Skip to main content
NCBI home page
SAGE Open Nursing logoLink to SAGE Open Nursing
. 2024 Feb 6;10:23779608241231000. doi: 10.1177/23779608241231000

Effectiveness of an Integrative Empowerment Intervention for Families on Caring and Prevention of Relapse in Schizophrenia Patients

Dwi Indah Iswanti 1,✉, Nursalam Nursalam 2, Rizki Fitryasari 2, Rika Sarfika 3, I Made Moh Yanuar Saifudin 4
PMCID: PMC10851764  PMID: 38333904

Abstract

Introduction

Patients with schizophrenia require extended treatment and recovery, leaving their families and support systems feeling helpless. Integrative empowerment is a strategy that utilizes outside-in and inside-out empowerment to increase the ability of families to care for their loved ones and prevent relapse.

Objective

This study aimed to investigate the impact of integrative empowerment intervention on enhancing the family's ability to care for and prevent relapse in patients with schizophrenia.

Methods

The study employed a quasi-experimental with a pre-test and post-test control group design. The research sample was comprised of 70 individuals from nuclear families residing in Semarang, all of whom were responsible for the care of individuals with schizophrenia. The participants were divided into two groups: the treatment group, consisting of 35 individuals, and the control group, also comprising 35 individuals. Participant selection was carried out using purposive sampling. Module and booklet were produced as an intervention tools. The integrative empowerment intervention program spanned a period of 5 weeks, involving one session per week, each lasting approximately 60–90 min. Data analysis was conducted through the utilization of the Wilcoxon and Mann–Whitney tests. The significance level for the study was set at p<.05.

Results

There was a significant change in the family's ability to care for patients with schizophrenia before and after the integrative empowerment intervention (p<.001), while there was no change in the control group's ability to care for patients with schizophrenia (p>.05). Integrative empowerment had a significant impact on increasing the family's ability to care for and prevent relapse in patients with schizophrenia (p<.001).

Conclusions

Nurses can help families strengthen their positive caregiving experiences through the home visit program by utilizing integrative empowerment. This study's findings highlight the importance of integrative empowerment in enhancing the family's ability to care for and prevent relapse in patients with schizophrenia.

Keywords: family ability, family nursing, integrative empowerment, schizophrenia

Introduction

Schizophrenia affects approximately 0.24 cases per 1000 populations, which translates to about 21 million cases worldwide (Sadock et al., 2017). Unfortunately, the rate of relapse among schizophrenia patients has been increasing over the last 3 years, from 28.0%, to 43.0%, and eventually to 54.0% (Pothimas et al., 2020). Records from the Psychiatric Hospital in Central Java showed that in 2021, 765 patients with schizophrenia were undergoing treatment, and the readmission rate within 0 days was 19% (Regional Psychiatric Hospital of Dr. Amino Gondohutomo, 2021). One of the factors contributing to such a short readmission period is the family's inability to care for the patient during relapse (Kandar, 2017).

According to Herdman et al. (2014), the treatment and recovery of schizophrenia patients require a long-term care which can deplete the supportive capabilities of families, leaving them feeling helpless. Kusumawardani et al. (2019) have also observed that families are unable to make appropriate decisions during schizophrenia relapse and may struggle to modify the environment to be comfortable and conducive for the patient. The prevalence of schizophrenia appears to be just the tip of the iceberg due to families’ reluctance to seek healthcare facilities for the condition (Rahayuni, 2019; Verity et al., 2021).

The burden on families caring for schizophrenia patients is significant, leading to feelings of helplessness and difficulty in making appropriate decisions during relapse episodes (Koujalgi & Patil, 2013). Reluctance to seek healthcare contributes to the underestimation of schizophrenia prevalence. High readmission rates indicate the family's limited ability to care for patients during relapse (Shamsaei et al., 2015). Hence, it is crucial to investigate the effects of interventions aimed at bolstering family capacities and enhancing long-term patient outcomes. The development of an integrative empowerment intervention that centers on families as caregivers and aims to prevent relapses in individuals with schizophrenia is an immediate priority.

Empowerment interventions are designed to enhance individual or community capacity for informed decision-making and self-control, as explored in the existing literature (Indah Iswanti et al., 2023; Robbins et al., 2002). An integrative empowerment approach distinguishes itself by encompassing a broader spectrum of factors and acknowledging the interconnectedness of biological, psychological, social, and environmental dimensions. Unlike more narrowly focused interventions, the integrative model adopts a holistic perspective, recognizing the complex interplay of individual, family, and community dynamics (Indah Iswanti et al., 2023). This approach seeks sustainable, long-term impacts, addressing not only immediate empowerment needs but also influencing systemic changes that support empowerment over time.

The literature on empowerment interventions suggests the need to identify and use family resources and strengths, such as acceptance of schizophrenia and the development of spirituality (Indah Iswanti et al., 2023; Mouchrek & Benson, 2023). Therefore, the integrative empowerment intervention is unique in its focus on family-centered care and prevention of relapses in individuals with schizophrenia, and it seeks to address the complex interplay of individual, family, and community dynamics.

Review of Literature

Schizophrenia is a debilitating mental disorder with persistent symptoms requiring prolonged treatment (Leucht et al., 2012). It ranks among the top 15 global causes of disability, imposing significant financial burdens on patients, families, and society (Domínguez-Martínez et al., 2017; Sadath et al., 2015; Vos et al., 2017). Symptoms include disruptions in cognition, perception, behavior, such as delusions, hallucinations, disorganized speech, and impaired functioning (American Psychiatric Association, 2013; Buckley & Foster, 2008).

The inability of families to effectively care for and prevent relapse in individuals with schizophrenia can have significant and wide-ranging impacts (Chakraborty et al., 2013). One of the consequences is increased treatment costs, as the lack of adequate family support may result in prolonged hospitalizations, frequent outpatient visits, and the need for additional interventions. The extended care duration places a strain on both the family and the patient, as they face ongoing challenges associated with managing the symptoms and navigating the complexities of the illness (Yu et al., 2021; Zhou et al., 2020).

Findings of previous study demonstrated the effectiveness of the empowerment intervention in diminishing feelings of hopelessness in individuals with schizophrenia (Hasan & Musleh, 2017). Another previous study discovered that family interventions not only reduce the frequency of relapses and hospitalizations among individuals with schizophrenia but also enhance the overall family environment (Pharoah et al., 2010). In contrast, a different study highlighted the limited availability of family interventions with a primary focus on the well-being of family caregivers. Most interventions tend to emphasize improvements in individuals with schizophrenia, particularly in terms of relapse rates (Awad & Voruganti, 2008).

