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Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4 235

A Multilevel Empowerment Approach to Prevent Relapse and Improve Quality of Life of People with Mental Disorders

Agustin Widyowati1,2, Bhisma Murti3, Aris Sudiyanto4, Suminah2 1Lecturer, School of Health Sciences Ganesha Husada, Kediri, East Java, 2Doctoral Student Program in

Community Development and Empowerment, Universitas Sebelas Maret, 3Professor, Masters Program of Public Health, Universitas Sebelas Maret, 4Lecturer, Department of Psychiatric Faculty of Medicine, Universitas Sebelas

Maret

Abstract The global health problem that increases significantly every year is psychiatric disorders. Decrease in the quality of life of people with mental disorders, error in the recurrence rate suffered. This study aims to see the effectiveness of holistic family-centered mental health care in preventing recurrence and improving the quality of life of people with mental disorders in Kediri Regency, East Java Province. The research design used RCT (Randomized Control Trial). The population in the study was people with mental disorders. The research sample consisted of 38 groups of respondents and 38 control groups with the multistage random sampling technique. Dependent variables were disease recurrence and quality of life for people with mental disorders. Va¬riabel independent is a family-centered holistic mental health care. The instrument uses a questionnaire that has been tested for validity and reliability. Data analysis used an independent t-test using STATA 13. The t-test results showed that the increase in the average increase in the treatment group after being given the intervention “family-centered holistic mental health care” while the control group did not change significantly. Holistic, family-centered mental health care with a multilevel approach in this study is effective in preventing relapses and improving the lives of people with mental disorders. It is hoped that it can be used to help improve the quality of life for a wider range of people with mental disorders

Keywords: disease recurrence, empowerment, family-centered, mental health care, quality of life

Introduction

One of the global health problems that increase significantly every year is psychiatric disorders. The decline in the quality of life for people with mental disorders is influenced by the high rate of recurrence. The impact of mental disorder client recurrence can result in drug resistance, progressive brain structure damage, personal distress, difficulties in the client’s rehabilitation process, anxiety, non-compliance with

treatment due to lack of knowledge, and side effects of treatment(1). Meanwhile, the impact on the family and society, namely injuring themselves and those around them, going berserk, and destroying objects around them. Globally, the recurrence rate of mental disorders can reach 50-92% due to non-compliance in treatment or lack of support and stress-prone living conditions, a stigma in the surrounding community(2).

Many programs have been carried out by the Indonesian government to improve the health of people with mental illness so that they have a better quality of life. The real manifestation of the government in protecting and caring for people with mental illness is contained in Law No. 36 of 2009 concerning Health Articles 148 and 149 which states that “People with

Corresponding Address: Agustin Widyowati P.O.Box: 57126. Doctoral student, Universitas Sebelas Maret, Ir. Sutami Street No. 36, Solo, Central Java, Indonesia, Email: [email protected] Phone number: +6285735399728

DOI Number: 10.37506/ijfmt.v15i4.16710

236 Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4

mental disorders have the same rights as citizens and are required to receive treatment and care in health care facilities” and Law No. 18/2014 on mental health article 86 states that “The act of shackling people with mental illness is an act which is prohibited and punishable by crime”. Besides, the government is also trying to tackle people with mental illness through the “Indonesia free from “pasung 2017” program, the formation of the Community Mental Health Implementation Team, and mental health integrated service post. However, lack of knowledge, low support, negative community stigma, and inadequate resources have resulted in the program not providing optimal results for sufferers and caregivers.

Although many kinds of research with psychoeducation interventions in families can prevent relapse, there is also a need for increased knowledge and mindset in the community, increased health personnel, and professional volunteer so that they can provide positive support and stigma to caregivers and sufferers. The stigma that exists in society is that people with mental disorders are someone who must be shunned because they are scary, something that must be shunned. Therefore, people with mental illness who live in a society that has a negative stigma will be hampered in the healing process because people tend to avoid or do not want to assist(3). Someone who has the support of friends and family allows them to have greater resources to coping with stressful events, thus enabling them to see the event as a problem less(4), thus serving as a preventive strategy to reduce stress. stress and its negative consequences(5). Kakuma state that it is necessary to involve mental health volunteer who coordinates with health workers to solve problems and improve public health, especially mental health. The synergy of family, friends, community, and health workers is expected to provide mental health care for caregivers and sufferers. This study aims to determine the effectiveness of family- centered holistic mental health care in preventing disease recurrence and improving the quality of life of people with mental disorders(6).

