IMPROVED QUALITY OF LIFE of SCHIZOPHRENICS: STUDY OF POST-CURE PATIENTS in KINSHASA. [Original Research]
KASWA KJ, MD*, MAMPUNZA MS, PhD*, LELO MG, PhD**, YASSA P, PhD***, KASWA C, MD**** MUTAPAY V, CO*****
*Department of Psychiatry CNPP, University of Kinshasa- DRC
** Department of Neurology CNPP, University of Kinshasa- DRC
***University Teaching Hospital, Lusaka, Zambia
****CUK, University of Kinshasa-DRC
***** Board of Management, University of Kinshasa-DRC
[emedpub – Psychiatry and Mental Health: Vol 1:6] [Date of Publication: 08.25.2013]
August 25, 2013 at 4:19 PM
JEAN KASIAMA KASWA MD, Department of Psychiatry CNPP, University of Kinshasa. Democratic Republic of Congo. e-mail : firstname.lastname@example.org,
Web site: http://kaswa.blog.com, www.scibd.com/doctakaswa
Contexte. La souffrance qu’éprouvent les schizophrènes, après l’hospitalisation, est souvent associée au vécu de sa maladie et sa qualité de vie n’est pas bonne. Le but de ce travail est d’évaluer, avant et après la psychoéducation, la qualité de vie subjective de ces patients en prenant en compte leur vécu de l’état du malade, leurs perceptions et leurs préférences en matière de décisions de santé.
Objectif. Améliorer la qualité de vie des schizophrènes en période de postcure, essentiellement dans la communauté.
Méthodes. Il s’agit d’une étude clinique d’autoévaluation par 19 patients de leur qualité de vie avec le questionnaire EQVS, en comparaison avec une autre échelle WHOQOL-26 avec 432 patients pour déterminer l’impact de la psychoéducation sur le vécu de la maladie dans l’amélioration de la qualité de vie des schizophrènes.
Résultats. Comparant le score global moyen avant (63,1) et après la psychoéducation, (67,17) dans l’EQVS, il y avait dans l’ensemble une amélioration qui se traduisait, lorsque nous essayions de mieux comprendre la situation par le regroupement de scores <75/75/>75, par ce qui suit : en première visite (V1): à moins de 75 de score (mauvaise Qualité de Vie), le nombre des sujets était de 63,2 % ; à 75 (bonne Qualité de Vie) de 5,3% et à plus de 75 (très bonne Qualité de Vie) de 31,5%. En V2: à moins de 75 de score (mauvaise QV), le nombre des sujets était de 66,7% ; à 75 (bonne QV) de 0% et à plus de 75 (très bonne QV) de 33,3%.
Avec l’échelle WHOQOL-26, en comparant la fréquence des effectifs avant et après la psychoéducation, il y’avait une différence ; le score de la qualité de vie, en général, avait changé dans le sens de l’amélioration. La valeur de p ou Signification asymptotique était inférieure à 0,05. L’analyse des données de la présente recherche indiquait que la différence de fréquence des effectifs en VI et en V2 était une réponse à la psychoéducation et à l’amélioration en V2. Cette différence entre les deux évaluations était donc très significative (khi-carré = 3117,820, ddl = 2832, p = 0,000).
En comparant les scores moyens de la qualité de vie avant et après la psychoéducation, le test t venait de nous donner un résultat important et positif pour la vérification de l’hypothèse de la recherche : la qualité de vie avant et après la psycho éducation était différente dans le sens de l’amélioration au sein de la population des schizophrènes. L’analyse des données de la présente recherche avait indiqué que QV/V2 avait gagné en moyenne de 70,13, alors que QV/V1 avait 60,86. Avec le même nombre de participants à V1 et V2 (n=432), la différence entre les deux mesures était donc très significative. Nous pouvions donc affirmer, sans beaucoup de chances de nous tromper, que la psychoéducation avait influencé la qualité de vie.