The integrative empowerment model is an intervention that combines outside-in empowerment and inside-out empowerment (Zhou et al., 2020). The basic components of the integrative empowerment model include schizophrenia management and caregiver stress management to address the difficulties and stressful situations faced by families in caregiving. Additionally, it helps families grow and explore new meanings in the process of caring for the patient by assessing positive aspects and emphasizing contributions in the relationship (Zhou et al., 2020).

Family-focused interventions that enhance understanding of schizophrenia and promote healthier family dynamics have dual benefits for both individuals with schizophrenia and their families. These interventions aim to effectively manage the illness and symptoms while improving family relationships and overall functioning (Chien, Ma et al., 2020). High caregiving burden can lead to high emotional expression towards patients and increase the risk of relapse, thus family interventions with supportive and educational elements is crucial in meeting the family's health needs (Chien, Bressington et al., 2020). Therefore, the objective of this study was to determine the impact of the integrative empowerment intervention on improving the family's ability to care for and prevent relapse in patients with schizophrenia.

Methods

Design

The study was a quantitative quasi-experiment with a pre-test and post-test control group design.

Research Question

The following research question were formulated in this study, including: (1) What is the effect of an integrative empowerment model on family members ability to provide caregiving including fulfilling activities of daily living (ADL) needs, assisting social interactions, and assisting productive skills towards schizophrenia patient, when comparing the intervention and control groups before and after the intervention?, (2) What is the effect of an integrative empowerment model on family members ability to prevent relapse, including recognizing relapse symptoms, acceptance of schizophrenia, medication adherence, and utilization of health services towards schizophrenia patient, when comparing the intervention and control groups before and after the intervention?

Hypothesis

Hypothesis of this study were as follows:

  • (H1) the integrative empowerment model has a significant effect on the capability of family members to support individuals with schizophrenia, encompassing their ability to help with ADLs, facilitate social interactions, and assist in developing productive skills for the patient,

  • (H2) the integrative empowerment model has a significant effect on family members’ capacity to prevent relapse in schizophrenia patients, including their ability to recognize relapse symptoms, accept the condition of schizophrenia, adhere to medication, and make use of healthcare services.

Sample and Settings

The study population consisted of all core families who cared for schizophrenia patients and lived in the city of Semarang. The sample size was determined using the formula for the difference between two proportions (Lemeshow et al., 1990), which was resulted in minimum sample of 70 respondents, including 35 respondents in the treatment group and 35 respondents in the control group using purposive sampling techniques. The selection of the treatment group was carried out at the Rowosari Health Center and the control group at the Kedungmundu Health Center Semarang city, where both Health Centers had the highest rate of schizophrenia in the city of Semarang. The selected health center serves a diverse range of individuals with various mental health needs. Support services for families, including educational programs and counseling, are provided. The hospital staff comprises healthcare professionals such as doctors, nurses, and therapists. Additional specialists like psychiatrists and psychologists were also contributed.

Participants were selected based on specific inclusion criteria, which included the following: (1) core family members (such as father, mother, or child) residing in the same household as the schizophrenia patient; (2) providing daily care for the schizophrenia patient at home; (3) Having a minimum of 1 year of experience in caring for schizophrenia patients; (4) age ranging from 20 to 60 years; (5) having a family member with schizophrenia who had received treatment at the respective Health Center in the development area.

Participants who fulfilled any of the specified exclusion criteria, which encompassed failure to complete the follow-up period, patient mortality, or withdrawal from the study due to lack of willingness to continue participating in the intervention, were excluded from the study. Nevertheless, in this study, none of the patients met the specified exclusion criteria, and thus, no participants were excluded from the study.

Instruments

Self-reported questionnaires were utilized to collect information from participants. The authors received written permission from the original questionnaire developer to translate and modify the questionnaires for the study by electronic mail. All ethical aspects related to instruments used have been resolved. Furthermore, construct validity and reliability testing were performed in this study. The instruments development was part of the Doctoral Dissertation and uploaded to university repository as unpublished work. Three instruments were used to collect the data, namely demographic datasheet, family ability to care for schizophrenia patient questionnaire, and family ability to prevent relapse questionnaire.

Firstly, a demographic datasheet was developed by the researchers to describe the characteristics of respondents, including gender, age, educational level, occupational status, family income, social security status, and relationship status with the patient. Secondly, the questionnaire to measure family ability to care for schizophrenia patient consists of three indicators, including fulfilling ADL needs, assisting social interactions, and assisting productive skills, with 18 items.

  1. Indonesian version of the fulfillment ADL needs questionnaire, which includes 10 statements derived from the Barthel index, as established by Fitryasari et al. (2021). After computing the validity and reliability testing, this questionnaire exhibited construct validity scores ranging from 0.472 to 0.824 and Cronbach’s alpha score of 0.912, demonstrating the validity and reliability of its items.

  2. Indonesian version of the Caregiving Tasks in Caring for an Adult with Mental Illness Scale (CTiCAMIS) comprises 5 items, developed by Fitryasari et al. (2021) to assess a family's ability to assist in the social interactions of schizophrenia patients. After computing the validity and reliability testing, CTiCAMIS construct validity scores ranging from 0.448 to 0.648 and Cronbach’s alpha score of 0.777, indicating the validity and reliability of its items.

  3. Indonesian version of the assisting productive skill questionnaire, consisting of three statements, based on the theoretical concept proposed by Janardhana et al. (2018). After computing the validity and reliability testing, this questionnaire demonstrated construct validity scores ranging from 0.618 to 0.771 and Cronbach’s alpha score of 0.861, signifying the validity and reliability of its items.

Thirdly, the questionnaire to measure family ability to prevent relapse consists of four indicators, including recognizing relapse symptoms, acceptance of schizophrenia, medication adherence, and utilization of health services.

  1. Indonesian version of relapse symptom recognition questionnaire consists of two statements developed from the concept (Tlhowe et al., 2017). After computing the validity and reliability testing, this questionnaire demonstrated construct validity scores of 0.778 and Cronbach’s alpha score of 0.872, signifying the validity and reliability of its items.

  2. Indonesian version of patient acceptance questionnaire consists of two statements developed from the concept (Tlhowe et al., 2017). After computing the validity and reliability testing, this questionnaire exhibited construct validity scores ranging from 0.587 to 0.834 and Cronbach’s alpha score of 0.860, demonstrating the validity and reliability of its items.

  3. Indonesian version of medication adherence questionnaire consists of five statements modified from the CTiCAMIS developed by Fitryasari et al. (2021). After computing the validity and reliability testing, this questionnaire exhibited construct validity scores ranging from 0.361 to 0.622 and Cronbach’s alpha score of 0.738, demonstrating the validity and reliability of its items.