Methodethod

The research was conducted in Kediri Regency, East Java Province in 2019. The research design used RCT (Randomized Control Trial). Sampling was carried out by multistage random sampling technique, consisting of 76 respondents, 38 respondents in the treatment group and 38 respondents in the control group. The dependent variables of this study were disease recurrence and quality of life for people with mental illness. Recurrence of disease is a patient who experiences an increase in symptoms of abnormal behavior. The quality of life for people with mental illness is the level of a person’s health that is perceived by the individual itself, including physical, psychological, social, and environmental relationships. Variable independent is a family-centered holistic mental health care. Family-centered holistic mental health care is an intervention or support from various levels of society provided to families (spouses, children, son-in-law, parents, or siblings) who have emotional bonds, love each other, and are responsible for caring for sufferers so that they can prevent recurrences. The intervention given to the treatment group using a multilevel empowerment approach: a) Community level: 1) health professionals (mental health) provide education and training to health workers and volunteer, form mental health posts, 2) socialization to caregivers, families, neighbors, communities, local village government / religious leaders/community leaders so that there is increasing knowledge and changes in mindset to reduce negative stigma and help caregivers and sufferers if needed, 3) involve sufferers in community activities according to their abilities 4) active role of the local village government through financial support, facilities, and infrastructure informing mental health volunteer and mental health posts. b) Individual level: psychoeducation to caregivers and families, conducting home visits/ caregiver assistance in caring for sufferers. The data collection instrument used a questionnaire. The disease recurrence questionnaire was adapted from the BPRS (Brief Psychiatric Rating Scale) and the quality of life questionnaire was adapted from WHOQOL-BREF. Data analysis using a t-test with the help of STATA13 was

Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4 237

used to determine the effectiveness of the application of a family-centered holistic mental health care model on disease recurrence and quality of life for people with

mental disorders in the control group and the treatment group. Before testing the hypothesis, the normality assumption test is fulfilled.

Results

The results include the characteristics of research respondents, variable measurement characteristics, and t-test.

Table 1 Characteristics of people with mental disorders

Characteristics Frequency (respondent) Percentage (%)

Age

12 – 25 year 2 2.6

26 – 45 year 37 48.7

46 – 65 year 37 48.7

Gender

Male 56 73.7

Female 20 26.3

Duration illness

< 2 year 1 1.3

2-5 year 10 13.2

>5 year 65 85.5

Total 76 100

Table 1 above, based on the age of the respondents, data shows that almost half of the respondents (48.7%) or as many as 37 people with mental disorders aged 26- 45 years and 46-65 years, only 2 people with mental disorders (2.6%) were 12-25 years old. Mental disorders can be experienced by all types of ages, the younger a person experiencing mental disorders will experience a decrease in IQ, psychomotor abilities, the greater the verbal memory which can affect the quality of life of people with mental disorders. Based on gender, data was obtained that most of the people with mental disorders (73.7%) were male, 56 respondents, and a small proportion of people with mental disorders (26.3%) were

female as many as 20 respondents. Men have a greater risk of experiencing mental disorders because the head of the family is the support for the household so that they experience greater life pressure and are less able to accept life situations than women. Based on the duration of illness, it was found that almost all respondents (85.5%) experienced people with mental disorders > 5 years as many as 65 people. The duration of illness is a description of the disease course of people with mental disorders starting from the acute phase, experiencing recurrence, stability, and even worsening mental health conditions.

238 Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4

Table 2 Distribution of respondents based on variable measurements

Variable Score Category

Frequency

Intervention Control

n % n (%)

Recurrence of Disease < 52 Low 20 26.3 17 27.6

≥ 52 High 18 23.7 21 23.7

Quality of Life people with mental disorders < 56 Low 27 35.5 26 34.2

≥ 56 High 11 14.5 12 15.8

Total 38 50 38 50

Disease recurrence in the intervention group experienced recurrence, 18 respondents (23.7%) and in the control group experienced recurrence, 21 respondents (27.6%). The more frequent recurrences, the worse the prognosis for people with mental disorders. Quality of life for people with mental disorders in the intervention

group had a low quality of life for people with mental disorders, 27 respondents (35.5%) and the control group had a low quality of life for people with mental disorders, 26 respondents (34.2%). One of the problems caused by people with mental disorders is the disruption of the quality of life of people who do not have mental disorders.