Conclusion. En comparant la fréquence des effectifs et les scores moyens de la qualité de vie avant et après la psycho éducation, il y avait une différence dans le sens de l’amélioration. La psychoéducation a eu de l’impact.
Context. The suffering that schizophrenics feel after the hospitalization is often attributed to their illness and it leads to a poor quality of life. The goal of this study is to evaluate the patients’ quality of life before and after psychological education, while taking into account their perceptions and their health preferences.
Objective. To improve the quality of life of schizophrenics during the period of after-care; essentially within their communities.
Methods. A clinical study of self-assessment of 19 patients for quality of life was conducted using the EQVS questionnaire. By comparison, scores of WHOQOL-26 scale used on 432 patients to determine the impact of psychological education on the improvement of quality of life were used.
Results. Comparing the middle global score before (63,1) and after the psychological education (67,2) in the EQVS, improvement was found across all areas of life. When we regrouped the scores in to three categories: < 75/75/>75, the results were interesting. In the first visit (V1) : <75 score (bad Quality of Life), the number of the topics was of 63.2%. For score of 75 (good Quality of Life), it was 5.3%; and for >75 (very good Quality of Life), it was 31.5% (Fig.6). In the second visit (V2): < 75 score (bad QL), the number of the topics was of 66.7%; with 75 (good QL), it was 0% and for> 75 (very good QL), it was 33.3%.
With the WHOQOL-26 scale, while comparing the frequency of patients’ strengths before and after psycho-education, there was a difference. The score of life quality, in general, had improved (p<0.05). The analysis of data of the present research indicated that the difference of frequency of the strengths in VI and in V2 was an answer to the psycho-education and to the improvement in V2. This difference between the two assessments was highly significant; therefore very meaningful (khi-square = 3117.8, ddl = 2832, p = 0.000).
While comparing the middle scores of the QL before and after the psycho education, the t test indicated that the quality of life before and after psycho-education was better for the schizophrenics. The analysis of data of the present research had indicated that QL/V2 had a score of 70.2 on average, whereas QL/V1 had 60.9. With the same number of participants in V1 and V2 (n=432), the difference between the two measures was significant. We could affirm, therefore, that the psycho-education had influenced their quality of life.
Conclusion. While comparing the frequency of the strengths and the middle scores of their life quality before and after the psycho-education, there was significant improvement. Psycho education had a beneficial effect.
Observed experience at the Center Neuro-Psycho-Pathological of the University of Kinshasa (CNPP) demonstrates that schizophrenics (post-cure) encounter a lot of difficulties to return to his home environment and to function as before. The suffering that they feel after the hospitalization is due to their illness. They feel that they have lost control over their own lives; this feeling is reinforced by the fact that often their communities and their physicians don’t take their feelings and impressions into account. Schizophrenics in their midlives suffer more or less the same. They have difficulty making and keeping new friends-old friends often already have moved away. They are negatively discriminated against, and their behaviors, feelings, and attitudes are dismissed by their peers and even their families (1).
Statistics from the World Health Organization (WHO) for 2004 indicate that schizophrenia affects populations in every country; these people suffer from considerable economic and social disadvantages. People affected by this illness suffer from high mortality rates, marginalization, and a poor quality of life (2). Because of this, schizophrenics and their families are actively searching to retrieve more data about this illness. We believe that schizophrenic patients and their families are more than capable to contribute to the goal of relapse reduction and to achieve improvement in the quality of their lives.
The goal of this work is ‘ to evaluate the patients’ quality of life before and after psychological education, while taking into account their perceptions and their health preferences. The objective of this study is to improve the quality of life of schizophrenics for the period of after-care within their communities.
MATERIAL AND METHOD:
An open clinical study was conducted from September 2007 to July 2011 in the Center Neuro-Psycho-Pathological (CNPP) of the University of Kinshasa, in Democratic Republic of Congo.