  4. Indonesian version of health service utilization questionnaire consists of three statements developed from the concept (Tlhowe et al., 2017). After computing the validity and reliability testing, this questionnaire demonstrated construct validity scores of 0.604 and Cronbach’s alpha score of 0.753, signifying the validity and reliability of its items.

Data Collection

In this study, the recruitment process began by identifying and contacting potential participants who met the study's criteria. The target population consisted of individuals from core families caring for schizophrenia patients living in the city of Semarang, Indonesia. Before enrolling participants, informed consent was obtained from each individual. Participants were selected based on specific inclusion and exclusion criteria. The study employed purposive sampling to assign participants to either the treatment group or the control group. Once eligible participants were identified, they were assigned to either the treatment group or the control group. For the treatment group, the integrative empowerment intervention program was administered in 5 weeks, with one session per week, each lasting 60–90 min. The specific content and approach of the intervention are described in Table 1. The control group did not receive the intervention but instead have received standard care or no additional intervention during the study period. Data regarding the participants’ experiences, outcomes, or changes in relevant variables were collected through appropriate measures before and after the intervention. The flow diagram of selecting and recruiting participants is illustrated in Figure 1.

Table 1.

The Integrative Empowerment Intervention.

Week Duration Activity Location Methods
I 10 min Pre-test Public health center Explanation and discussion
30 min Description of the objectives and factors of family empowerment based on integrative empowerment
60 min Family's approach to strengthening influencing factors and steps towards family empowerment based on integrative empowerment
II 45 min Management of schizophrenia patient care Family houses Demonstration
45 min Management of family stress in caring for schizophrenia patients
III 45 min Finding new meanings and discovering new perspectives in parenting/caring Family houses Demonstration
45 min Reflecting on the family's ability to provide care
IV 60 min Family's ability to care for the patient Family houses Demonstration
V 60 min The ability of the family to prevent patient relapse Family houses Demonstration
VI-XIII 90 min Assistance for families to perform Integrative Empowerment Online assistance Guidance via WhatsApp platform
XIV 30 min Evaluation and discussion of the benefits of Integrative Empowerment Family houses Explanation and discussion
10 min Post-test
Open in a new tab

Figure 1.

Figure 1.

Open in a new tab

Flow diagram of study participants.

Study Procedure

Integrative Empowerment Intervention Module

The integrative empowerment intervention module was designed for nurses to educate family members. Additionally, booklet was also produced for family members of individuals with schizophrenia, based on information from the module. The module was developed through the integration of three stages. The first stage involved module development, where the researcher conducted a preliminary cross-sectional study to identify the factors contributing to families’ ability to care for patients with schizophrenia. Seven variables were classified, including patient factors, family factors, social environmental factors, healthcare service factors, outside-in empowerment, inside-out empowerment, and family empowerment.

In the second stage, the researcher conducted three focus group discussions (FGDs) with different groups, which included families of individuals with schizophrenia, healthcare professionals (such as psychiatrists, psychologists, and mental health nurses), and social support groups for families. FGDs were carried out in several contexts and objectives including, (1) FGDs involving families of individuals with schizophrenia were conducted to delve deeply into the issues affecting these families, which are considered strategically significant, and to explore potential solutions, (2) FGDs involving healthcare professionals were performed to extract insights from healthcare providers and gather input to enrich the module that would be developed and (3) FGDs involving social support groups were employed to ascertain the perspectives of the community, represented by Community Health Workers and Local Administrators, regarding the predefined strategic issues. The recommendations stemming from the FGDs regarding the development of the integrative empowerment-based family empowerment model for enhancing the family's caregiving abilities and preventing relapses in schizophrenia patients can be found in Table 2.

Table 2.

Focus Group Discussions Recommendation.

Issue Recommendation
Apart from the onset and comorbidities, the severity of the illness is also a significant patient-related factor

  • 1) Family counseling regarding the treatment and care of chronic schizophrenia patients, encompassing not only activities of daily living (ADL) but also the provision of motivation through positive reinforcement.

  • 2) Families should exhibit sensitivity and concern regarding medication adherence and enhance their knowledge to recognize early signs of relapse.

  • 3) Families should receive education on the importance of a healthy diet and meeting the nutritional needs of schizophrenia patients. In the event of common medical conditions arising, families should provide support and seek medical attention.
In addition to socioeconomic status, caregiving experience, available resources, internal vulnerabilities, and cultural values, family factors also encompass education and knowledge.

  • 1) Implementation of government policies to ensure free access to ambulance transportation for mental health services.

  • 2) Ongoing education involving religious leaders, healthcare professionals, and cross-sector collaboration to impart knowledge on how to care for schizophrenia patients, so that they do not become a burden and can accept patients with open arms.

  • 3) Education through spiritually accurate content and involvement in activities that enhance spirituality and promote positive cultural values. This involves not just resigning to fate but actively seeking treatment at healthcare facilities.

  • 4) Shared caregiving responsibilities within the family and support from other family members and the community when caring for schizophrenia patients.
Social environmental factors, particularly community social support, stigma, and the family's social network, play a significant role.

  • 1) Families should have a social support network as a platform for sharing caregiving experiences and alleviating the caregiving burden. Psychiatric hospitals should establish community associations or family gatherings as a bridge to accommodate the schizophrenia family community.

  • 2) Families should open to their immediate surroundings regarding the condition of schizophrenia patients.

  • 3) It is important to educate society to offer assistance and refrain from making judgments about individuals with schizophrenia and their families
Healthcare service factors primarily revolve around the availability of infrastructure, including transportation, accessibility to nearby mental healthcare facilities, and the presence of mental healthcare professionals.

  • 1) Families should enhance their utilization of health insurance as a social safety net for caring for patients and receive orientation on utilizing mental healthcare facilities, especially at public hospitals and community health centers.

  • 2) The provision of free ambulance services should accessible to families and the promotion of its usage, or community-driven initiatives such as having ambulances at the local neighborhood level, like within each residential area.

  • 3) Expanding mental healthcare services at public hospitals and community health centers by making it a flagship program and improving community mental healthcare through continuity of care initiatives.
Outside-in empowerment is primarily influenced by family factors, including the family's understanding of how to care for the patient, their coping skills in managing health issues, and the dynamics of family interactions.

  • 1) Families should receive training and support to care for schizophrenia patients, along with coping skills tailored to the family's level of understanding.

  • 2) Utilizing family resources, both physical and emotional, by fostering awareness of the situations that must be faced, emphasizing the concept of "unconditional love."

  • 3) Enhancing the spiritual and emotional awareness of the family and garnering support from other family members and the community in the pursuit of the patient's treatment.
Inside-out empowerment is primarily shaped by family factors, including the family's ability to imbue caregiving with meaning and engage in self-reflection while caring for schizophrenia patients

  • 1) Providing education and training to families regarding the patient's condition, enabling them to discover positive meaning and cultivate skills for making meaning through spiritual aspects.

