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Q U A LI T Y O F L I F E

Quality of life of individuals with schizophrenia living in the


community: relationship to socio-demographic, clinical and
psychosocial characteristics
Chiu-Yueh Hsiao, Ming-Hong Hsieh, Chiu-Jung Tseng, Shu-Hui Chien and Ching-Chi Chang

Aims and objectives. To examine the level of quality of life in individuals with schizophrenia and to test its association with
socio-demographic, clinical and psychosocial characteristics.
Background. Quality of life has been a focus of concern in mental health care, yet the level of quality of life and its determinants
for individuals with schizophrenia are not well known.
Design. Cross-sectional, descriptive design.
Methods. A total of 148 individuals with schizophrenia participated in the study. A demographic information sheet, the
18-item Brief Psychiatric Rating Scale, the Chinese Health Questionnaires, the Mutuality Scale and the World Health
Organization Quality of Life Scale, brief version, were used to collect data. Data were analysed with descriptive statistics,
Pearson productmoment correlation and stepwise multiple linear regression.
Results. Most of participants were single, unemployed, had a low education level and were supported financially by family.
Quality of life was positively correlated with age of mental illness onset, mutuality, employment status and monthly
household income, whereas it was negatively associated with the length of mental illness, symptom severity and health
status. Health status, mutuality, symptom severity, monthly household income and employment status were found to be key
significant predictors with mutuality having the greatest effect on quality of life.
Conclusions. The findings increase our understanding of socio-demographic, clinical and psychosocial characteristics
influencing the degree of quality of life in individuals with schizophrenia. Incorporation of families and communities into
the treatment programmes would enhance patients capabilities of social integration and satisfaction with their lives.
Relevance to clinical practice. Health care providers should make use of community-oriented intervention programmes that
aim to strengthen psychosocial functioning. Particularly, programmes that enhance health status and mutuality should be
identified and developed for both individuals with schizophrenia and their families.
Key words: community, nurses, nursing, quality of life, schizophrenia, Taiwan
Accepted for publication: 19 November 2011

Authors: Chiu-Yueh Hsiao, PhD, RN, Associate professor, College of


Nursing, Chung Shan Medical University; Ming-Hong Hsieh, MD,
PhD (c), Psychiatrist, Department of Psychiatry, Chung Shan Medical
University Hospital; Chiu-Jung Tseng, MSN, RN, Preceptor,
Department of Nursing, Hung Kong University, Taichung; Shu-Hui
Chien, RN, Head Nurse, Department of Nursing, Tsaotun
Psychiatric Center, Department of Health, Nantou; Ching-Chi

Chang, MD, Psychiatrist, Department of Psychiatry, Chung Shan


Medical University Hospital, Taichung, Taiwan
Correspondence: Ching-Chi Chang, Psychiatrist, Department of
Psychiatry, Chung Shan Medical University Hospital, 110, Sec. 1,
Chein Kuo N. Rd, Taichung, Taiwan.
Telephone: +886 4 2473 9595 Ext: 38633.
E-mail: fmaj7@seed.net.tw

2012 Blackwell Publishing Ltd


Journal of Clinical Nursing, 21, 23672376, doi: 10.1111/j.1365-2702.2012.04067.x

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C-Y Hsiao et al.