Our study was about consolidated 432 schizophrenics, according to the DSM IV and recruited out-patient. For adapting to socio-cultural differences, we used:
- The scale of assessment of the quality of life of the Schizophrenic EQVS, under validation
- The scale of the WHO already validated, WHOQOL-26 to compare the results
For the research on our patients, so that the speech is the same for all of the subject matter, it was necessary to have a module of intervention (module of psycho-education):
– To inform the patient of schizophrenics’ condemnation, of the negative perception of the mental illness, and their human, social, and economic cost
– To teach the patient to improve their quality of life, to reduce the negative repercussions of their physical, psychological, and social states and treatments
– To improve the state of chronic mental patient and his quality of life;
In this study, family members were also included in order to share their information and suggestions. We used Excel and SPSS-10 as tools for the analysis and results.
Before executing our research, we decided to get some authorization beforehand for our study. We asked our department of psychiatry to examine the scientific value and ethical aspects of our research. We then contacted the administrative authorities of the Center Neuro-Psycho-Pathological (CNPP) of Kinshasa in order to get their approval for the recruitment of schizophrenics.
Since our study is about improving and evaluating the life of schizophrenics, during one period data we again began to weigh ourselves on the problem of ethics. During the present survey, our team strictly respected the Declaration of Helsinki II and all recommendations of ethics for the medical research (respect of anonymity and confidentiality in the harvest and the analysis of data). We had arrived to the conclusion that a conflict of ethics didn’t occur in this survey because the three principles of basis were respected:
– Individual respect
Since schizophrenia is a chronic illness, sooner or later all of these patients will benefit from our work (assuming we reach our goal of this research).
The measure of the life quality belongs to the domain of the numbers, d years is used for the level of quality of life of the schizophrenics, which we had to use for some scales. As rigor was necessary in this assessment, we were obligated to apply a certain severity to get maximum cooperation from the schizophrenics and participants that were going to work with us.
Beginning in February 2007, the assessment of life quality with the EQVS scale ended in March of the same year (3). Nineteen topics were answered, two times, in the interval of 2 weeks, in regard to their experience in the last 7 days. They evaluated their quality of life in their domains of life:
- Physical health
- Psychological health
- Familial relationships
- Social and romantic reports
- Community participation
- Financial situation
- Condition of life
- 11. Autonomy
The possible answers were Ever, Rarely, Sometimes, Often, Always. For every assessment, the patient had to choose one answer for every item. Once finished, the questionnaire was recovered to calculate the score and to determine the level of life quality, both before and after the psycho-education. For the EQVS, the answer ‘ever’ corresponds to the score of 0% (bad life quality), ‘rarely’ to 25% (bad enough life quality), ‘sometimes’ to 50% (good enough life quality), ‘often’ to 75% (good life quality) and ‘always’ to 100% (excellent life quality).
The quality of life for a schizophrenic was good when the average of scores of the 11 domains of life of the scale was equal or >75%, was bad when less than75%. Some are the results gotten with the EQVS, the scale being in the process of validation, we had to compare these data with those of the validated scales; so, resorted in the WHOQOL-26, a scale, validated and reliable, to value the quality of life of the schizophrenics (4).
To improve the precision of our results, it was necessary for us to recruit again during the month of August 2007. We increased our number of schizophrenics to 329 for improved validity and reliability. So, the schizophrenics evaluated their quality of life while answering questions of how they felt during the last 4 weeks, mainly in the 26 items of 6 domains of quality of life of the WHOQOL-26 scale:
- Health and quality of life in general
- Physical health
- Psychological health
- Level of independence
- Social relations
The anonymous answers were organized according to the scale of Lickert type: ‘not at all satisfied’ to ‘very satisfied’ (5). For every assessment, the patient had to choose only one answer for every item. Once finished, we conducted the score: ‘not at all’, score 0% (bad life quality);‘a few,’ 25% (bad enough life quality);‘moderately,’ 50% (good enough life quality);‘sufficiently,’ 75% (good life quality), ‘quite,’ 100% (excellent life quality).