  • 2) Offering families ongoing counseling and training to enhance their self-reflection abilities, including fostering a culture of shared experiences among family members, a sort of "contagious sharing," when it comes to caregiving experiences.
Integrative empowerment is influenced by both inside-out empowerment and outside-in empowerment, encompassing the ability to manage the illness, cope with caregiving stress, and explore new meanings

  • 1) Families should organized into community groups for schizophrenia families to facilitate sharing experiences on effective patient management.

  • 2) Enhancing the quality time spent within the family as a form of healing and receiving social support from the community to reduce caregiving stress.
The family's ability to care for schizophrenia patients is influenced by integrative empowerment, encompassing the capacity to fulfill ADL needs, skills in aiding social interactions, and productive skills aligned with the patient's hobbies

  • 1) The family should meets and facilitates the patient's ADL needs, particularly in self-care, with appropriate guidance.

  • 2) Social support from the community aids the family in fulfilling the patient's ADL requirements.

  • 3) Families should receive education and have their abilities enhanced to be ready and mentally prepared to help the patient integrate and socialize within their social environment.

  • 4) The family should explore the patient's hobbies, facilitate them, and provide opportunities for the patient to engage in activities according to their abilities.
Open in a new tab

In the final stage, the researcher consulted experts to gain valuable input and validation for the module development. The selected experts were a nursing professor specializing in mental health nursing and a clinical mental health practitioner (Psychiatrist) from Mental Health Hospital in Central Java Province. The researcher compiled the recommendations from the FGDs and expert consultations and developed a module for family empowerment based on integrative empowerment, considering the feedback and suggestions from the experts. Finally, the researcher created a module book for nurses and a booklet for family members containing a readily implementable module for family empowerment rooted in integrative empowerment principles.

Integrative Empowerment Intervention

The overall intervention was developed by researcher based on previous module development and the final program consisted of four indicators including professional dominance, family participation, challenge, and collaboration. The implementation of the integrative empowerment intervention program was carried out in 5 weeks, with one session per week and a duration of 60–90 min per session, taking into account the respondents’ availability and ethical principles of research. In weeks 6 to 13, family assistance in carrying out integrative empowerment. Then, on week 14, evaluation, discussion, and post-test were conducted. The researcher, who had received prior training and was acquainted with the intervention, administered the intervention. The details of the implementation are presented in Table 1.

Data Analysis

The statistical analysis of the data was performed using IBM SPSS Statistics (IBM Corp., Armonk, N.Y., USA). To describe the respondents’ characteristics and the family's ability to care for and prevent relapse in schizophrenic patients, univariate analysis was utilized, including frequency (f), percentage (%), mean and standard deviation (SD). Normality test was performed using Kolmogorov–Smirnov test, and abnormal distribution was found among continuous data in both treatment and control group. Consequently, non-parametric testing was performed. Furthermore, Wilcoxon test was employed to examine the similarities and differences in the family's ability to care for and prevent relapse in both the intervention and control groups before and after the study. To determine the differences in the family's ability to care for and prevent relapse in the control and intervention groups after the study, the Mann–Whitney test was utilized. The level of significance was set at p<.05.

Ethical Consideration

The written informed consent was obtained from all human adult participants and the parents or legal guardians. Prior to their involvement, all participants granted informed consent, which exemplified the ethical principles of respecting autonomy, promoting beneficence, and avoiding non-maleficence. Moreover, participants were furnished with extensive details regarding the study's aims, procedures, confidentiality, and the freedom to discontinue their participation before data collection was finalized. By offering thorough information, safeguarding confidentiality, and emphasizing the right to withdraw, potential risks were minimized, and the well-being of the participants was safeguarded. The Ethics Review Board approved the research at the health research ethics committee of Universitas Airlangga number 2637-KEPK on September 8, 2022, and Regional Psychiatric Hospital number 420/12375 on September 7, 2022.

Results

Characteristics of the Participants and Homogeneity Testing

The results presented in Table 3 show the demographic characteristics of families responsible for the care of patients with schizophrenia in two health centers in Semarang city. The study found that the majority of caregivers in both groups were female (71.4%), middle-aged adults (60%), with a senior high school education (44.3%) and unemployed (51.4%). The study also found that the majority caregivers’ income was below the minimum wage of Semarang city (71.4%), and they utilized social security through the government-funded social security agency (82.9%). The homogeneity test results showed that the data variance for respondent characteristics in both groups was the same or homogeneous (p>.05). This indicates that the two groups of caregivers were comparable and that any differences observed in the study were likely due to the intervention being tested, rather than differences in the characteristics of the caregivers.

Table 3.

Respondent Characteristics and Homogeneity Test.

Intervention group (n=35) Control group (n=35) Total (n=70)
Variable f % f % f % p-value
Gender 1.000
Male 10 28.6 10 28.6 20 28.6
Female 25 71.4 25 71.4 50 71.4
Age 1.000
Early adulthood (20–30) 7 20.0 7 20.0 14 20.0
Middle adulthood (31–55) 21 60.0 21 60.0 42 60.0
Late adulthood (56–60) 7 20.0 7 20.0 14 20.0
Educational level .951
Elementary 10 28.6 8 22.9 18 25.7
Junior high school 5 14.3 6 17.1 11 15.7
Senior high school 15 42.9 16 45.7 31 44.3
Diploma 5 14.3 5 14.3 10 14.3
Occupational status .758
Unemployed 19 54.3 17 48.6 36 51.4
Laborer 6 17.1 4 11.4 10 14.3
Self-employee 5 14.3 7 20.0 12 17.1
Private employee 5 14.3 7 20.0 12 17.1
State employee 0 0.0 0 0.0 0 0.0
Retired 0 0.0 0 0.0 0 0.0
Family income .383
<RMW 23 65.7 27 7.1 50 71.4
=RMW 7 20.0 3 8.6 10 14.3
>RMW 5 14.3 5 14.3 10 14.3
Social security status .751
Government-funded social security agency (BPJS) 28 80.0 30 85.7 58 82.9
Self-funded social security 7 20.0 5 14.3 12 17.1
Relationship status with the patient .836
Father 5 14.3 5 14.3 10 14.3
Mother 4 11.4 7 20.0 11 15.7
Siblings 11 31.4 8 22.9 19 27.1
Son/Daughter 5 14.3 5 14.3 10 14.3
Wife 6 17.1 4 11.4 10 14.3
Husband 4 11.4 6 17.1 10 14.3
Open in a new tab

Note. RMW = regional minimum wage per month; BPJS = Badan Penyelenggara Jaminan Sosial.