Table 3 The results of the t-test on the effectiveness of “family-centered holistic mental health care” on the recurrence of people with mental disorders

Intervention status n Mean SD p

Before intervention

Control group 38 35.61 11.61 0.671

Intervention group 38 34.45 12.07

After intervention

Control group 38 36.42 14.09 0.001

Intervention group 38 17.03 11.16

Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4 239

Table 3 shows that the recurrence of disease before the intervention “Family-Centered Holistic Mental Health Care” shows that the mean is not much different and is still in the same range, the control group mean is 35.61 (Mean = 35.61; SD = 11.61) and the intervention group means is 34.45 ( Mean = 34.45; SD = 12.07). So it can be concluded that both groups had the same disease recurrence in people with mental disorders (p = 0.671).

After receiving the intervention “Family-Centered Holistic Mental Health Care” showed a different mean, the intervention group had a lower result, , 17.03 (Mean = 17.03; SD = 11.16) compared to the control group of 36.42 (Mean = 36.42; SD = 14.09). So it can be concluded that there was a decrease (rarely) of disease recurrence after receiving the intervention “Family- Centered Holistic Mental Health Care” (p <0.001).

Table 4 The results of the t-test on the effectiveness of “family-centered holistic mental health care” on the quality of life for people with mental disorders

Intervention status n Mean SD p

Before intervention

Control group 38 52.74 5.95 0.751

Intervention group 38 53.16 5.58

After intervention

Control group 38 52.53 6.09 0.001

Intervention group 38 62.82 8.36

Table 4 shows that the quality of life of people with mental disorders before the intervention “Family- Centered Holistic Mental Health Care” shows that the mean is not much different and is still in the same range, the control group mean of 52.74 (Mean = 52.74; SD = 5.95) and the mean of the intervention group of 53.16. (Mean = 53.16; SD = 5.58). So it can be concluded that both groups have the same quality of life for people with mental disorders (p = 0.751). After receiving the intervention “Family-Centered Holistic Mental Health Care” showed a different mean, the intervention group had a higher result, 62.82 (Mean = 62.82; SD = 8.36) compared to the control group of 52.53 (Mean = 52.53; SD = 609). So it can be concluded that there is an increase in the quality of life of people with mental disorders after receiving the intervention “Family-Centered Holistic

Mental Health Care” (p <0.001).

Discussion

The effectiveness of “Family-Centered Holistic Mental Health Care” against disease recurrence

Mental disorders affect patients and their families. people with mental disorders will experience disruption of daily activities, interpersonal relationships, roles, and social. Families experience rejection, stigma, helplessness, anxiety, fatigue, decreased personal needs, and the development of personal resources(7). This burden makes the family depressed which has an impact on people with mental disorders nursing or people with mental disorders healing(8). Caregiver/ family involvement can reduce patient recurrence(9) so that caregivers need support in dealing with the chronic

240 Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4

phase of the disease(10). Support can be obtained from formal support (health workers and volunteers) and informal support (family, friends, neighbors) in caring for people with mental disorders. The individual level is psychoeducation to families and caregivers. Psychoeducation can have a positive impact on people with mental disorders, namely accelerating the recovery process(11) and preventing recurrence(12). In line with research conducted by Kusumawaty, psychoeducation assistance can improve caring caregiver behavior for people with mental disorders(13). Community-level, namely health workers and volunteers, peers, neighbors, and the community. Social support from the surrounding environment, both from family, friends, neighbors, and the surrounding community are needed by caregivers in facing difficulties(14). Health workers have an important role in treating people with mental disorders through caregivers involving mentally healthy volunteers (15).

The effectiveness of “Family-Centered Holistic Mental Health Care” on the quality of life of people with mental disorders.

Mental disorders account for the largest proportion of the burden of disability or year lived with disabilities (YLDs) so that it affects the quality of life. Basic needs in the form of self-care that are not fulfilled will have an impact on the quality of life of people with mental disorders. Such as physical impacts, including susceptibility to various diseases of the skin, oral mucosa, and nails. Psychosocial impact in society, namely disruption of social interaction in daily life activities, people with mental disorders will be rejected by the community because of poor personal hygiene, people with mental disorders have low self-esteem, especially in terms of identity and behavior, people with mental disorders considers himself unable to overcome his shortcomings(16). People with mental disorders often don’t care about self-care in their life. This causes people with mental disorders to be isolated in the family and society. Nearly all patients with mental disorders had self-care deficits. This is due to ignorance and helplessness related to circumstances so that there is a self-care deficit(17). Their daily independence has

decreased, especially in carrying out their roles and functions, such as taking care of themselves, attending school or work, and other functions. Therefore, people with mental disorders need help from other parties, especially families to survive and improve their quality(18). Combination therapy will be effective if accompanied by optimal family support(19). Without the support and care provided by family members to people with mental disorders, they can’t remain in the community and improve their quality of life(7). This study is in line with the research of Javadpour(20) which states that psycho-educational interventions together with patient support systems in the treatment of bipolar mental disorder are effective in improving quality of life and reducing recurrence. Based on a literature review conducted by Puolakka(21), it was found that there was the effectiveness of psychosocial interventions (family intervention, health education, skills training on the quality of life of schizophrenic patients. Research conducted by Puspitosari(22), also resulted in Community-Based Rehabilitation being carried out. by health workers, volunteers, and sub-district social welfare workers, it is effective to improve the quality of life for schizophrenics in the community.