Introduction
Quality of life (QOL) is a worldwide matter of central concern
in schizophrenia research (Chan et al. 2007, Galuppi et al.
2010, Ho et al. 2010). Schizophrenia is a severe and persistent
mental illness affecting approximately 1% of the worlds
population (Mueser & McGurk 2004, Austin 2005). According to the Department of Health (2011), the prevalence of
schizophrenia in Taiwan affects 033% of the population.
Most patients with schizophrenia are often stigmatised and
discriminated against in Taiwanese society (Huang et al.
2008a,b, Hsiung et al. 2010, Kao et al. 2011). The clinical
characteristics of schizophrenia are often detrimental to
various aspects of life for those who are affected (Picardi et al.
2006, Eack & Newhill 2007, Meijer et al. 2009). In the
community mental health care system, a specific interest in the
QOL for patients with schizophrenia is emerging as a result of
patients continuous efforts to adapt to illness-related circumstances and other stressful daily life events.
Taiwan, along with the rest of the world, is making a
transition in mental health care from institutional to community-based health care services as part of a national policy of
deinstitutionalisation (Lin et al. 2008, Hsiao & Van Riper
2009, Huang et al. 2010). Unfortunately, most patients with
mental illness have often been discriminated against because of
negative public attitudes and have encountered difficulties in
their attempts to live in the community without sufficient
availability of adequate quality mental health care (Chan et al.
2007, Huang et al. 2008a,b; Lin et al. 2008). As a result of
reform in the mental health care system, assisting people with
schizophrenia to live in the community is an important
paradigm shift for community-oriented mental health care
(Lin et al. 2008, Galuppi et al. 2010). In addition to traditional
psychological or biological measures, it is imperative that
QOL is increasingly acknowledged as a critical outcome
measure for the effects of mental health care services on health
status in general and on schizophrenia in particular (Chan
et al. 2007, Galuppi et al. 2010). Although QOL has been
a focus of concern in mental health care, little is known
about the QOL of Taiwanese individuals with schizophrenia
living with their families in the community. Information on
QOL and its correlates is of particular importance to develop
evidence-based intervention programmes that can improve
satisfaction with multiple aspects of life for individuals with
schizophrenia.

Background
With increasing progress towards holistic care, the improvement of QOL has been recognised by health care providers as

2368

one of the most valuable treatment goals for people with


schizophrenia (Galuppi et al. 2010, Ho et al. 2010, Kao et al.
2011). The World Health Organization (WHO) has defined
QOL as an individuals perceptions of their position in life,
in the context of the culture and value systems where they live
and in relation to their goals, expectations, standards and
concerns [The World Health Organization Quality of Life
(WHOQOL) Group, 1998, p. 551]. In this respect, QOL is a
multidimensional concept that includes the subjective perspectives of individuals satisfaction with various aspects of
their lives in the context of physical health, psychological
state, social relationships and relationship to salient features
of the environment. This is particularly critical for patients
with schizophrenia. An optimal goal for such a specific
population should strive to help them have satisfying lives
rather than focusing narrowly on symptom management
(Chan et al. 2007, Eack & Newhill 2007, Galuppi et al.
2010).
Given the devastating and unpredictable symptoms of
schizophrenia, patients are traditionally considered by the lay
public as strange, aggressive, dangerous, lacking in selfcontrol and threatening to others, even if they are clinically
stable (Crisp et al. 2000; Xiang et al. 2008). Stigmatisation
and discrimination often aggravates the condition and
imposes undue constraints on people with schizophrenia
(Chan & Yu 2004, Dimitriou et al. 2009). Patients with
schizophrenia have reported significantly poorer QOL than
those in the general population in Western countries (Bobes
& Carcia-Portilla 2006, Picardi et al. 2006, Evans et al.
2007) as well as in Eastern countries such as Japan (Kunikata
et al. 2005), Singapore (Tan et al. 2004), China (Chan & Yu
2004, Xiang et al. 2007) and Taiwan (The WHOQOLTaiwan Group 2005; Yen et al. 2008). Yet, most studies have
been carried out in Western countries, and their findings
might not be applicable to non-Western cultures such as
Taiwan.
Individuals with schizophrenia are not generally subject to
only one stressor or demand (e.g. unemployment); thus, they
are more likely to face multiple challenges (e.g. poor quality
of relationship with their family caregivers). Cumulative
demands stemming from normative and non-normative
stressors have a profound impact on the quality of various
aspects of patients lives. Determinants of the QOL in persons
with schizophrenia have been extensively reported, including
socio-demographic characteristics (e.g. gender, education,
marital and employment status and household income) (Chan
& Yu 2004, Kao et al. 2011), illness-related or clinical
characteristics (e.g. length of mental illness, number of
previous hospitalisations, symptom severity) (Picardi et al.
2006, Chan et al. 2007) and psychosocial characteristics (e.g.
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 23672376