Hypothesis Testing Results

The findings from the hypothesis testing of the study are detailed in the subsequent section, providing an in-depth exploration and analysis of the results.

Description of Family Caregiving Abilities and Relapse Prevention for Schizophrenia Patients

The results presented in Table 4 show that the Integrative Empowerment intervention had a positive impact on the family's ability to care for their loved ones with schizophrenia. Most families (88.6%) were able to improve their ability to meet the ADL needs of the patients, while 82.9% of families improved their ability to assist the patients in social interactions, and 68.6% of families helped patients improve their productive skills. Additionally, the intervention also had a positive effect on the family's ability to prevent relapse among their loved ones with schizophrenia. The families demonstrated an improvement in recognizing the symptoms of relapse (62.9%), accepting their loved ones (68.6%), ensuring adherence to treatment (77.1%), and utilizing mental health services (77.1%).

Table 4.

Description of Family Caregiving Abilities and Relapse Prevention for Patients After Integrative Empowerment Intervention (n=35).

Variable Category Frequency (f) Percentage (%)
Ability to care for schizophrenia patients
Fulfillment of ADL (activities of daily living) needs Poor (score 10–20) 0 0.0
Sufficient (score 21–30) 4 11.4
Good (score 31–40) 31 88.6
Assisting social interactions Poor (score 5–10) 0 0.0
Sufficient (score 11–15) 6 17.1
Good (score 16–20) 29 82.9
Assisting productive skills Poor (score 3–6) 0 0.0
Sufficient (score 7–9) 11 31.4
Good (score 10–12) 24 68.6
Ability to prevent relapse of schizophrenia patients
Recognizing symptoms of relapse Poor (score 2–4) 1 2.9
Sufficient (score 5–6) 12 34.3
Good (score 7–8) 22 62.9
Patient acceptance Poor (score 3–6) 0 0.0
Sufficient (score 7–9) 11 31.4
Good (score 10–12) 24 68.6
Medication adherence Poor (score 5–10) 0 0.0
Sufficient (score 11–15) 8 22.9
Good (score 16–20) 27 77.1
Utilizing health services Poor (score 2–4) 0 0.0
Sufficient (score 5–6) 8 22.9
Good (score 7–8) 27 77.1
Open in a new tab

Intervention and Control Group Comparison

The results of the study in Table 5 indicate an improvement in the ability of families to care for patients with schizophrenia in fulfilling ADL needs, helping with social interaction, and productive skills with a p-value < .001, which means there is a significant change in the treatment group after the intervention of Integrative Empowerment compared to the control group. Meanwhile, the ability of families to care for patients with schizophrenia in the control group showed a p-value > .05, meaning there was no significant change after the intervention of Integrative Empowerment. Likewise, there was an increase in the ability of families to prevent relapse of schizophrenia patients, such as recognizing relapse symptoms, patient acceptance, medication compliance, and utilizing mental health services, with a p-value < .001, indicating a significant change in the treatment group after the intervention of Integrative Empowerment compared to the control group. However, the ability of families to prevent relapse of schizophrenia patients in the control group showed a p-value > .05, meaning there was no significant change after the intervention of Integrative Empowerment.

Table 5.

Changes in Family Caregivers’ Ability and Relapse Prevention for Schizophrenia Patients Before and After Integrative Empowerment Intervention.

Variable Group Pre Post
Mean SD Mean SD p-value§
Ability to care for schizophrenia patients
Fulfillment of ADL (activities of daily living) needs Intervention 15.17 4.08 34.29 4.13 <.001*
Control 18.14 2.53 18.71 2.90 .366
Assisting social interactions Intervention 10.20 3.51 16.97 2.07 <.001*
Control 10.29 3.43 10.40 3.40 .180
Assisting productive skills Intervention 6.06 2.58 10.17 1.54 <.001*
Control 6.71 1.77 6.77 1.71 .414
Ability to prevent relapse of schizophrenia patients
Recognizing symptoms of relapse Intervention 3.57 1.17 6.74 0.91 <.001*
Control 3.57 1.11 3.51 1.14 .732
Patient acceptance Intervention 4.03 0.78 6.94 0.93 <.001*
Control 4.20 0.86 4.34 0.99 .327
Medication adherence Intervention 10.51 2.92 17.14 2.13 <.001*
Control 11.54 2.50 11.86 2.36 .070
Utilizing health services Intervention 7.71 2.61 10.69 1.43 <.001*
Control 8.51 2.40 8.69 2.29 .161
Open in a new tab

Note. §Wilcoxon test was performed.

*Significant at p<.05.

The Effects of Intervention on Family Ability to Care and Prevent Relapse in Schizophrenia Patients

The results presented in Table 6 indicate that there are differences in the improvement of family caregivers’ ability to care for and prevent relapse in schizophrenia patients between the treatment and control groups. The statistical test results show a p-value < .001, indicating that there is an effect of Integrative Empowerment intervention on the family caregivers’ ability to care for schizophrenia patients. Similarly, there are differences in the improvement of family caregivers’ ability to prevent relapse in schizophrenia patients, including recognizing relapse symptoms, patient acceptance, medication adherence, and utilization of healthcare services in the treatment group compared to the control group. The statistical test results show a p-value < .001, indicating that there is an effect of Integrative Empowerment intervention on the family caregivers’ ability to prevent relapse in schizophrenia patients.

Table 6.

The Effect of Integrative Empowerment Intervention on Family's Ability to Care and Prevent Relapse in Schizophrenia Patients.

Variable Group Pre Post
Mean SD p-value§ Mean SD p-value§
Ability to care for schizophrenia patients
Fulfillment of ADL (activities of daily living) needs Intervention 15.17 4.08 .848 34.29 4.13 <.001*
Control 18.14 2.53 18.71 2.90
Assisting social interactions Intervention 10.20 3.51 .881 16.97 2.07 <.001*
Control 10.29 3.43 10.40 3.40
Assisting productive skills Intervention 6.06 2.58 .124 10.17 1.54 <.001*
Control 6.71 1.77 6.77 1.71
Ability to prevent relapse of schizophrenia patients
Recognizing symptoms of relapse Intervention 3.57 1.17 .971 6.74 0.91 <.001*
Control 3.57 1.11 3.51 1.14
Patient acceptance Intervention 4.03 0.78 .315 6.94 0.93 <.001*
Control 4.20 0.86 4.34 0.99
Medication adherence Intervention 10.51 2.92 .127 17.14 2.13 <.001*
Control 11.54 2.50 11.86 2.36
Utilizing health services Intervention 7.71 2.61 .187 10.69 1.43 <.001*
Control 8.51 2.40 8.69 2.29
Open in a new tab

Note. §Mann–Whitney test was performed.

*Significant at p<.05.

