Introduction
Schizophrenia is the most common psychiatric disorder, which is characterised by hallucinations, fantastically chaotic emotional lives, and relatively intact intellectual preservation.1 In India, it constitutes approximately 0.64% of all people with major psychiatric complaints.2 It is also a serious chronic psychiatric disorder that can cause long-term disabilities. In a previous study, 53.7% of individuals with schizophrenia displayed disability certifiable in India.3 Consequently, it affects both the sufferer and their caregivers/family members.
Social support is defined as a person's personal assumptions and views about how much they believe, love, respect, and appreciate others. They are a part of a community where there is open communication and shared responsibility.4 Social support has been found to act as a protective shield against the unfavourable consequences of providing care for family members.5 In addition, caregivers frequently struggle with social issues as a result of others around them. This results in discrimination and stereotypes against carers, making it even more challenging for them to ask for assistance and support from others.6, 7 Cechnicki and Wojciechowska8 revealed the positive correlation between higher subjective treatment satisfaction and a compound system of social support and a sizable social network with a high level of support.
Self-esteem affects many aspects of life and may be a key element in determining life satisfaction. According to Rosenberg, self-esteem is an affective evaluation to one’s self-worth.9 Positive self-esteem is a human need that is necessary for healthy adaption and is capable of being strongly linked to ideal functionality and personal happiness.10 Caregivers of patients with schizophrenia are exposed to shame, low self-esteem, low perceived devaluation, low social self-efficacy, and social isolation due to perceived stigma.6, 7, 8, 9, 10, 11 These caregivers need psychosocial interventions to enhance the overall family environment to have a better adaptive state among families.12, 13
Indian studies have clarified that the care burden, social stigma and psychological distress are very high in caregivers of persons with schizophrenia.12, 13, 14 There are no Indian studies describing social support predictors that contribute to the self-esteem among caregivers of patients with schizophrenia. We intend to look at the area of social support and to know the role of self-esteem among caregivers of chronic patients with schizophrenia.
Materials and Methods
The present study was a hospital based cross-sectional comparative study and conducted from the outpatient department (OPD) of the Central India Institute of Mental Health and Neuro Sciences, Dewada, Rajnandgoan, Chhattisgarh, India and nearby areas (Dewada and Kopedih) of CIIMHANS for normal population through the purposive sampling technique. A total of 100 samples were selected for this investigation, which was further divided into 50 caregivers of persons with schizophrenia and 50 normal controls. Caregivers were interviewed using socio-demographic sheets, social support was evaluated by PGI Social Support Questionnaire and self-esteem was evaluated by Rosenberg Self-Esteem Scale.
Inclusion criteria
Patients who were already diagnosed as per the ICD-10 DCR 15 criteria for schizophrenia. Caregivers who were living with at least 5 years of the patient's illness. Both gender (male and female), those who have no significant psychiatric co-morbid condition and those caregivers who gave written informed consent for the participants were selected for the study.
Exclusion criteria
Those caregivers who had chronic debilitating physical illness & history of past/current psychiatric consultation were not included in the study.
Instruments
Semi-structured Socio-Demographic and Clinical Data Sheet: The socio demographic data sheet developed for the present study consisted of variables related to demographic information of the schizophrenia patients and their caregivers included in the study. Socio-demographic and Clinical details such as age, sex, education, occupation, domicile, age of onset, duration of illness etc. was included.
PGI Social Support Questionnaire: It was developed by Nehra and Kulhara16 and consists of 18 items, adapted through content analysis, from the original scale. The “Hindi” adaptation was done by the same authors in 1995. There are four response alternatives for each item. The item no. 2, 4, 8, 9, 11, 12 and 18 are positively worded and scored as such but item no. 1, 3, 5, 6, 7, 10, 13, 14, 15, 16 and 17 are negative items and have to be scored in the reverse order. The total score indicates the amount of social support perceived by the individual. Higher score indicates more perceived social support. It was a reliable and valid questionnaire. Test retest reliability after two weeks interval on 50 subjects was found to be 0.59**, significant at .01 level.
