0.197* -0.012 -0.011 0.036 0.258** 0.243** -0.185*
Psychosocial (X4) 1 0.637** 0.708** 0.193* 0.091 0.179* -0.002 -0.023 0.056 0.284** 0.219** -0.196*
Motivation/energy 1 0.576** 0.085 0.032 0.148 -0.078 -0.026 -0.060 0.082 0.156 -0.081
(X5)
Symptom/side effect 1 0.025 0.042 0.134 0.045 0.046 0.061 0.177* 0.204* -0.121
(X6)
PDD (X7) 1 0.338** 0.168* -0.111 -0.300** -0.066 0.151 0.373** -0.258**
Stigma-coping
orientation
Secrecy (X8) 1 0.395** 0.192* 0.044 0.108 0.297** 0.213* -0.166*
Withdrawal (X9) 1 0.186* 0.111 0.144 0.400** 0.414** -0.136
Educating (X10) 1 0.677** 0.070 0.096 -0.108 0.039
Challenging (X11) 1 0.020 0.075 -0.158 0.082
Distancing (X12) 1 0.389** 0.090 -0.062
Stigma-related
feelings
Misunderstood 1 0.263** -0.079
(X13)
Different and 1 -0.246**
ashamed (X14)
Medication 1
adherence (X15)
*P < 0.05;
**P < 0.01. PDD, perceived devaluation-discrimination; SQLS, Schizophrenia Quality of Life Scale.

the participants after discharge. Participants (38.3%) reported
always, often, or sometimes worry about my future,
while 32.9% always, often, or sometimes nd it difcult
to mix with people. All of these concerns would impact QOL.
Our ndings demonstrate that those with poorer QOL per-
ceived a higher level of stigma and more frequently endorsed
withdrawal as a coping strategy. When diagnosed with schizo-
phrenia, individuals have to face many frustrations, especially
rejection and discrimination by the public, and withdraw as a
coping strategy to avoid rejection, which may result in isolation
from society, less opportunity for employment, and ultimately a
lower QOL. Previous ndings reported that high levels of inter-
nalized stigma were correlated with decreased QOL (Switaj
et al. 2009; Livingston & Boyd 2010).
Although the PDD subscale means are not signicantly
above the 2.5 midpoints, and the different/shame feelings sub-
scale is even lower than the midpoint, participants still predom-
inantly report perceived stigma. Over two-thirds (76%)
strongly agreed or agreed that Most people would not hire a
former mental patient to take care of their children, even if
he or she had been well for some time, and 60.9% strongly
agreed, and agreed that Most young women would be reluc-
tant to date a man who has been hospitalized for a severe men-
tal disorder.
Perceived devaluation-discrimination was found to be signif-
icantly and positively correlated with age and duration of
schizophrenia, which implies that individuals who are older,
with longer disease duration experience a higher level of

Table 4. Predictors of SQLS and subscale (n = 146)

2 2
Dependent Variable Step Predictors R R Adjusted R F P

a
SQLS 1 Misunderstood .258 .067 .060 10.283 .002**
b
2 Difference/ashamed .316 .100 .087 7.922 .001**
c
3 Age .376 .141 .123 7.772 .000**
a
Psychosocial domain 1 Misunderstood .284 .081 .074 12.609 .001**
b
2 Age .349 .122 .110 9.933 .000**
c
3 Difference/ashamed .401 .161 .143 9.095 .000**
a
Symptom/side effect domain 1 Difference/ashamed .204 .042 .035 6.252 .014*
*P < 0.05;
**P < 0.01. SQLS, Schizophrenia Quality of Life Scale.