Quality of life

social support, stigma, mastery, self-esteem and personal and


social functioning) (Galuppi et al. 2010, Ho et al. 2010,
Hsiung et al. 2010). Most of the research examining influential factors of QOL has primarily focused on the impact of
psychiatric symptoms. These studies have indicated a significantly negative relationship between QOL and positive
symptoms (Picardi et al. 2006, Xiang et al. 2008), negative
symptoms (Bozikas et al. 2006, Picardi et al. 2006) and
general psychopathology (e.g. anxiety, depression) (Eack &
Newhill 2007, Xiang et al. 2008, Meijer et al. 2009),
wherein greater symptom severity is related to poor QOL.
However, findings on the association of socio-demographic,
illness-related or clinical characteristics with QOL remain
inclusive.
Mutuality is described as an affective relationship involving
past and current closeness, shared activities and confiding in
one another (Horowitz & Shindelman 1983). Archbold et al.
(1990) further defined mutuality as a positive quality of care
recipientcaregiver relationship. Given that traditional Taiwanese families place great value on harmonious interpersonal
relationships and interdependence, providing care to a loved
one is regarded as an integral part of close interactions or
relationships between the care recipient and the caregiver.
Patients, as a care recipient in the family care circumstance,
perceive the quality of interactions or reciprocity in the
relationship with family caregivers. Likewise, the care recipient
has traditionally been considered as a potential stressor who
may deteriorate the reciprocity in relationships and, thereby,
place the family caregiver at risk for compromised well-being
(Schumacher et al. 2007, Tanji et al. 2008, Ball et al. 2010).
However, little research focuses on how mutuality affects care
recipients. It should be noted that mutuality is a critical
correlate of outcomes for both care recipients and caregivers.
In the light of the increasingly complicated needs of care
recipients, however, more is involved than just an emphasis
on caregiver outcome. Research examining the perspectives
of care recipients quality of relationship with their family
caregivers suggests that greater mutuality correlates with
improved psychosocial functioning among care recipients
(Lyons et al. 2002, Ball et al. 2010) and is negatively
affected by care recipients impairment (Lyons et al. 2007,
Ball et al. 2010). Yet, far less is known about patients
mutuality with their family caregivers and its impact on
QOL in patients with schizophrenia. It will benefit patients,
family caregivers and health care providers in general to
understand what factors contribute to greater perceived
mutuality among individuals with schizophrenia.
To summarise, QOL is being considered as a particular
indicator in understanding the impact of mental illness and
mental health care services on various aspects of the lives of
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 23672376

Quality of life of individuals with schizophrenia

individuals with schizophrenia. Such patients usually face


cumulative demands (e.g. unemployment, financial difficulty,
poor health and conflicts among family members) in their daily
lives. Clarifying the relationships between influencing factors
and QOL would be helpful in determining treatment priorities
in the face of unmet needs and limited resources. By considering
the limited research in Taiwan that examines QOL and its
contributing factors in individuals with schizophrenia, perhaps
the relative contributions of associated factors of QOL may be
found across different cultures.
The aims of this study were: (1) to examine the level of
QOL in individuals with schizophrenia in Taiwan, (2) to
examine the association of QOL with socio-demographic
characteristics (e.g. gender, education, marital and employment status and monthly household income), clinical characteristics (e.g. age at mental illness onset, number of
previous hospitalisations, the length of mental illness and
symptom severity) and psychosocial characteristics (e.g.
health status and mutuality), and (3) to identify factors that
predict the degree of QOL in accordance with the results of
their correlations with the socio-demographic, clinical and
psychosocial characteristics.

Methods
Study design and sampling
A cross-sectional, correlational research design was used to
recruit subjects. A convenience sample of 148 individuals with
schizophrenia was recruited from a psychiatric outpatient
department (OPD) in central Taiwan. This sample size can
detect correlations between variables with a medium effect size
at the power of 080, a of 005 and a p-value of 005 (Cohen
1992). Inclusion criteria were: (1) diagnosis of schizophrenia
according to DSM-IV criteria (American Psychiatric Association 2000), (2) aged 20 years or above, (3) outpatients living
with their families in the community have been clinically stable
for at least three months before recruitment [Clinical stability
was defined as an increase in the dose of drug(s) not more than
50% over the past three months (Lobana et al. 2001), and (4)
able to understand or speak a Taiwanese and Mandarin
language. Exclusion criteria included: (1) neuro-cognitive
impairment (e.g. dementia) or known organic disorders, (2)
current inpatient treatment, and (3) presence of visual,
language or communication difficulties.