Discussion

The findings revealed that integrative empowerment had a significant positive impact on the family's capacity to care for and prevent relapses in individuals with schizophrenia. This included fulfilling ADL requirements, offering support for social interactions, and enhancing productive skills. The main goal of this study was to assess how integrative empowerment affects the ability of families to provide care and prevent relapse in patients diagnosed with schizophrenia. These results imply that integrative empowerment can serve as an effective intervention for enhancing the quality of care and support that families provide to individuals with schizophrenia.

The study analyzed the family's ability to care for schizophrenia patients. The Integrative Empowerment intervention improved caregiving by enhancing daily living activities, social interaction, and productive skills. Traditionally, families relied on their knowledge without recognizing caregiving's positive impact. The intervention aimed to increase skills, knowledge, and appreciation of caregiving to prevent relapse and improve care. Results demonstrated improved family caregivers’ ability to fulfill daily needs, support social interaction, and enhance skills. Previous studies by Grácio et al. (2018) and Kaakinen et al. (2018) support the importance of family caregiving for schizophrenia patients. Additionally, the treatment group receiving the integrative empowerment intervention showed improved family caregivers’ ability to prevent schizophrenia relapse. This included symptom recognition, patient acceptance, medication compliance, and utilization of health services. Families have strengths in reducing relapse, such as acceptance, utilizing services, faith, patient involvement, and awareness of exacerbating factors (Tlhowe et al., 2017). Family support, including acceptance, assistance, hope, and good communication, can also prevent relapse (Indah Iswanti et al., 2023; Mamnuah, 2021; Nurhidayati et al., 2023; Wuandari et al., 2022).

The results of the study are consistent with the recovery-oriented approach to mental health care, underscoring the significance of empowering individuals and their families to actively participate in their care and recovery (Frost et al., 2017). This approach, rooted in the belief that individuals with mental illness can lead meaningful lives with proper support, emphasizes family involvement as a crucial component, providing support, encouragement, and advocacy (Park et al., 2014). The Integrative Empowerment intervention aligns with this approach by concentrating on improving family caregiving skills, fostering knowledge, promoting acceptance and support, and preventing relapse in individuals with schizophrenia (Waller et al., 2019).

After receiving Integrative Empowerment interventions, the treatment group showed significant improvement in families’ ability to prevent relapses in schizophrenia patients, including symptom recognition, patient acceptance, treatment adherence, and healthcare utilization. Empowering families involves positive changes through family-centered nursing interventions, health promotion, and cultural appropriateness, enhancing competence in caring for schizophrenic patients at home. Previous studies conducted by van Es et al. (2019) and Zhou et al. (2020) support family empowerment in reducing mental health problems and improving family function. Integrative Empowerment improved schizophrenia relapse prevention in families through symptom recognition, patient acceptance, treatment adherence, and healthcare utilization. Strong family support reduces relapse risk (Pothimas et al., 2020). Families’ role includes acceptance, assistance, hope, and communication (Mamnuah, 2021). Low expressed emotion or normal affective style decreases relapse frequency (Ahmad et al., 2017). Families manage the disease through symptom recognition, advocacy, and utilizing mental health services.

The study found that the group receiving Integrative Empowerment intervention showed improved outcomes in meeting ADL needs, social interaction, and productive skills compared to the control group. This intervention provided families with knowledge, training, and support for caring for schizophrenia patients at home. It enhances family understanding and disease management abilities (van Es et al., 2019; Zhou et al., 2020). Families receiving the intervention demonstrated a greater ability to prevent relapse by recognizing symptoms, accepting the patient, adhering to medication, and utilizing healthcare services. Family involvement reduces relapse risk and improves the schizophrenia family environment. Integrative Empowerment aligns with cognitive-behavioral theory of relapse and influences the interpersonal environment of schizophrenia patients (Ong et al., 2021; Zhou et al., 2020).

Furthermore, the study underscores the necessity for a comprehensive mental health care approach that considers individual, family, and community dynamics influencing mental health and well-being (Frost et al., 2017; Park et al., 2014). The recovery-oriented approach highlights the importance of addressing social determinants such as poverty, discrimination, and social isolation, which can contribute to the onset and worsening of mental illness. In alignment with this perspective, the Integrative Empowerment intervention acknowledges the interconnected nature of biological, psychological, social, and environmental dimensions (Waller et al., 2019). It involves diverse stakeholders, including individuals, families, healthcare providers, community organizations, and policymakers, thereby aligning with the principles of a holistic recovery-oriented approach to mental health care (Shera & Ramon, 2013).

In future studies, it is important to conduct comprehensive and varied long-term research to confirm integrative empowerment's effectiveness in assisting families who support individuals with schizophrenia. Furthermore, investigating how integrative empowerment can be adapted and customized to suit specific needs within diverse cultural and demographic settings would yield valuable insights. Additionally, exploring the sustainability of improvements in caregiving quality over the long term will enhance our understanding of the intervention's enduring impact on family support systems.

Strengths and Limitations

The strength of this study lies in its clear focus on the role of psychiatric nurses in empowering families to care for and prevent relapses in schizophrenia patients. The study likely employed a systematic approach in designing and implementing the intervention, incorporating evidence-based practices and guidelines for educating and supporting families. However, there are several limitations to this study that should be noted. Firstly, the study design was not a true experimental design, which raises the possibility of selection bias among the participants. Therefore, it would be beneficial to conduct further research using a randomized control trial design. Secondly, it is important to note that the target population of this study was limited to Javanese ethnic group, and as such, the findings may only be applicable to this specific population. Future studies should aim to include a more diverse sample to determine the generalizability of the results to other populations.

Implication for Practice

The findings of the study suggest that psychiatric nurses can play a crucial role in empowering families to care for and prevent relapses of schizophrenia patients. Nurses can provide education and support to families in enhancing their skills, knowledge, and experience in nurturing the patient. They can also help families discover new meanings in nurturing and develop positive attitudes towards caring for the patient. Additionally, nurses can use the Integrative Empowerment intervention as a tool to improve the family's ability to care for and prevent relapses of schizophrenia patients. By doing so, nurses can improve the overall care and outcomes for patients with schizophrenia while also promoting the well-being of their families.

Conclusion

Integrative empowerment enhances the ability of families to care for and prevent relapses of schizophrenia patients through assessing the needs and situations of families in caring for patients, managing illness and parenting stress, such as positive caregiving experiences, and being free from depressive feelings. Additionally, it involves exploring new meanings through making meaning and self-reflection to control the family's emotional expression.

Acknowledgment

The authors thank the participants for their interest and generous participation in this study. Authors would also thank the Faculty of Nursing, Universitas Karya Husada Semarang and Universitas Airlangga, for the support and facilities provided. The authors are also grateful to the nurses and the Public Health Center Semarang City staff, who helped distribute questionnaires and in data collecting.