2016 John Wiley & Sons Australia, Ltd.

Quality of life for people with schizophrenia
stigma. With increasing age expectancies for those with schizo-
phrenia, people are more likely to encounter enacted or per-
ceived stigma when they are in contact with the community.
According to modied labeling theory (MLT), they internalize
the stigmatized reaction from others and label themselves as
mentally ill, leading to an increased expectation of stigma (Link
et al. 1989).
Higher levels of perceived stigma result in an increase in
avoidance coping strategies, demonstrated by signicant posi-
tive correlations between PDD and the coping orientation of
secrecy and withdrawal. Secrecy, to an extent, may be the best
choice to protect individuals against social rejection and com-
bat stigma when seeking a job or interacting with acquain-
tances. However, concealment of a stigmatized attribute
might limit opportunities and social support, and arouse shame,
resulting in negative self-evaluation and recovery (Ow & Lee
2015). Secrecy is one of the most common coping orientations
and positively correlated with PDD, and in the context of a Chi-
nese population, cultural difference needs to be taken into ac-
count. Chinese traditional cultural values and beliefs are
strongly inuenced by Confucianism, which deems that pa-
tients have schizophrenia as a result of their own moral failure;
therefore, it is understandable that Chinese people with schizo-
phrenia suffer from high levels of stigma, related to the idea of
face (mianzi) in Chinese society (Lam et al. 2010; Lv et al.
2013). Face is akin to the notion of reputation in Western
values and is a symbol of social status and identity in Chinese
social class (Lam et al. 2010; Lv et al. 2013). Unfortunately, a di-
agnosis of schizophrenia gives rise to a loss of face for the pa-
tient, family or even the whole group ; in order to preserve
face, a majority of individuals must conceal their mental dis-
orders (Yang 2007; Lv et al. 2013). Our ndings are supported
by the results of several pioneer studies (Chung & Wong
2004; Lv et al. 2013).
Only 20.5% (n = 146) of the participants recorded scores of
high adherence. Overall, adherence behavior was in the satis-
ed level because 97.9% of the participants in the study re-
ported: There were no days when I did not take the
prescribed antipsychotics medicine over the past two weeks,
and 100% said they took their medicine yesterday. It is likely
that the participants were in a stable mental state, their aware-
ness of their illness systematically recovered, and they realized
the medication was benecial for them, so were more willing to
adhere to medication. Another explanation may be that strict
management and monitoring in the psychiatric hospital ensures
that patients take drugs under surveillance and cannot refuse
prescribed treatment whether willing or not; however, 41.1%
of participants reported: Sometimes forget to take prescribed
pills, and 35.6% feel hassled about sticking to the prescribed
antipsychotics treatment plan. This nding is a potential risk
factor for non-adherence after discharge.
Negative correlations between medication adherence and
SQLS and psychosocial domain underlined that an individual
with higher medication adherence had a better QOL. This nd-
ing is understandable in that medication can control psychotic
symptoms and reduce the likelihood of relapse and re-
hospitalization, ultimately improving QOL. Considering the
correlation between medication adherence and SQLS, one
must recognize that antipsychotic medication could reduce
5
symptoms and improve QOL on one hand, but its side effects
may destroy QOL (Pinikahana et al. 2002; Kuo et al. 2007).
Puschner et al. (2009) found that QOL was inuenced by adher-
ence at baseline, and affected by symptom severity and side ef-
fects of medication at follow-up. No correlation between
adherence and the symptom/side effect domain of SQLS was
found in this study. The means and SD of symptom/side effects
(13.09 11.75) were less than other domains, indicative that the
participants experienced fewer symptoms and side effects. A
probable reason may be that psychiatric symptoms were con-
trolled by antipsychotic medications and participants were will-
ing to adhere to the medication because of a gradual recovery
of insight. Another suggestion is that the side effects could be
accepted and tolerated related to the choice of antipsychotic
atypical medication. Verication with participants medical re-
cords conrmed that most patients were prescribed atypical an-
tipsychotics, such as quetiapine, olanzapine, and risperidone.
Medication adherence was found to be signicantly and neg-
atively associated with PDD, different/shame feelings, and cop-
ing via secrecy, implying that a person with higher perceived
stigma inclined toward poorer adherence. Self-stigma was con-
sidered a patient-related obstacle for adherence, and even the
best predictor of treatment adherence (Fung et al. 2008; Tsang
et al. 2009). Additionally, the unwanted side effects caused by
