WORLD JOURNAL OF ADVANCE SJIF Impact Factor: 3.458 Cempaka et al. Page ISSN: 12457-0400 of 154 Volume: 2. HEALTHCARE RESEARCH Issue: 4. Page N. 150-154 Year: 2018 Original Article www.wjahr.com MEDICATION ADHERENCE AS A DOMINANT FACTOR INFLUENCING SCHIZOPHRENIA RELAPSE Anindya Arum Cempaka* 1, Setyawati Soeharto 2 and Tina Handayani Nasution 3 1 Master s Program of Nursing, Faculty of Medicine, Universitas Brawijaya, Indonesia. 2,3 Faculty of Medicine, Universitas Brawijaya, Indonesia. Received date: 20 May 2018 Revised date: 10 June 2018 Accepted date: 01 July 2018 Corresponding Author: Anindya Arum Cempaka Master s Program of Nursing, Faculty of Medicine, Universitas Brawijaya, Indonesia. ABSTRACT Background: The occurrence of relapses in schizophrenic patients has great potential to harm and endanger patients, family and society. Relapse increases the burden of care and is a significant economic burden for families and communities because if the patient has rehospitalization in the psychiatric clinic, it increases the cost of the family for the treatment. Objective: The aim of this study was to analyze the factors related to schizophrenia relapse and to find out the dominant factors related to schizophrenia relapse in Puskesmas Bantur Working Area, Malang Regency. Methods: Analytic observational design with cross-sectional approach was utilized. There were 83 respondents contributed in this study. The respondents were obtained using total sampling technique. Results: The results showed a significant relationship between medication adherence, expression emotion and schizophrenia onset with schizophrenia relapse. The result from multiple logistic regression shows medication adherence has the highest OR value at 27.182. Conclusions: There were significant correlation between medication adherence, expression emotion and schizophrenia onset with schizophrenia relapse. Medication adherence as a dominant factor influencing schizophrenia relapse. KEYWORDS: Relapse, schizophrenia. INRODUCTION World Health Organization (WHO) from 2012 show that around 450 million people worldwide suffer from mental disorders. Based on Indonesia s Basic Health Research data in 2007, the number of people with severe mental illness reached 4.6 per mile and decreased to 1.7 per mile in 2013. East Java is one of the provinces in Indonesia having a high number of people with severe mental illness, which were 3.1 per mile in 2007 and decreased to 2.2 per mile in 2013 (Riskesdas, 2007). Majority of schizophrenics experience acute symptomatic relapses with periods of complete or partial remission (Xiao et al, 2015). The definition of relapse in people who have been diagnosed with schizophrenia is the recurrence of hospitalization and re-emergence of symptoms of schizophrenia experienced by patients (Olivares, 2013). Patients with a diagnosis of schizophrenia are estimated to recur 50% in the first year, 70% in the second year and 100% in the fifth year after discharge from hospital (Madriffa i et al, 2015). There are four factors that influence of schizophrenia relapse; patient factor, which is medication adherence, caregiver factor, and family supportive factor (Kaplan and Saddock, 2016). Patients who do not take regular medication tend to relapse, while caregivers have more opportunities to meet clients so they can see early symptoms and take immediate action (Keliat, 2006). Regular medication may reduce relapse, but long-term use of antipsychotics may lead to extrapyramidal side effects such as uncontrolled and drowsy movements (Raharjo, 2014). In addition to the medication adherence, family knowledge also plays a role in preventing recurrences (Fadli, 2013). Family knowledge determines how the family behaves and how families judge positively or negatively on an object that the patient is (Ronald, 2016). Family knowledge is effective in improving the adaptability of the patient (Aghayusefi, 2016). If family knowledge of schizophrenia is lacking, the family's attitude towards the patient will be less assertive (Fadli, 2013). The lack of knowledge about mental health in the family is responsible for the unfair treatment that patients receive. Family support involves emotional expression. Families with high emotional expression (hostile, criticizing, rude,
Cempaka et al. Page 151 of 154 oppressive and accusing) cause patients relapse (Prihandini et al, 2012). The results showed the possibility of relapse patients increased by 8 times when the family showed a high EE level (Roseliza, 2014). It because the schizophrenic patient is easily affected by the stress of a pleasant life (marriage, promotion) or miserable (Death, loss, accident). Puskesmas Bantur is one of government-mandated community health clinics located across Indonesia in Malang Regency with total of schizophrenia patient 134 in 2017 spread in 5 Villages. Compared to 2016, the number of relapse schizophrenics reached 50%. The activity of mental health service at puskesmas bantur is good enough, as evidenced by the existence of mental health clinic and mental health cadre