Data collection
Data were collected between 2009 and 2010. Prior to
commencing the study, ethics approval for this study was

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C-Y Hsiao et al.

granted by the hospitals involved. The principal investigator


approached primary mental health care providers (psychiatrists and nurses) to explain the purpose and the procedures
of the study and asked for their collaboration in identifying
potential subjects. Eligible persons were approached by the
principal investigator or a trained research assistant and were
invited to participate in this study. Written informed consent
was obtained with full explanation of the purpose of the
study. Participants were assured that all of the information
would be strictly confidential, participation was voluntary
and they could withdraw from the study at any time. After
obtaining their consent, each participant was asked to
complete the questionnaire in the private setting of an
outpatient clinic. The questionnaire required approximately
30 minutes to complete.

Measures
Socio-demographic data
All participants completed a demographic information sheet,
which included data on gender, education, marital status,
employment status, monthly household income, age of
mental illness onset, length of mental illness and number of
previous hospitalisations.
Symptom severity
The 18-item Brief Psychiatric Rating Scale (BPRS; Overall &
Gorham 1962) was used to assess the presence and severity of
psychiatric symptoms. It is a seven-point Likert-type scale
from 0 (not present) to 6 (extremely severe). Higher scores
indicated a higher level of mental symptoms (total score
range of 0108). Cronbachs alpha has been reported, ranging from 062 to 087 (Overall & Gorham 1962, Huang et al.
2008a,b). In this study, the Cronbachs alpha was 073.
Health status
Heath status was assessed with the Chinese Health Questionnaire (CHQ; Cheng et al. 1990). It is a 12-item questionnaire and scored via the 0-0-1-1 method, with higher
scores indicating poor health status. The CHQ has been
shown to have acceptable criterion validity and satisfactory
internal consistency with a Cronbachs alpha of 084 and 083
in the community and hospital groups, respectively (Cheng
et al. 1990). Cronbachs alpha for the present sample was
084.
Mutuality
The Chinese version of the Mutuality Scale (Shyu et al. 2010)
was used to assess the quality of relationship between the
caregiver and the care recipient. The scale is composed of 15

2370

items describing the frequency (0 = not at all; 4 = a great


deal) of communication, positive engaging interactions,
attachment and emotional support. Item responses were
averaged. Cronbachs alpha values of 091094 have been
reported for family caregivers (Archbold et al. 1990, Shyu
et al. 2010) and for care recipients (Tetz et al. 2006). For this
study, Cronbachs alpha was 097.
Quality of life
Quality of life was measured using the World Health Organization Quality of Life Scale, brief version (WHOQOLBREF), Chinese version (Yao 2002, The WHOQOL-Taiwan
Group 2005), which includes four subscales with 26 items and
two additional items measuring comprehensive QOL and
general health perceptions. The scale consists of four domains
including physical health, psychological state, social relationships and environmental features. It is a 5-point Likerttype scale (1 = very dissatisfied to 5 = very satisfied). Three
items (3, 4 and 26) were recoded. Higher scores indicated
higher QOL (total score range of 28140). The psychometric
properties have been found to be sound, with Cronbachs
alpha of the total scale ranging from 089 to 091 and those of
the four domains ranging from 061 to 083 (Yao 2002,
Hsiung et al. 2010, Kao et al. 2011). In our study, the Cronbachs alpha of the total scale was 094 and those of the four
domains were physical health, 076; psychological state, 079;
social relationships, 080; and environmental features, 089.

Data analysis
Data were analysed using the Statistical Package for the
Social Sciences (SPSS ) version 17.0 for Windows (SPSS,
Chicago, IL, USA). Statistical significance was determined
at p < 005. Descriptive statistics such as frequency, mean
value and standard deviation were used to analyse sociodemographic, clinical and psychosocial characteristics. The
Pearson productmoment correlation test was used to examine the association of QOL with socio-demographic, clinical
and psychosocial characteristics. Stepwise multiple linear
regression was carried out to test variables that had significant correlations with QOL to determine the relative
importance of the variables in contributing to variation in
QOL.

