INTRODUCTION:

Schizophrenia is a disorder that affects the way a person acts, thinks, and sees the world. People with schizophrenia have an altered perception of reality and may withdraw from the outside world and or act out in confusion and fear. It follows a chronic or persistent course with enduring symptoms and incomplete social recovery. There are subtypes of schizophrenia; Paranoid, Hebephrenic, Catatonic, Undifferentiated, Simple and Residual schizophrenia.

World Health Organization estimated 24 million (1%) people worldwide suffer from schizophrenia. Prevalence studies of schizophrenia in India report rates of 1.5 to 2.5 per 1000, with a crude incidence rate of 4/10,000.¹About 2% of the Kerala state’s total population suffers from severe psychiatric disorders such as schizophrenia and manic depression.^2,3Institute of Mental Health and Neurosciences (IMHANS), Kozhikode, stated 3.2 lakh people in the State suffer from schizophrenia.⁴

Schizophrenia causes behavior tribulations, i.e. aggressive behavior, violence, or social isolation that affect not only the patients' lives, but also the health status and daily routine of caregivers or family members.⁵ Psychological distress or burden of caregivers often results in poor care provided to these patients.⁶ Most studies^5,6 showed that high expressed emotion in the family leads to high relapse-rate of schizophrenia. Family members experience significant stress in coping with a person with schizophrenia and they often experience feelings of loss and sorrow.^7,8

BACKGROUND:

Family can help their loved ones get treatment and take their medication once they reached home. Family can also help patients by setting sensible goals. When persons with schizophrenia are pressured and criticized, they usually do not get well. Telling them when they are doing something right is the best way to help them move forwards.⁹

Deficient knowledge regarding the signs and symptoms of disease among caregivers is a basic and vibrant crisis. The treatment is more effective when caregivers are equipped with adequate knowledge related to schizophrenia and its home management.¹⁰ If caregivers do not have adequate knowledge and support, they might not be able to take up the duties of caring for the ill persons, thus leading to relapse or readmission.¹¹ Evaluating the care competency among family caregivers is important to ensure the therapeutic compliance and to prevent relapse.¹² But, instruments measuring the home management competency of caregivers of schizophrenia could not be identified by the researcher even with the extensive literature search.

METHODOLOGY:

Aim:

The purpose of this study was to develop and test the psychometric properties of Home Management checklist-Schizophrenia (HMCL-S) for family caregivers of persons diagnosed with schizophrenia.

Design:

This was a mixed-methods study that adopted a sequential quantitative dominant exploratory design and an instrumental development model.¹³ During phase 1, data were collected and integrated from literature review and feedback and suggestions made by a panel of subject experts regarding the content of HMCL-S. The consecutive second phase was a field test of the finalized version of the HMCL-S by conducting a cross-sectional study. (Figure-1)

Phase 1: Development of HMCL-S:

Critical literature review and in-depth interviews:

As illustrated in Figure 1, three different tasks were encompassed within the first phase of the study that lasted for about a year. First the authors conducted in-depth interviews with family caregivers attending psychiatric outpatient department with their patients for the follow up and conducted a critical review of relevant literature. A convenient sample of seven family caregivers was recruited. The mean age of these participants was 47.8 Years, and they had educational status from High school to graduation. Focused interviews were conducted by authors using a previously established interview guide. Family caregivers were encouraged to elaborate on any concerns related to taking care of persons diagnosed with schizophrenia at home. The narrative content of the interviews was then transcribed and analyzed to produce major themes.

During the same period, a critical literature review was conducted to retrieve relevant articles from PubMed, MEDLINE and Google Scholar. Many reviewed studies reported on instruments measuring knowledge about schizophrenia in general only. No specific instruments measuring caring competencies among family caregivers could find by the researchers even with the extensive review of literature. Based on the data from focused interviews done among family caregivers and extensive review of literature, a preliminary draft with 40 items having dichotomous choices (Yes/No) was formulated.

Review of the content of the HMCL-S by a panel of experts:

A panel of experts (n=7) was formed to examine the content validity of HMCL-S. The experts were all professionals practicing in the field of psychiatry/Mental health with more than 10 years of clinical or academic working experience in a hospital or a medical college located in Kerala, India.

Each expert was asked to review the relevancy, clarity, and appropriateness of each item and rate them according to a four-point scale (1=not relevant, 2=somewhat relevant, 3=quite relevant, 4= highly relevant). The Content Validity Index (CVI) of the scale was calculated as 0.87, which was higher than the 0.80, CVI value recommended for developing a new instrument.¹⁵ The researchers also incorporated the suggestions made by the experts to revise the scale by rephrasing, retaining, adding or deleting items encompassed within the HMCL-S. After summarizing the feedback from the experts, six items were excluded due to redundancy. Finally, a 34-item version of the HMCL-S was formulated.