Footnotes

Author Contributions: Dwi Indah Iswanti: writing the original manuscript, substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. Nursalam Nursalam: writing the original manuscript, drafting the work or revising it critically for important intellectual content. Rizki Fitryasari: writing the original manuscript and final approval of the version to be published. Rika Sarfika: writing the original manuscript and final approval of the version to be published. I Made Moh. Yanuar Saifudin: writing the original manuscript and final approval of the version to be published.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Consideration: The written informed consent was obtained from all human adult participants and the parents or legal guardians. Prior to their involvement, all participants granted informed consent, which exemplified the ethical principles of respecting autonomy, promoting beneficence, and avoiding non-maleficence. Moreover, participants were furnished with extensive details regarding the study's aims, procedures, confidentiality, and the freedom to discontinue their participation before data collection was finalized. By offering thorough information, safeguarding confidentiality, and emphasizing the right to withdraw, potential risks were minimized, and the well-being of the participants was safeguarded. The Ethics Review Board approved the research at the health research ethics committee of Universitas Airlangga number 2637-KEPK on September 8, 2022, and Regional Psychiatric Hospital number 420/12375 on September 7, 2022.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs: Dwi Indah Iswanti https://orcid.org/0000-0002-8607-278X

Nursalam Nursalam https://orcid.org/0000-0002-9052-6983

References

  1. Ahmad I., Khalily M. T., Hallahan B., Shah I. (2017). Factors associated with psychotic relapse in patients with schizophrenia in a Pakistani cohort. International Journal of Mental Health Nursing, 26(4), 384–390. 10.1111/inm.12260 [DOI] [PubMed] [Google Scholar]
  2. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. [Google Scholar]
  3. Awad A. G., Voruganti L. N. P. (2008). The burden of schizophrenia on caregivers. PharmacoEconomics, 26(2), 149–162. 10.2165/00019053-200826020-00005 [DOI] [PubMed] [Google Scholar]
  4. Buckley P. F., Foster A. (2008). Schizophrenia: Current concepts and approaches to patient care. American Health & Drug Benefits, 1(4), 13–22. [PMC free article] [PubMed] [Google Scholar]
  5. Chakraborty S., Bhatia T., Anderson C., Nimgaonkar V. L., Deshpande S. N. (2013). Caregiver’s burden, coping and psycho-education in Indian households with single- and multiple-affected members with schizophrenia. International Journal of Mental Health Promotion, 15(5), 288–298. 10.1080/14623730.2013.856633 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Chien W. T., Bressington D., Lubman D. I., Karatzias T. (2020). A randomised controlled trial of a caregiver-facilitated problem-solving based self-learning program for family carers of people with early psychosis. International Journal of Environmental Research and Public Health, 17(24), 9343. 10.3390/ijerph17249343 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Chien W. T., Ma C. F., Bressington D., Suen L. K. (2020). Family-based interventions versus standard care for people with schizophrenia. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD013541 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Domínguez-Martínez T., Medina-Pradas C., Kwapil T. R., Barrantes-Vidal N. (2017). Relatives’ expressed emotion, distress and attributions in clinical high-risk and recent onset of psychosis. Psychiatry Research, 247(2017), 323–329. 10.1016/j.psychres.2016.11.048 [DOI] [PubMed] [Google Scholar]
  9. Fitryasari R., Nursalam N., Yusuf A., Hargono R., Lin E. C., Tristiana R. D. (2021). Development of a family resiliency model to care of patients with schizophrenia. Scandinavian Journal of Caring Sciences, 35(2), 642–649. 10.1111/scs.12886 [DOI] [PubMed] [Google Scholar]
  10. Frost B. G., Tirupati S., Johnston S., Turrell M., Lewin T. J., Sly K. A., Conrad A. M. (2017). An integrated recovery-oriented model (IRM) for mental health services: Evolution and challenges. BMC Psychiatry, 17(1), 22. 10.1186/s12888-016-1164-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Grácio J., Gonçalves-Pereira M., Leff J. (2018). Key elements of a family intervention for schizophrenia: A qualitative analysis of an RCT. Family Process, 57(1), 100–112. 10.1111/famp.12271 [DOI] [PubMed] [Google Scholar]
  12. Hasan A., Musleh M. (2017). The impact of an empowerment intervention on people with schizophrenia: Results of a randomized controlled trial. International Journal of Social Psychiatry, 63(3), 212–223. 10.1177/0020764017693652 [DOI] [PubMed] [Google Scholar]
  13. Herdman T. H., Kamitsuru S., Takao Lopes C. (2014). NANDA International, Inc. nursing diagnoses: definitions and classification. Wiley-Blackwell. [Google Scholar]
  14. Indah Iswanti D., Nursalam N., Fitryasari R., Kusuma Dewi R. (2023). Development of an integrative empowerment model to care for patients with schizophrenia disorder. Journal of Public Health Research, 12(3), 1–10. 10.1177/22799036231197191 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Janardhana N., Raghevendra G., Naidu D. M., Prasanna L., Chenappa T. (2018). Caregiver perspective and understanding on road to recovery. Journal of Psychosocial Rehabilitation and Mental Health, 5(1), 43–51. 10.1007/s40737-018-0108-2 [DOI] [Google Scholar]
  16. Kaakinen J. R., Coehlo D. P., Steele R., Robinson M. (2018). Family health care nursing: Theory, practice, and research. FA Davis. [Google Scholar]
  17. Kandar K. (2017). Gambaran Karakteristik Pasien Gangguan Jiwa Yang Mengalami Rawat Inap Ulang. Jurnal Ilmiah Permas: Jurnal Ilmiah STIKES Kendal, 7(1), 11–15. https://journal.stikeskendal.ac.id/index.php/PSKM/article/view/155 . [Google Scholar]
  18. Koujalgi S. R., Patil S. R. (2013). Family burden in patient with schizophrenia and depressive disorder: A comparative study. Indian Journal of Psychological Medicine, 35(3), 251–255. 10.4103/0253-7176.119475 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Kusumawardani W., Yusuf A., Fitryasari R., Ni’mah L., Tristiana R. D. (2019). Family burden effect on the ability in taking care of schizophrenia patient. Indian Journal of Public Health Research & Development, 10(8), 2654. 10.5958/0976-5506.2019.02269.1 [DOI] [Google Scholar]