The quality of life was good when the average of scores of 6 domains of the scale was equal or >75%, bad when less than75%. The improvement of life quality depends on the change that the schizophrenic experiences with self-esteem, autonomy, and better life after psycho-education (Fig. 3). The improvement of quality of life for schizophrenics through the approach of our psychiatric services of the CNPP is a revolution that few practice (6, 7, 8).
So that the speech is the same for all patients, we used a module of intervention of which the techniques of basis consisted of attentive monitoring, the understanding of monitoring, and advice. The themes to land were precise, the definite mode (only or with several patients) and the number of known sessions. Data analysis was compiled in the Statistical Package heart the Social Sciences (SPSS), Microsoft Excel, Microsoft Access, and in file texts. It was easy for us to gather the collected data and to analyze them using Excel and SPSS-10. With a sample of sufficient size, schizophrenics (432 topics) showed a small improvement that could be significant on the statistical plan, according to the resulting indicator as the quality of life it could do change for the schizophrenic or the clinician. Leaving from a score of less 75% with the WHOQOL-26 scale, when we passed to a superior score, after the psycho education, the schizophrenics were considered as improved.
Between the scores of 75% to 100%, the quality of life was considered good.
The most current measures that we had used here were those of the central tendency of which the average (arithmetic mean), the median (value above or below which is the half of the observations,) the measures of the scattering, and the statistics that measure the quantity of variation or scattering in data (the standard deviation, minimal and maximal).
3.1. Assessment of the life quality with the EQVS
Table 1: Frequencies of the strengths according to the score of life quality before (V1) and after (V2)
|QV||Effectif V1||Effectif V2|
The study observed a significant difference in observations during the two visits (X2 =3117.8 (p=0.000))
Table 2: Quality of life before the psycho-education
Domains: D1.General health and quality of life: 74,20, D2. Physical health: 65,35, D3 Psychological health: 73,06, D4. Independence: 71,33, D5. Socio-relationship: 63,09, D6. Environment: 55,00.
Control: WHOQOL-26 SCALE: 60,86 of QV The average for the QV, the time 22,10.
Table 3: Quality of life after the psycho-education
Domains: D1.General health and quality of life: 81, 39, D2. Physical health: 70, 80, D3 Psychological health: 74, 42, D4. Independence: 73, 49, D5. Socio-relationship: 67, D6. Environment: 57, 78.
Control-WHOQOL-26 SCALE: 70, 19. The average for the QV, the time 19,91.
We found that the quality of life of the schizophrenics consolidated by the neuroleptic was not good, after their hospitalization to the Center Neuro-Psycho-Pathological of Kinshasa. Through a study of psycho education in the domains of schizophrenic life, we found that the patients must improve their quality of life, post-cure. The goal of this work is to evaluate, before and after the psycho education, the quality of life of these patients while taking into account the patients’ state, perceptions, and their health-related preferences. Comparing the results of the EQVS with those of WHOQOL-26, after forty five days of psycho-education, the general objective was to improve the quality of life of the schizophrenics in period of after-care, essentially within their communities.
Assessment of the life quality with the EQVS
We included 19 patients affected by schizophrenia according to the criteria of the DSM-IV TR, consolidated by neuroleptic classics or the antipsychotic atypical to the Center Neuro-Psycho-Pathological (CNPP) to the University of KINSHASA (UNIKIN), in Democratic Republic of Congo. They answered twice in the interval of 2 weeks.
a. Middle life quality before the psycho education
The middle score (63,1) of the quality of life for the 19 patients with less than 75% in the EQVS scale, the quality of life of 19 schizophrenic patients was not good before the psycho-education (Fig.1).
b. Middle life quality after the psycho education
After the psycho education, the middle score (67,17) of the quality of life for the 19 patients was less than 75% in the EQVS scale, the quality of life of schizophrenic patients was not always good despite some progression and improvement (Fig. 2).