Rosenberg Self-Esteem Scale: This scale was developed by Morris Rosenberg.9 Rosenberg’s scale was used to assess the self-esteem of students which consists of 10 questions. This scale measures global self-worth by measuring both positive and negative feelings about the self. The scale has 10 items. Each item of the scale has 4 point options (0, strongly disagree to 3, strongly agree). The scale ranges from 0-30. 15 is a cutoff score in which those who score less than 15 are considered to have low self-esteem and the scores 15 to 25 considered to be normal self-esteem, and score above 25 is high self-esteem. The scale demonstrated good internal consistency of high school students with alpha coefficients ranging from 0.72 to 0.87.
Ethics and informed consent
The present study was carried out with the approval of the Ethical Research Committee of the Central Institute of Mental Health and Neuro Sciences (CIIMHANS), Dewada, Chhattisgarh. Before the study, participants were given the opportunity to clarify any doubts. The decision to participate in the study was completely voluntary, and participants had the option to withdraw at any moment. During the study, participants' privacy, respect for human rights, and other ethical considerations were all upheld.
Statistical Analysis
The statistical analyses were done with the help of the statistical package for social sciences version 25.0 for Windows, Manufactured by IBM, New York, USA. The descriptive variables from demography were tested using mean, standard deviation and chi-square. The difference between study variables in both groups was calculated using mean and standard deviation (t-test). Pearson's correlation was used to see the correlation between social support and self esteem among caregivers of patients with Schizophrenia. The multiple linear regression analysis was done to see the variance of social support and self esteem among caregivers of patients with Schizophrenia. The statistical significance was considered to be p<0.05 for the present study.
Results
Table 1 Shows the distribution of the socio-demographic details of caregivers of patients with schizophrenia and normal controls. The mean age of caregiver of patients with schizophrenia was 45.14 years (SD= 12.27) and 42.56 years (SD= 5.98) years for the normal controls. The majority of 80.0% caregivers of patients with schizophrenia and 74.0% of normal controls were male. Thirty eight percent caregiver of patients with schizophrenia and 24% of normal controls educated up to high secondary. In occupation, 42% caregiver of patients with schizophrenia and 30% of the normal controls were farmers. In domicile, the majority of (56% caregiver of patients with schizophrenia and 72% of normal controls) belonged to rural areas. There were no significant differences between the groups on demographic variables including age (t=1.336; p>0.05), gender (χ2= 0.508; p>0.05), education (χ2= 2.935; p>0.05), occupation (χ2= 1.587; p>0.05), and domicile (χ2= 3.638; p>0.05).
Table 1
Comparison of socio-demographic details of caregivers of patients with schizophrenia and normal control.
Table 2 reveals theclinical profile of the patients with schizophrenia. The average age of the patient (schizophrenia) was 36.70 years (SD=10.33). The average duration of illness (schizophrenia) was 4.50 years (SD= 1.03). The average age of onset of the illness (schizophrenia) was 30.50 years (SD=9.86).
Table 2
Clinical variable of socio-demographic details of patients with schizophrenia.
|
Variable |
Range |
Mean±SD |
|
Patient’s age |
19-60 |
36.70±10.33 |
|
Duration of illness |
3-6 |
4.50±1.03 |
|
Age of onset |
16-57 |
30.50±9.86 |
Table 3 Shows the mean score and SD of the social support and self esteem among the caregivers of patients with schizophrenia and normal control groups. The total Mean±SD score in social support among caregivers of patients with schizophrenia was 32.08 ± 4.61 and in normal control groups was 49.50 ±4.91. The total Mean±SD score in self esteem among caregivers of patients with schizophrenia was 15.98 ± 2.86 and in normal control groups was 25.32 ± 2.51. The result (t= -18.275and p<0.01) shows that there was significant difference between caregivers of patients with schizophrenia and normal control groups in terms of their social support. The result (t= -17.352 and p<0.01) shows that there was significant difference between caregivers of patients with schizophrenia and normal control groups in terms of their self-esteem.
