Family support and adaptation mechanisms of adults outpatients with schizophrenia.

Background: The presence of psychotic symptoms in adults' with schizophrenia need an increase in family control and support to prevent the risk of aggressive behavior. However, the issue of whether psychotic symptoms hold any clinical relevance in relatively stable outpatient samples has not been established. The purpose of this study, therefore, was to identify the relationship between family supports and adaptation mechanisms of adults' outpatients with schizophrenia. Design and methods: The study design involves quantitative research and descriptive correlation, attained through purposive sampling approach. 101 samples were obtained from the population of schizophrenia outpatients. The questionnaires of House & Kahn were used as an instrument to evaluate family support, while Nursalam questionnaires were used to access adaptation skills.
Results: Findings from Spearman's rho test showed P<0.005, indicating the provision of high family support, while patients were highly adaptive to the symptoms of schizophrenia. Conclusions: This study indicates the positive influence of family support on the adaptability of schizophrenia outpatients, hence there is need for relatives to provide good level of support, in order to facilitate adaptability. ©Copyright: the Author(s).

Introduction

Schizophrenia is a disease that affects the brain, leading to perceptions, emotions, movement, and behavioral disturbances.[1] This is characterized by the symptoms of delusions, hallucinations, disorganization of the mind, speech disorder and irregular behavior.[2] The signs and symptoms of hallucinations include frequent laughter, hearing things, disturbed speech, a decline in the ability to solve problems, disorientation with respect to time, place, and people, anxiety, and also changes in sensory function.[3] According to the WHO, about 450 million people worldwide experience mental health disorders, which is approximately 1 out of every 4 individuals. Schizophrenia in particular is ranked 4th out of the 10 top diseases, based on the report that states the existence of about 25,000,000 sufferers.[1] This illness is manifested by 0.46 % of Indonesian, alongside severe psychotic disorders, according to the mental health data of PUSLITBANG Ministry of Health, Republic of Indonesia, while the prevalence of severe mental disorders, including schizophrenia is 1.7% or 400,000 people. The preliminary studies conducted at the Menur Mental Hospital, Surabaya, on January 17th, 2017, within the last three months, showed the presence of 5,816 registered patients undergoing outpatient treatments, and 337 hospitalized patients, 135 of which experiencing hallucinations, based on the nursing diagnostics. Family is a major support system that provides direct care to healthy people, as well as schizophrenia patients.[4] Previous researches have shown the practice of self-care in about 70% of ten families, which involves making the patient available for treatment, providing supervision while taking medications, and engaging the individual with activities. Specifically, family support includes the provision of emotional, informational, instrumental and research assistance by the client’s relatives, in order to maintain a therapeutic regime.[5-7] The delivery of home care by the family members to strengthen and augment health services maintains the independence and dignity of schizophrenia outpatients.[8] Being the closest unit to a patient, families play a role in determining the nature of care, and also to prevent relapse. This participation helps in the initiation of treatment at home, in order to prevent the possibility of relapse.[9] The support provided has been associated with the decline in stress levels, which consequently strengthens the individual and collective mental health. Furthermore, social support is an important coping strategy adopted to protect families from stress, as an affected persons lack the ability to accomplish vary social functions.[10] Further, family support form a stronger and self-respecting individual for achieving a better level of healing and social functioning.[11,12] Therefore, there is a need to structure family interventions in a model of comprehensive care. This background shows the importance of identifying the relationship between family support and adaptation mechanisms of adults’ outpatients with schizophrenia.

Design and methods

This study was approved by research ethics committee from Menur Hospital Surabaya (Rumah Sakit Jiwa Menur Surabaya), and it uses analytic correlation with the cross-sectional design. The population includes 135 schizophrenia outpatients and their families, living in the Surabaya area. 101 samples were selected and followed for 12 months, and the investigation was conducted with family considered as the independent variable, while adaptability was dependent variable. The measurement of social support required the use of a questionnaire developed by House and Kahn (1085). This consisted of 24 questions, in 4 parts, within the domains of social (1,3,5,7,9,11), information (2,4,6,8,10,12), instrumental (13,15,17,19,21,23) and valuation support (14,16,18,20,22,24). In addition, respondents’ adaptation mechanisms were measured by the use of an adaptation response questionnaire ideated by Nursalam, encompassing social, spiritual and psychological responses. SPSS 22.0 was used for data analysis, with p<0.05 considered as statistically significant. Descriptive statistics was performed to describe the respondents’ family support, while Spearman’s Rho statistical test was applied to determine the relationship between family support, and adaptation mechanisms of adults’ outpatients with schizophrenia.

Results and discussion

Table 1 shows the respondent’s family characteristics, where the highest proportion in age was in the age range 36-55 years (50%), with the majority being women (80%). In addition, the most recently acquired education level was mainly high school (80%), with a higher percentage having a job (70%). The most dominant relationship to the patient was that of mother and child (50%).

Table 1.

Characteristics of families.

Category	N=101	Percentage
Age
15-35 years old	20	20
36-55 years old	51	50
56-75 years old	30	30
Gender
Man	20	20
Girl	81	80
Educational Level
Junior High School	20	20
High school	81	80
Working Status
Working	71	70
Not working	30	30
Relationship with patients
Mother	50	50
Husband	10	10
Sister	10	10
Daughter	21	20
Son	10	10

On the other hand, Table 2 shows the characteristics of schizophrenia outpatients, where the highest proportion in terms of age was in the age range of 15-35 years (40%) with the male as the most common sex (61%). In addition, high school education was recently acquired by 40%, and most patients were not involved in any form of work (61%).

Table 2.

Characteristics of adults outpatients with schizophrenia.