c. Gathered score of life quality <75, 75, >75, before and after the psycho education
Comparing the middle global score before (63,1) and after psycho-education (67,17) in the EQVS (Fig. 1-2), there was an improvement across all areas when we tried to understand the situation better by regrouping the scores < 75/75/>75. At first visit (V1): with a score less than 75% (bad Quality of Life), the number of the topics was of 63.2%; a score of 75% (better Quality of Life) had 5.3%; and a score of more than 75% (very good Quality of Life) had 31.5%. During the second visit (V2): a score less than 75% (bad QV), the number of the topics was of 66.7%; a score of75% (better QL) had 0%; and a score of more than 75% (very good QV) had 33.3% (Fig. 3). The fact that there was an improvement of 30% after the psycho-education brought us hope. In this stage, however, it was difficult to demonstrate that there was an interrelationship between the quality of life and intervention (psycho education) because of our access to very few topics and because our scale was again being validated.
Today, one can wonder lawfully about the relevance of a survey achieved with the scale EQVS in Congo. We must know that the quasi-totality of the scales of life quality currently available has been validated in English language. Their use in the Democratic Republic of Congo would return to the problems met at the time of the validation trans-culturally of such scales in other countries. The socio-cultural variations, particularly marked in regard to the handling of the chronic mental patients and the problems of social adaptation-reinsertion of these patients, can put difficulties of transposition of these tools of a country to the other. It is because of this that we had begun to value the quality of life of the Congolese schizophrenics with our own instrument before making it with other strangers.
To shortcoming in the literature, the quality of life of the patients affected by schizophrenia has been studied extensively (9). Today, ‘quality of life’ is a very extensively used term and is in full expansion. Authors Lilia and Zaghdoudis, W., in a survey titled “Quality of life among the patients affected by schizophrenia treated by neuroleptic: classical and atypical” concluded that the antipsychotic atypical compared to the neuroleptic classics improve some aspects of the quality of life of the schizophrenics and generate less effects extrapyramidaux. This last point contributes itself to the improvement of the quality of life of these patients; in any case, the quality of life remains poor (10).
Assessment and Improvement of the Life Quality with WHOQOL-26
All planes of open study must aim to determine the reason of all changes or observed gaps in any chosen measure. We had included that patients affected by schizophrenia, according to the criteria of the DSM-IV TR treated by a neuroleptic classic or an antipsychotic atypical since at least six months. Knowing the quality of life of the schizophrenics in the CNPP with the EQVS; with stronger results, we wished to go farther while resorting to the WHOQOL-26 scale. The problem of reliability and validity, to the basis of all measure activity, didn’t arise with this instrument (we wanted to be sure of the significance of our observations). We had thought that a survey would deepen the interrelationships between the scores, and the variables should bring us answers concerning the significance of psycho education in the assessment of life quality (1, 2,12.14). The WHOQOL-26 scale explored 26 items mainly in 6 domains of quality of vie.
a.General features of the population of the survey
During the five years between November 2007 and February 2011, 470 patients entered the study. Numerous disappeared after the psychological interview either by relapses, by death, or simply by abandonment. At the end, only 432 topics were really evaluated. Most schizophrenics had only primary schooling; some had never been to the school and had not studied. Some reached the secondary level, but even less reached the superior level of education. The biggest number was located in between 21-31 years and the smallest between 10-20 years. They especially came from the neighboring townships of places and tribes such as Luba, Manianga, and Mbala. Of 432 patients, 74.1% were men and 25.9% were women.
The schizophrenics are, on average, 37 years old. These individuals didn’t have schizophrenia as children as schizophrenia does not generally get diagnosed in childhood. Trouble occurs quickly enough (in less than one year) at the end of adolescence as young adulthood begins. Schizophrenia appears between 15 and 24 years in men and between 25 and 34 years in women (11).
b.Statistical stages of the quality of life of the population in the survey
The quality of life in the Whoqol-26 scale is good when the score is equal or >75. Ignoring the score of the life 75 quality toward the maximum score of 99, the number of topics was more important in V2 than in V1 (Tab.1).