of 210 people. With a considerable number of cadres and active mental health services, schizophrenics should be supervised to take medication regularly and obediently. However, the number of relapsing schizophrenic patients is still quite high in 2017. It is interesting to examine whether adherence to medication and caregiver knowledge influences the recurrence of schizophrenic patients in the Puskesmas Bantur. METHODS This research used observational analytic design with cross-sectional approach. The research locations were 5 villlages in Bantur Malang, Indonesia. The research was held from March 01 st to March 311 st, 2018. The samples were 83 caregivers selected by total sampling technique. The research instruments were questionnaires from Family Questionnaire, Knowledge Questionnaireon Home Care 36 Schizophrenics, and Morisky Medication Adherence Scale 8. This research performed three types of analysis: univariate, bivariate, and multivariate analysis. The univariate analysis aimed to describe the characteristic of the research respondents, the bivariate analysis used Chi-Square correlation test with significant level (α) = 0.05, and the multivariate analysis used logistic regression test to examine the independent variable having the most dominant relationship with the dependent variable. RESULTS Table 1: Characteristics of Respondents by Gender, Education, and occupation. Characteristics Frequency (n) Percentage (%) Male 31 37 Caregiver Gender Female 52 63 Primary School 64 77 Junior High School 14 17 Caregiver Education Senior High School 4 5 University 1 1 Labor 70 84 Caregiver Occupation Unemployed 13 16 Male 31 37 Caregiver Gender Female 52 63 Labor 70 84 Caregiver Occupation Unemployed 13 16 Primary School 64 77 Junior High School 14 17 Caregiver Education Senior High School 4 5 University 1 1 Table 1 shows that 52 (63.0%) of the respondents were female, 64 (63.0%), most of them were labor (84%) with their most recent education being at primary school (77.0%).
Cempaka et al. Page 152 of 154 Table 2: Chi Square correlation test results between medication adherence, caregiver knowledge, caregiver expressed emotion, schizophrenia onset and schizophrenia relapse. Independent variable Relapse p-value Medication Adherence 0.000 Caregiver Knowledge Caregiver Expressed emotion Schizophrenia Onset 0.208 0.000 0.042 Table 2 shows that training and supervision had p = 0.010 and p = 0.001< α (0.05) respectively, which indicated a significant relationship between training and supervision and nosocomial infection prevention and control practices by nurses in the ED. Training and supervision had a strong relationship with positive direction toward the nosocomial infection prevention and control practices, which was marked with the value of r of 0.296 and 0.366 respectively. Table 3: Logistic regression test results between medication adherence, caregiver knowledge, caregiver expressed emotion, schizophrenia onset and schizophrenia relapse. Variables The value of p Exp(B) R Square Medication Adherence 0.000 27.182 Caregiver Expressed Emotion 0.000 7.124 Caregiver Knowledge 0.386 0.047 0.659 Schizophrenia Onset 0.425 2.535 Table 3 shows that supervision was the most dominant factor on the nosocomial infection prevention and control practices by nurses in the ED, as shown by Exp(B) of 8,342 higher than Exp(B) of training factor of 3,703. DISCUSSION The Relationship between training and the nosocomial infection prevention and control practices by nurses in the ED The result of the bivariate analysis showed that there was a significant relationship between training and the nosocomial infection prevention and control practices by nurses in the ED. Research in the field found that a few nurses never participated in training on nosocomial infections, either from the hospital or outside the hospital. The results of this study are in line with one theory stated that training is an activity to increase knowledge and expertise of individuals guided by competent persons in a particular field to increase skills and responsibility in a particular area based on a specified and fixed procedure. Training is one effort to improve the competence of an individual. Competent individuals have the adequate ability in the nosocomial infection prevention and control practices (Notoadmodjo, 2012). This is in contrast with research conducted by Pancaningrum (2011) and Herpan (2012) that there was no significant relationship between training and the performance of nurses in the nosocomial infection prevention and control. A study by Kusworo (2014) conducted in Yogyakarta found that there was a significant relationship between training obtained by nurses and the implementation of Universal Precautions containing the standard precautions on the nosocomial infection prevention and control practices. With training, a person will gain competence. In the implementation of the job and the duty, an individual must have sufficient capability and be supported by a skilled attitude categorized as competence. Competence refers to certain