Phase 2: Psychometric Evaluation of the HMCL-S:

This phase was primarily composed of two sections, conducting a field test and a psychometric evaluation of the collected data. During the field test, a cross-sectional survey was conducted in selected psychiatric settings in Kerala, India. Item analysis was done by computing the corrected item-to-total correlations which needed to be above 0.30 to be considered sufficiently related.¹⁴ Reliability was also evaluated by calculating the coefficient of Cronbach’s alpha for the HMCL-S. A value of at least 0.80 indicates adequate internal consistency for a well developed instrument based on the recommendations under Table-1.

Table 1: Interpretation of Cronbach's alpha¹⁶

Cronbach's alpha	Internal consistency
α ≥ 0.9	Excellent (High-Stakes testing)
0.8 ≤ α < 0.9	Good (Low-Stakes testing)
0.7 ≤ α < 0.8	Acceptable (Surveys)
0.6 ≤ α < 0.7	Questionable
0.5 ≤ α < 0.6	Poor
α < 0.5	Unacceptable

Sample:

During the process of field test, random sampling was adopted in a psychiatric outpatient department in a Neuro-psychiatric hospital in Kerala, India to recruit family caregivers of schizophrenia patients. The original number of recruit was 120. All samples were asked their ability to read and comprehend English.

Data analysis:

All the data were entered and analyzed using SPSS v.16 (SPSS Chicago, IL.). Descriptive analysis was performed to describe the item responses and characteristics of participants recruited for the study.

Ethical considerations:

The study was approved by the Institutional Ethics Committee of the hospital where the study was conducted. Family caregivers were given an informed consent form and oral explanation of the study and were given chance to clarify questions before they decided to participate in the study. All the data were anonymous. The family caregivers of schizophrenia patients were assured that they could decline participation in the study process without harm to their personal rights.

RESULTS:

Participant demographics:

The valid sample in the field test consisted of 52 family caregivers (Response rate of 43.33%) aged between 43 years to 58 years. Most caregivers were males (58%), whose mean age was 49.36 years (SD=11.22). Most of them were from nuclear family (74%) and having average family income per month was below Rs 5000 (76%). The mean duration of caring the patients was 34.31 years ranging from 21 to 44. Most (76%) of the patients were diagnosed with paranoid schizophrenia. About 40% of the caregivers had completed high school level of education and were employed. Most (92%) were married, but only 40% reported a family history of psychiatric illness.

Psychometric properties of the HMCL-S:

Item analysis:

The corrected item-total correlations of the 32 items ranged from 0.71 to 0.80 and were above the average cut-off point of 0.30. There was an improvement in Cronbach’s alpha when those item was deleted; therefore 2 items with low to the cut-off point were removed.

Internal consistency:

Cronhach’s alpha was calculated to examine the internal consistency of the HMCL-S. The coefficient alpha was 0.84 for the entire instrument and thus the instrument found to be internally consistent.

DISCUSSION:

This study reports the development and psychometric testing of Home Management checklist-Schizophrenia (HMCL-S) to measure the care-competency of family caregivers of patients diagnosed with schizophrenia. The findings provide evidence supporting the adequate internal consistency of the HMCL-S which had a Chronbach’s alpha of 0.84. The final version of the HMCL-S consisted of 32 items and takes only 10-15 minutes to complete.

Although the HMCL-S is an illness-specific instrument proposed to specifically measure the family caregivers’ competency in meeting the needs of the persons diagnosed with schizophrenia when discharged and being in home. The content of the final HMCL-S seemed to include some generic items that may also applicable to other major psychotic illnesses. Caring issues faced when schizophrenia patient having a psychotic symptom is similar having a patient diagnosed with Major Depression, Mania with psychotic symptoms or even a person in acute substance withdrawal phase. Hence the items related to caring clients reported to hear voices when alone might also be applicable to caring for patient with other psychotic illnesses.

Disease-specific items were limited in the finalized version of the HMCL-S to establish more convincing evidence sustaining the construct validity of this instrument. The family caregivers of patient having schizophrenia also encounter stressful life events such as moving to a new residence, changing school, job loss, or family conflicts that are similar to those encountered by caregivers of any chronic illnesses.¹⁷ Those psychosocial issues are not being addressed in this instrument. This instrument is a self-administered checklist and another instrument which could a professional adapted to check the caring skill is recommended.

CONCLUSION:

It is concluded from the study findings that the HMCL-S showed a reliability and validity within an acceptable range. This instrument could better be incorporated into the practice providing this with the family caregivers at the time of patients discharge. This can function as a self screening instrument among caregivers ensuring their practices in home are therapeutic to be carried on.

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Received on 29.07.2016 Modified on 05.08.2016

Asian J. Nur. Edu. and Research.2017; 7(2): 235-238.

DOI: 10.5958/2349-2996.2017.00049.0