c.Comparison of the frequencies of the strengths
While comparing the frequencies of the strengths in V1 and in V2, the score of the life quality, in general, had improved significantly (Tab.2). With the number of participants in V1 and in V2 (n = 432), the value of p or asymptotic significance was <0.000.This allowed us to reject the hopeless hypothesis (H0) and to conclude that there was a meaningful difference between the strengths in V1 and in V2; H1 was true. The analysis of data of the present research indicated that the difference of frequency of the strengths in VI and in V2 was an answer to the psycho-education and to the improvement in V2. This difference between the two assessments was therefore very meaningful (khi-square = 3117.820, ddl = 2832, p = 0.000). One could conclude, therefore, that the psycho education had influenced the change of the life quality in V2.
d. Comparison of middle score of the life quality
Before the psycho education (V1)
In V1, there were 432 schizophrenics, most of whom had experience with hospitalization; the average for the QV was 60.86, the middle age of participants was 33 years, and the middle time to answer was 22 minutes. The score of the middle life quality, in different domains:
– Domains: D1. General health and quality of life: 74, 20; D2. Physical heath: 65, 35; D3 Psychological heath: 73,06, D4; Independence: 71, 33; D5. Socio-Relationship: 63,09; D6. Environment: 55, 00.
– WHOQOL-26 SCALE: 60, 86 of QV The average for the QV, the time 22,10 (Tab.3).
After the psycho education (V2)
In V2, there were 432 schizophrenics, many with experience with hospitalization; the average for the QV was of 70.1, the middle age was always 33 years, and the middle time to answer was 19 minutes. The score of the middle life quality in different domains:
– Domains: D1. General health and quality of life: 81,39; D2 Physical heath: 65,35 70,80, Psychological heath: 74,42; D4. Independence : 73,49 ; D5. Socio Relationship: 67 ; D6. Environment: 57, 78.
– WHOQOL-26 SCALE: 70, 19. The average for the QV, the time 19, 91(Tab.4).
The patients (432) estimated to have a quality of life of a middle score to the WHOQOL-Brief close to 60,86 to the 1st visit and 70,1 to the 2nd visit (Tab. 3-4). Whereas, the quality of life was poor before the psycho education, after the psycho education, although still poor, it had improved distinctly globally in all domains and in some more than in others. Indeed, one could note a lot of improvement in physical health, psychological health, and quality of life-although very little in social relationships and environment.
It was as important to note that after the psycho education, in spite of improvement, to part the domain of life D1, the quality of life with a score of < 75 had remained poor in all other domains of life. The D5, in relation to the other domains, was below the others with an average of score of QV to 63,09 (Tab.3-4). When we crossed the scores of V1 and V2, while regrouping them to < 75/75/>75, according to the Face 4, in V2 31.3% compared to 6.7% of patients in V1 met with >75, a very good quality of life; to 75, in V2 4.6% against 0.9% of patients in V1. On the whole, there was a clear improvement of quality in 35.9% of patients; the quality of life after the psycho education (V2) was better. The good quality of life, in the group of 75 and of more than 75, was 5 times better in V2 than in V1.
By comparing the averages of the life quality before and after psycho-education, the t test gave us an important and positive result. With the same number of participants in V1 and V2 (n=432), the difference between the two measures was therefore meaningful, (Test t = -15,130, dl=431, p = 0,000). The value of p was significant. There was a difference and a real change came from an effect, statistically meaningful and no of the at random. We could affirm therefore, without a lot of odds to deceive us, that the psycho-education had positively influenced their quality of life.
By reviewing the data analysis harvested by the schizophrenic patients and scholarly literature, the present study not only demonstrated that the quality of life of schizophrenics consolidated by the neuroleptic, estimated with the EQVS scales and WHOQOL-26 was poor after hospitalization, but also that they had improved using a psycho-educational approach with a good quality of life in 1/3 of the studied population.
To all of these patients who confided in us to search for an improvement in their quality of life. We sincerely thank them; as well as all collaborators, male nurses, social agents, psychologists, and physicians.
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Category: emedpub – Psychiatry and Mental Health
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