knowledge, attitudes, and skills of a profession as the characteristic of a professional (Wibowo, 2012). Competence is a physical, intellectual, and interpersonal skill which underlies nurses in performing the nosocomial infection prevention and control in the department. Therefore, nurses are required to attend the training to achieve the competence. The relationship between supervision and the nosocomial infection prevention and control practices by nurses in the ED The result of the bivariate analysis on supervision and the nosocomial infection prevention and control practices by nurses indicated that there was a significant relationship between supervision according to nurse perception and the infection prevention and control practices. Moreover, the results of logistic regression test showed that supervision was the most significant factor related to the infection prevention and control practices with Exp(B) value of 8,342. It proved that supervision had the most dominant relationship when compared to training factor. Research in the field also found that supervision according to nurse perception on the nosocomial infection prevention and control practices in the Emergency Department was mostly good. Only a few were still lacking especially in the evaluation aspect, investigation of the extraordinary incidence of nosocomial infections, and assessment of nurse training needs regarding nosocomial infections. The results of this study are in accordance with Ponco s (2016) research that there was a significant relationship between supervision, whether the supervision was done by the head of the departments or related parties, and the
Cempaka et al. Page 153 of 154 attitude of the nurses to the compliance of the infection prevention and control practices on infusion installation based on the predetermined procedure. Setyowati (2016) also stated that the motivation factor, in this case supervision, had a significant relationship on the nurse compliance in the infusion installation in accordance with the fixed procedure in the Emergency Department which was one of infection prevention and control practices. According to the Ministry of Health of the Republic of Indonesia (2016), a committee in organizing the nosocomial infection prevention and control was established in achieving the visions, missions, and objectives of the Infection Prevention and Control practices. The establishment was based on organizational provisions with minimal work systems and many functions and could perform tasks, responsibility, and authority efficiently and effectively. Effective meant all competent individuals could be engaged in supporting maximal health services, especially in infection prevention and control (MOH, 2008). Aditya et al. (2016) stated that supervision had an important influence on nurse compliance in applying standard precautions. Supervision could be in the form of performance monitoring on supervised subjects aimed to help improving the desired results by giving suggestions, criticism, and assistance at the right time, specifically in the nosocomial infection prevention and control practices to comply with predetermined standards to reduce adverse effects which might appear at any time (Suarli & Bahtiar, 2007). The infection prevention and control team has the responsibility to explain the policy on infection control to all hospital staffs, coordinate and supervise the departments regarding the implementation of standard precautions, analyze and manage the surveillance data obtained in the department and submit the data to the IPC committee periodically, and manage group discussions with nurses in the department about the incidence of infection (Darmadi, 2008). IPCN (infection prevention and control nurse) should monitor the nosocomial infection prevention and control regularly to collect the data on the incidences using available checklists and input the data in the computer. IPC Team in Hospital should conduct the evaluations at least once a month, while IPC committee should evaluate at least once in 3 months. IPC Committee should make regular written reports of infection incidences and report them to the hospital director (MOH, 2011). Supervision in the research locations showed a positive result of 78.4%. Purpose of supervision was to encourage the organization member, in this case nurses in the ED, to contribute actively to organizational goals. Effective and routine supervision by IPC team was hoped to motivate nurses in the emergency department to ensure better nosocomial infection prevention and control practices. As the results, organizational goals such as improving patient safety quality and minimizing the incidence of nosocomial infections in the hospital could be achieved. Optimal effort from IPC committee and IPC team in hospitals regarding the monitoring activity such as supervision and evaluation on each incident of nosocomial infection in the departments became an important motivation for nurses in the infection prevention and control practices. 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