Category	N=110	Percentage
Age
15-35 years old	41	40
36-55 years old	30	30
56-75 years	30	30
Gender
Male	61	61
Female	40	40
Educational level
Elementary school	20	20
Junior high school	20	20
High school	41	40
University	20	20
Work
Working	41	41
Not working	60	60

Table 3 shows the measurements collected from respondents regarding family support, where the majority (61%) testified to have received assistance both socially, information-wise, instrumentally, and also in terms of appraisal support.

Table 3.

Types of family support.

Types of family support	N= 101	Percentage
Social support
High	61	60
Moderate	40	40
Low	0	0
Information support
High	61	60
Moderate	40	40
Low	0	0
Instrumental support
High	61	60
Moderate	40	40
Low	0	0
Appraisal support
High	61	60
Moderate	40	40
Low	0	0

Family support has a value of 60% for high support, and 40% for moderate support, respectively. Family support is a very important prerequisite to meet the psychosocial needs of family members, characterized by the provision of care, love, warmth and mutual assistance between relatives.[13,14] More than half of families provide high emotional support (60%), which was the main coping goal in dealing with adaptation. This is possibly realized in the form of affection, trust, attention, listening and being listened to, in order to attain adherence to patient’s adaptability. Furthermore, this approach also strengthens the family, subsequently leading to the avoidance of psychosocial effects.[15,16] There is also a provision of high information support (60%), especially in the form of advice or direction, alongside the delivery of important information required to improve the current health status. Meanwhile, this form of support was assumed as a form of family function in maintaining the health condition of affected relatives, subsequently enhancing productivity. Therefore, this practice is important as it helps increase enthusiasm and motivation, leading to an optimal improvement in personal adaptabilities.[16-19] This study showed the provision of high instrumental support (60%), characterized by the burden of implementing care which include financial costs, for management and treatment, as well as the provision of shelter, food, and transportation. Meanwhile, instrumental support is an economic and health care function, often applied by families, through the accordance of attention. This is attained by regularly conveying patients to the mental facility, seeking advice related to the development of patient care, maintaining the adherence to medications, and engaging the patient in activities. Despite the family burden related to mental health access, especially in the aspect of finances, it is very important to conduct this exercise.[16,20-22] High appraisal support (60%) affects the function of patients, subsequently improving the health status. This practice is also recognized for the impact on minimal and simple abilities in other activities, including the direct positive influence on self-esteem. Therefore, the adaptability of patients are improved by the increase in support.[23,24] Table 4 shows the distribution of respondents’ adaptation abilities, where about 70% were able to perform social, psychological, spiritual as well as appraisal response. Better adaptation mechanisms were found in schizophrenia outpatients with high family support (100%), compared to moderate (25%), while maladaptive adaptation was highly expressed in moderate (75%), in contrast with high (0%).

Table 4.

Adaptation of schizophrenia outpatients.

Category	N=101	Percentage
Social response
Adaptive	71	70
Maladaptive	30	30
Psychological response
Adaptive	70	70
Maladaptive	31	30
Appraisal response
Adaptive	70	70
Maladaptive	31	30
Spiritual response
Adaptive	71	70
Maladaptive	30	30

The capacity of adaptation demonstrated social adaptive abilities (70%), as this high level is strongly influenced by social response. This is assumed to capably describes an individuals’ tendency to interact properly with the environment, which is subsequently used to assess the patient for adaptive or maladaptive competence.[5,25] The adaptation capacity demonstrated adaptive psychology (70%), which is dependent on an individuals’ stress level.[25] The responses for adaptation capacity in relation with family support ratings were 70%, as patients find it difficult dealing with the stigma attributed by the community towards “crazy people”, This involves individuals with strange behavior, characterized by a challenging healing process, and the experience of social isolation, therefore exaggerating the feeling of inferiority, and the practice of social contact avoidance. It is very important for families to pay attention to the appraisal responses, in order to facilitate the provision of better support and enhance interactive skills with others.[26,27] The ability to familiarize with spiritual responses in adaptive family support was 70%, as hallucinatory patients tend to easily surrender to God in times of trials. This encompasses the ability to for sufferers to accept the befalling conditions and subsequently submit to God.[28] Furthermore, the rho value of correlation from table 5 obtained from the Rank spearman test was 0.803 (very strong), with significance (P=0.00), where H0 in declined if P<0.05. This indicates the existence of a relationship between family support and adaptation mechanisms of schizophrenia outpatients. The results showed a 60% adaptive adaptability for patients provided with family support. This particularly showed the affective function of family, as an internal task, performed in order to meet up with the psychosocial needs of affected members, through the provision of care, love and mutual support.[29,20] The family is also assumed to be the most comfortable environment for schizophrenia patients, based on the collective ability to boost enthusiasm and motivation for adaptive behavior. This is attained through the provision of family support, as well as appropriate care and treatment facilities, which is perceived through the attitude, action, and acceptance by family members. Also, the affected individuals experience varying nature and types of support, in the form of emotional, information, instrumental and appraisal support, which is important for the attainment of satisfactory healing.[29,30] Family support greatly influences the adaptation level of hallucinatory patients (100%). Therefore, it is necessary to demonstrate the affective internal functions required to meet obtain the numerous psychosocial needs, which includes caring for one another, providing love, and warmth.[13,14]

Table 5.

The relationship between family support and adaptation of adults outpatients with schizophrenia

	Adaptation of schizophrenia outpatients
Family support	Adaptive response		Maladaptive response
	N=71	%	N=30	%
High	61	100	0	0
Moderate	10	25	30	75
Low	0	0	0	0

Spearman's Rho statistical test, P=0.000.

Conclusions

This study indicates the positive influence of family support on the adaptability of schizophrenia outpatients, hence there is need for relatives to provide good level of support, in order to facilitate adaptability.