  20. Lemeshow S., Hosmer D. W., Klar J., Lwanga S. K., World Health Organization. (1990). Adequacy of sample size in health studies. Chichester: Wiley. [Google Scholar]
  21. Leucht S., Tardy M., Komossa K., Heres S., Kissling W., Salanti G., Davis J. M. (2012). Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: A systematic review and meta-analysis. The Lancet, 379(9831), 2063–2071. 10.1016/S0140-6736(12)60239-6 [DOI] [PubMed] [Google Scholar]
  22. Mamnuah M. (2021). The role of the family in preventing relapse of schizophrenia patient. Open Access Macedonian Journal of Medical Sciences, 9(T4), 44–49. 10.3889/oamjms.2021.5789 [DOI] [Google Scholar]
  23. Mouchrek N., Benson M. (2023). The theory of integrated empowerment in the transition to adulthood: concepts and measures. Frontiers in Sociology, 8(2023), 1–17. 10.3389/fsoc.2023.893898 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Nurhidayati T., Firdaus A. D., Harningtyas S. (2023). The relationship between family support with self-concept in patients with post mastectomy. The Journal of Palembang Nursing Studies, 2(1), 42–49. 10.55048/jpns.v2i1.61 [DOI] [Google Scholar]
  25. Ong H., Fernandez P., Lim H. (2021). Family engagement as part of managing patients with mental illness in primary care. Singapore Medical Journal, 62(5), 213–219. 10.11622/smedj.2021057 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Park M. M., Zafran H., Stewart J., Salsberg J., Ells C., Rouleau S., Estein O., Valente T. W. (2014). Transforming mental health services: A participatory mixed methods study to promote and evaluate the implementation of recovery-oriented services. Implementation Science, 9(1), 119. 10.1186/s13012-014-0119-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Pharoah F., Mari J. J., Rathbone J., Wong W. (2010). Family intervention for schizophrenia. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD000088.pub3 [DOI] [PubMed] [Google Scholar]
  28. Pothimas N., Tungpunkom P., Chanprasit C., Kitsumban V. (2020). A cross-sectional study of factors predicting relapse in people with schizophrenia. Pacific Rim International Journal of Nursing Research, 24(4), 448–459. https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/226797 . [Google Scholar]
  29. Rahayuni I. G. A. R. (2019). Psikoedukasi kelompok Kader Kesehatan Jiwa (K3J) dalam pemberdayaan penderita skizofrenia di masyarakat di Kelurahan Pedungan–Denpasar Selatan. Jurnal Riset Kesehatan Nasional, 3(1), 112–117. http://ojs.itekes-bali.ac.id/index.php/jrkn/article/view/145/82 . 10.37294/jrkn.v3i1.145 [DOI] [Google Scholar]
  30. Regional Psychiatric Hospital of Dr. Amino Gondohutomo (2021). Dr. Amino Gondohutomo hospital readmission data of schizophrenia patients in 2021 .
  31. Robbins T. L., Crino M. D., Fredendall L. D. (2002). An integrative model of the empowerment process. Human Resource Management Review, 12(3), 419–443. 10.1016/S1053-4822(02)00068-2 [DOI] [Google Scholar]
  32. Sadath A., Muralidhar D., Varambally S., Jose J. P., Gangadhar B. N. (2015). Family intervention in first-episode psychosis. SAGE Open, 5(4), 215824401561310. 10.1177/2158244015613108 [DOI] [Google Scholar]
  33. Sadock B. J., Sadock V. A., Ruiz P. (2017). Comprehensive textbook of psychiatry 10th edition. Wolters Kluwer. [Google Scholar]
  34. Shamsaei F., Cheraghi F., Bashirian S. (2015). Burden on family caregivers caring for patients with schizophrenia. Iranian Journal of Psychiatry, 10(4), 239–245. [PMC free article] [PubMed] [Google Scholar]
  35. Shera W., Ramon S. (2013). Challenges in the implementation of recovery-oriented mental health policies and services. International Journal of Mental Health, 42(2-3), 17–42. 10.2753/IMH0020-7411420202 [DOI] [Google Scholar]
  36. Tlhowe T. T., du Plessis E., Koen M. P. (2017). Strengths of families to limit relapse in mentally ill family members. Health SA Gesondheid, 22(2017), 28–35. 10.1016/j.hsag.2016.09.003 [DOI] [Google Scholar]
  37. Van Es C. M., Mooren T., Zwaanswijk M., te Brake H., Boelen P. A. (2019). Family empowerment (FAME): Study protocol for a pilot implementation and evaluation of a preventive multi-family programme for asylum-seeker families. Pilot and Feasibility Studies, 5(1), 62. 10.1186/s40814-019-0440-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Verity F., Turiho A., Mutamba B. B., Cappo D. (2021). Family care for persons with severe mental illness: Experiences and perspectives of caregivers in Uganda. International Journal of Mental Health Systems, 15(1), 48. 10.1186/s13033-021-00470-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Vos T., Abajobir A. A., Abate K. H., Abbafati C., Abbas K. M., Abd-Allah F., Abdulkader R. S., Abdulle A. M., Abebo T. A., Abera S. F., Aboyans V., Abu-Raddad L. J., Ackerman I. N., Adamu A. A., Adetokunboh O., Afarideh M., Afshin A., Agarwal S. K., Aggarwal R., Murray C. J. L. (2017). Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: A systematic analysis for the global burden of disease study 2016. The Lancet, 390(10100), 1211–1259. 10.1016/S0140-6736(17)32154-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Waller S., Reupert A., Ward B., McCormick F., Kidd S. (2019). Family-focused recovery: Perspectives from individuals with a mental illness. International Journal of Mental Health Nursing, 28(1), 247–255. 10.1111/inm.12528 [DOI] [PubMed] [Google Scholar]
  41. Wulandari R. A., Maulidia R., Firdaus A. D. (2022). The relationship between family support and depression among patient with renal failure patients. The Journal of Palembang Nursing Studies, 1(2), 34–39. 10.55048/jpns.v1i2.5 [DOI] [Google Scholar]
  42. Yu B. C. L., Mak W. W. S., Chio F. H. N. (2021). Family involvement moderates the relationship between perceived recovery orientation of services and personal narratives among Chinese with schizophrenia in Hong Kong: A 1-year longitudinal investigation. Social Psychiatry and Psychiatric Epidemiology, 56(3), 401–408. 10.1007/s00127-020-01935-4 [DOI] [PubMed] [Google Scholar]
  43. Zhou D.-H. R., Chiu Y.-L. M., Lo T.-L. W., Lo W.-F. A., Wong S.-S., Luk K.-L., Leung C.-H. T., Yu C.-K., Chang Y. S. G. (2020). Outside-in or inside-out? A randomized controlled trial of two empowerment approaches for family caregivers of people with schizophrenia. Issues in Mental Health Nursing, 41(9), 761–772. 10.1080/01612840.2020.1734992 [DOI] [PubMed] [Google Scholar]

Articles from SAGE Open Nursing are provided here courtesy of SAGE Publications

RESOURCES