Table 3
Comparison of social support questionnaire and self-esteem among caregivers of persons with schizophrenia and normal control
|
Variables |
Group (N= 60) |
t |
df |
p-value |
|
|
Schizophrenia Mean±SD |
Normal control Mean±SD |
||||
|
Social support |
32.08 ± 4.61 |
49.50 ±4.91 |
-18.275 |
98 |
0.000** |
|
Self esteem |
15.98 ± 2.86 |
25.32 ± 2.51 |
-17.352 |
98 |
0.000** |
Table 4 Shows social support has a significantpositive correlation with self-esteem (r= 0.724; p<0.01). It means when social support increases in caregivers of patients with schizophrenia than self-esteem also increases.
Table 4
Correlation between social support and self-esteem in caregivers ofpatients with schizophrenia.
|
Variables |
Self-esteem |
|
Social support |
0.724** |
Table 5 Shows the care burden contributes significantly to the prediction of social support among caregivers of patients with schizophrenia [F(1,546)=52.95, p=0.000]. Social support contributes 52.5% to low self-esteem and the remaining 47.5% factors were attributed to the variable which is not included in the study. Overall social support strongly contributes to the variance on self-esteem (Beta=0.724, t=7.277, p=0.000).
Discussion
The present study reported that caregivers of patients with schizophrenia had a lower level of social support compared to the normal controls. There was a significant difference in social support among caregivers of patients with schizophrenia and normal controls. Some previous studies supported it, Yin et al.17 stated that caregivers of patients with schizophrenia experienced inadequate perceived social support. Vasudeva et al.18 Caregivers with schizophrenia have a much higher burden in the areas of external assistance, caregiver routine, and other relationships. Raj et al.14 found that relatives of patients with schizophrenia suffered significantly higher social burden and Social support has been shown to serve as a buffer against the negative effects that are associated with family caregiving.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19
The present study reported that there was a significant difference in self-esteem and lower level of self-esteem among caregivers of patients with schizophrenia and normal controls. The results are in line with previous studies, Rajendran et al.20 showed the significantly lower level of self-esteem among caregivers of patients with schizophrenia. Jobin et al.21 reported the significantly low self-esteem not only in patients with remitted schizophrenia but also in spouses. Sharma et al.22 revealed that caregivers face anxiety, sadness, loss, anger, despair, hopelessness, shame, guilt, tension and communication pressures, and disability in the care process.
Regression analysis in the present study shows that the overall social support contributes 52.5% of the variance in self-esteem in caregivers. Social support has a significant positive correlation with self-esteem. It means when social support increases in caregivers of patients with schizophrenia than self-esteem also increases. Some previous studies also suggested similar findings, the self-stigmatization and poor social support of individuals who care for patients with schizophrenia may cause shame, low self-esteem, a decrease in quality of life, and a decrease in caregiving capacity.21, 22, 23 Thoits24 showed the perceived availability of social support may lead to a more benign appraisal of the situation when faced with a stressful event, low self-esteem thereby preventing a cascade of negative emotional and behavioural responses. Cechnicki and Wojciechowska25 revealed the positive correlation between higher subjective treatment satisfaction and a compound system of social support and a sizable social network with a high level of support. Rajendran et al.20 showed the significant positive correlation between resilience, perceived social support, self-esteem and self-efficacy caregivers of patients with schizophrenia.
Limitations
The caregivers of patients with schizophrenia were selected from only OPD of the hospital who came in for a follow-up, and therefore the results cannot be generalised to the entire population. Only two scales were used in this study. There could have been more measures employed to gain a more comprehensive picture of psychological co-morbidity and burden among caregivers of schizophrenia patients.
Implications
The present findings of the study are helpful to understand the family social support and its relationship to self-esteem in caregivers of patients with schizophrenia. Mental health professionals can help these caregivers with early assessment and proven interventions with positive effects on the burden. Family therapy and psychoeducation can be planned to reduce self-esteem, emotional problems, and behavioural symptoms as well as deal with the social burden.
Conclusion
The present findings in our study have furthered the growing evidence showing that schizophrenia can have a significant impact on families, especially primary caregivers. This study suggests that caregivers of patients with schizophrenia have a lower level of social support and self-esteem. Caregivers caring for patients with schizophrenia particularly experience high social burden, stigma and psychological comorbidity for their ill relatives. This study also demonstrates some of the important social burden factors that have an impact on a caregiver's sense of self-esteem.
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