Conclusion

Holistic family-centered mental health care with a multilevel approach in this study proved effective in preventing relapses and improving the quality of life for people with mental disorders. It is hoped that it can be used to help improve the quality of life for people with a wider range of mental disorders. Future research can be more devoted to one mental disorder.

Acknowledgment: I would like to thank the respondents who participated.

Conflict on Interest: There is no conflict of interest to be declared

Source of Funding: None

Ethical Clearance: The study was approved by the health research ethics committee of Dr. Moewardi Faculty of Medicine, Sebelas Maret University Surakarta

Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4 241

Number: 439 / III / HREC / 2019.

References

1. Kazadi NJB, Moosa MYH, Jeenah FY. Factors associated with relapse in schizophrenia. South African J Psychiatry. 2008;14(2):52–62.

2. Covarrubias I, Han M. Mental health stigma about serious mental illness among MSW students: Social contact and attitude. Soc Work [Internet]. 2011 [cited 2021 Apr 24];56(4):317–25. Available from: https://pubmed.ncbi.nlm.nih.gov/22308664/

3. Mestdagh A, Hansen B. Stigma in patients with schizophrenia receiving community mental health care: A review of qualitative studies [Internet]. Vol. 49, Social Psychiatry and Psychiatric Epidemiology. Soc Psychiatry Psychiatr Epidemiol; 2014 [cited 2021 Apr 24]. p. 79–87. Available from: https:// pubmed.ncbi.nlm.nih.gov/23835576/

4. Başoğul C, Buldukoğlu K. Ebeveyninde Depresyon Olan Ergenlerde Depresyonu Önlemede Aile Odaklı Psikoeğitim Uygulamaları: Sistematik Derleme Family-Based Psychoeducation Programs for Prevention of Depression in Adolescents with Depressed Parents: A Systematic Review. Psikiyatr Güncel Yaklaşımlar-Current Approaches Psychiatry [Internet]. 2015 Jul 12 [cited 2021 Apr 24];7(3):265–79. Available from: www.cappsy.org

5. Shiraishi N, Watanabe N, Katsuki F, Sakaguchi H, Akechi T. Effectiveness of the Japanese standard family psychoeducation on the mental health of caregivers of young adults with schizophrenia: A randomised controlled trial. BMC Psychiatry [Internet]. 2019 Sep 2 [cited 2021 Apr 24];19(1):263. Available from: https://bmcpsychiatry. biomedcentral.com/articles/10.1186/s12888-019- 2252-y

6. Kakuma R, Minas H, Van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. Human resources for mental health care: Current situation and strategies for action [Internet]. Vol. 378, The Lancet. Elsevier B.V.; 2011 [cited 2021 Apr 24]. p. 1654–63. Available from: https://pubmed.ncbi. nlm.nih.gov/22008420/

7. Tristiana RD, Yusuf A, Fitryasari R, Wahyuni SD, Nihayati HE. Perceived barriers on mental health services by the family of patients with mental illness. Int J Nurs Sci [Internet]. 2018 Jan 10 [cited 2021 Apr 24];5(1):63–7. Available from: /pmc/ articles/PMC6626224/

8. Möller-Leimkühler AM, Mädger F. Personality factors and mental health outcome in caregivers of first hospitalized schizophrenic and depressed patients: 2-year follow-up results. Eur Arch Psychiatry Clin Neurosci [Internet]. 2011 [cited 2021 Apr 24];261(3):165–72. Available from: https://pubmed.ncbi.nlm.nih.gov/20878414/

9. Camacho EM, Ntais D, Jones S, Riste L, Morriss R, Lobban F, et al. Cost-effectiveness of structured group psychoeducation versus unstructured group support for bipolar disorder: Results from a multi- centre pragmatic randomised controlled trial. J Affect Disord [Internet]. 2017 Mar 15 [cited 2021 Apr 24];211:27–36. Available from: https:// pubmed.ncbi.nlm.nih.gov/28086146/