antipsychotic medication can make individuals with mental dis-
orders more easily recognizable and, hence, lead to stigma and
feelings of shame (Lee et al. 2005). Consequently, individuals
adopt secrecy as a strategy for self-protection, which may in-
crease non-adherence to medication.
Not only were high levels of different/shame and misunder-
stood stigma-related feelings correlated with a decrease in the
total QOL score and the psychosocial and symptom/side effect
domain, but they were also the best predictors of QOL. This
nding suggests that feelings of shame might impact the level
of perceived stigma. When people with schizophrenia felt mis-
understood, separated, and different from others because of
mental illness, they were angry, embarrassed, ashamed, and
afraid (Link et al. 2004). These negative emotional responses
would signicantly inuence the internalization of stereotypes
into self-evaluation and, invariably, lead to the adoption of
avoidant coping orientation (secrecy and withdrawal) to relieve
shameful feelings, which may ultimately impact upon capacity
for social interaction and hinder every aspect of QOL.
Age is one of the best predictors of the dependent variables,
which implies that older age is linked with more favorable psy-
chosocial QOL. In general, QOL declines when age increases;
however, we found the opposite. A possible explanation may
be an adaptation to the characteristics of the illness to achieve
relatively better QOL via response shift (Boyer et al. 2013).
With increased age, patients may have had lower expectations
and sought more efcient ways to attain higher satisfaction
(Priebe et al. 2010). Another reason may be that the ages of
the 119 participants (81.5%) in our study were between 18
and 40; that is, they were in middle adulthood, and their phys-
ical health was better than that of elderly people. Our nding
is supported by the results of previous studies, in that individ-
uals with schizophrenia have a lower physical QOL and mild
cognitive impairment, but have improved psychosocial func-
tion with age, because they strive to adapt to the illness,
2016 John Wiley & Sons Australia, Ltd.
6 X. Q. Wang et al.
develop effective coping strategies, and increased capacity for
self-management (Folsom et al. 2009; Jeste et al. 2011; Shep-
herd et al. 2012).
Several limitations of the study should be considered. The re-
spondents were recruited from a limited number of psychiatric
hospitals via purposive sampling; the application of these re-
sults to people with schizophrenia in other areas of Mainland
China may be restricted. QOL, perceived stigma, and medica-
tion adherence are complex concepts inuenced by multiple
factors, and these variables inuence each other. Thus, rela-
tionships between the variables may be explained in reverse;
for example, an increase in age is associated with more favor-
able QOL and correlated with a higher level of perceiving
stigma; however, a higher level of perceived stigma is corre-
lated with poorer QOL. Therefore, future studies should be
conducted with a larger multi-center or multi-region sample,
using random sampling to improve the accuracy and generaliz-
ability of the results.
CONCLUSION AND IMPLICATIONS
Signicant evidence-based ndings of Chinese people with
schizophrenia were obtained: (i) the relationships that exist
among the variables of QOL, perceived stigma, and medication
adherence; and (ii) the best predictors of QOL. Misunder-
standing and difference/shame were predictors of QOL in the
psychosocial domain, which suggested that a patients negative
emotional reaction may strengthen internalized stigma and de-
crease QOL. Age was a predictor of QOL and the psychosocial
domain, which underlined that adaptation to illness could re-
lieve the perceived stigma and achieve positive QOL.
The results of this study suggest implications for clinical
practice. Because community mental health services for people
with psychiatric disorders are not well-developed in Mainland
China, psychiatric professionals play a crucial role in assisting
patients to establish positive self-evaluation and effective
coping strategies in order to weaken perceived stigma and feel-
ings of shame (Wang et al. 2016). Mental health professionals
mentor patients to adapt gradually to their mental disorder
through a variety of interventions, such as health education,
group activities, and recreation therapy. Knowledge of medica-
tion provided to patients and family members may improve
medication adherence after discharge. At the same time,
community-based psychiatric services should be established,
and psychiatric professionals should be educated to help pa-
tients adapt smoothly to society and achieve social
rehabilitation.
ACKNOWLEDGEMENT
We gratefully acknowledge all participants of the study.
CONTRIBUTIONS
Study design: XQW, PM
Data Collection and Analysis: XQW
Manuscript Writing: XQW, PM, DEM
2016 John Wiley & Sons Australia, Ltd.
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