10. Petrakis M, Laxton S. Intervening Early with Family Members during First-Episode Psychosis: An Evaluation of Mental Health Nursing Psychoeducation within an Inpatient Unit. Arch Psychiatr Nurs [Internet]. 2017 Feb 1 [cited 2021 Apr 24];31(1):48–54. Available from: https:// pubmed.ncbi.nlm.nih.gov/28104058/

11. Sharif F, Mahmoudi A, Alavi Shooshtari A, Vossoughi M. The effect of family-centered psycho-education on mental health and quality of life of families of adolescents with bipolar mood disorder: A randomized controlled clinical trial. Int J Community Based Nurs Midwifery [Internet]. 2016 Jul 1 [cited 2021 Apr 24];4(3):229–38. Available from: /pmc/articles/PMC4926002/

12. Basirun S, Thahir A, Mawarni A. Family Psychoeducation: Effect of Enhancing the Knowledge of Controlling Violent Behavior of People with Schizophrenia Pilot Study. J Psychol Psychother [Internet]. 2019 Jul 9 [cited 2021 Apr 24];09(03):1–6. Available from: https://www.longdom.org/open-access/family-

242 Indian Journal of Forensic Medicine & Toxicology, October-December 2021, Vol. 15, No. 4

psychoeducation-effect-of-enhancing-the- knowledge-of-controlling-violent-behavior-of- people-with-schizophrenia-pilot-study-43994.html

13. Kusumawaty I. PSYCHOEDUCATION ASSISTANCE: STRENGTHENING CARING BY FAMILY CAREGIVERS AGAINST PEOPLE WITH MENTAL DISORDERS. J Med (Media Inf Kesehatan) [Internet]. 2020 May 31 [cited 2021 Apr 24];7(1):83–90. Available from: https://jurnal. poltekkesbanten.ac.id/Medikes/article/view/206

14. Oktaviana A. The Relationship between Locus of Control and Social Support with Resilience of Deaf Adolescents. Psikoborneo J Ilm Psikol [Internet]. 2013 Jan 17 [cited 2021 Apr 24];1(1). Available from: http://e-journals.unmul.ac.id/index.php/ psikoneo/article/view/3272

15. Cheng JF, Huang XY, Hsu YS, Su CH. Influencing factors of community mental health nurses caring for people with schizophrenia in Taiwan. J Psychiatr Ment Health Nurs [Internet]. 2012 May [cited 2021 Apr 24];19(4):319–26. Available from: https://pubmed.ncbi.nlm.nih.gov/22070523/

16. Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a community health worker delivered health, nutrition and responsive stimulation package and conditional cash transfers on child development and growth in rural Tanzania: Protocol for a cluster-randomized trial. BMC Public Health. 2019;19(1):1–7.

17. Caqueo-Urízar A, Rus-Calafell M, Craig TKJ, Irarrazaval M, Urzúa A, Boyer L, et al. Schizophrenia: Impact on Family Dynamics. Curr Psychiatry Rep [Internet]. 2017 Jan 1 [cited 2021

Apr 24];19(1):1–8. Available from: https://link. springer.com/article/10.1007/s11920-017-0756-z

18. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Prentice-Hall, Englewood Cliffs, NJ. Pbk. ed. Englewood Cliffs N.J.: Prentice-Hall; 1980.

19. Duckworth K, Halpern L. Peer support and peer-led family support for persons living with schizophrenia. Curr Opin Psychiatry [Internet]. 2014 [cited 2021 Apr 24];27(3):216–21. Available from: https://pubmed.ncbi.nlm.nih.gov/24662961/

20. Javadpour A, Hedayati A, Dehbozorgi GR, Azizi A. The impact of a simple individual psycho- education program on quality of life, rate of relapse and medication adherence in bipolar disorder patients. Asian J Psychiatr [Internet]. 2013 Jun [cited 2021 Apr 24];6(3):208–13. Available from: https://pubmed.ncbi.nlm.nih.gov/23642977/

21. Puolakka K, Pitkänen A. Effectiveness of psychosocial interventions on quality of life of patients with schizophrenia and related disorders: A systematic review. Arch Psychiatr Nurs [Internet]. 2019 Oct 1 [cited 2021 Apr 24];33(5):73–82. Available from: https://pubmed.ncbi.nlm.nih. gov/31711598/

22. Puspitosari WA, Wardaningsih S, Nanwani S. Improving the quality of life of people with schizophrenia through community based rehabilitation in Yogyakarta Province, Indonesia: A quasi experimental study. Asian J Psychiatr [Internet]. 2019 Apr 1 [cited 2021 Apr 24];42:67– 73. Available from: https://pubmed.ncbi.nlm.nih. gov/30974306/

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