Results
Characteristics of participants and main study variables
The characteristics of participants and the mean and standard
deviation of main study variables are summarised in Tables 1
2012 Blackwell Publishing Ltd
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Quality of life

Quality of life of individuals with schizophrenia

69
79

466
534

provided by the family members and had been hospitalised at


least once. As shown in Table 2, particularly, total mean
scores of the four domains of the WHOQOL-BREF indicate a
higher level of satisfaction with physical health and environmental features, while a lower degree of satisfaction in the
domains of social relationships and psychological state.

109
15
24

736
101
163

Association of quality of life with socio-demographic,


clinical and psychosocial characteristics

51
97

345
655

47
72
29

318
486
196

63
85

426
574

133
15

899
101

Table 1 Characteristics of participants (n = 148)


Variables

Age (years) (M SD)


Gender
Male
Female
Marital status
Single*
Married
Separated/divorced/widowed
Employment status
Yes
No
Education
Less than senior high
Senior high school graduate
College and graduate
Monthly household income
<25,000
325,000
Monthly household income
provided by the family members
Yes
No
Age at mental illness onset
(years) (M SD)
Number of previous
hospitalisation
<1
31
Financial support
Family members
Significant others
Friends
Self
Length of mental illness
(years) (M SD)

%
3865 1043

248 602

7
141

47
953

133
6
1
8

898
41
07
54
139 978

*Single refers to a person who has never been married.

Predictors of QOL

Table 2 Characteristics of main study variables

Variables

SD

Range

Possible
range

Symptom severity
Health status
Mutuality
Total quality of life (QOL)
Physical health
Psychological health
Social relationships
Environmental features

380
530
3393
9030
1328
1243
1279
1297

383
306
1572
1857
279
298
322
307

023
012
060
32132
420
519
420
420

0108
012
060
28140
420
420
420
420

and 2. A total of 148 participants took part in the study. The


majority of patients were female, single, unemployed, had a
high school degree or less, had monthly household income
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 23672376

Pearson productmoment correlation coefficients were calculated to examine the association of QOL with sociodemographic, clinical and psychosocial characteristics. All
variables were considered as continuous except gender,
education, marital and employment status and monthly
household income, which were dichotomous. QOL was
positively and statistically significantly correlated with age
of mental illness onset (r = 025, p < 001), mutuality
(r = 0508, p < 001), employment status (r = 0229,
p < 001) and monthly household income (r = 0303,
p < 001) and negatively correlated with the length of
mental illness (r = 0285, p < 001), symptom severity
(r = 0306, p < 001) and health status (r = 0194,
p < 005). Patients with early onset of schizophrenia, greater
mutuality with their family caregivers, employment and
greater monthly household income perceived greater satisfaction with their QOL. Likewise, patients who perceived less
satisfaction with their QOL were those who had longer
duration of schizophrenia, severe psychiatric symptoms and
worse health status. There was no significant relationship of
QOL with gender, number of previous hospitalisations,
marital status and education.

Multiple linear regression analysis with the stepwise method


was conducted to determine the predictors of QOL, using
socio-demographic characteristics (i.e. employment status
and monthly household income), clinical characteristics (i.e.
age of mental illness onset, length of mental illness and
symptom severity) and psychosocial characteristics (i.e.
health status and mutuality) as the predictor variables
(Table 3). The results showed that mutuality, symptom
severity, monthly household income and employment status
were significant predictors of the QOL and accounted for
443%. Of these variables, mutuality (b = 0495, p < 0001)
made the largest unique contribution and symptom severity
(b = 0315, p < 0001), monthly household income
(b = 0247, p < 0001) and employment status (b = 0153,
p < 005) also made statistically significant contributions.

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C-Y Hsiao et al.


Table 3 Stepwise multiple regression of the predictors of quality of
life (QOL) (n = 148)
Variables
Mutuality
Symptom severity
Monthly household
income
Employment status
Excluded variables
Age at mental illness onset
Length of mental illness
Health status

b
0495
0315
0247

8014***
5087***
3941***

0153
1328
0116
0083
0106

2437***
279
1741
1227
1565

Model summary: R = 0677, R2 = 0458; Adjusted R2 = 0443;


F = 30201, p < 0001.
*Variables were selected based on bivariate analyses (Pearson correlation coefficients) using QOL as the dependent variable and
p < 005; p < 001.
*p < 005; **p < 001; ***p < 0001.

However, the other variables did not significantly contribute


to the regression model. These results revealed that greater
mutuality, less severe psychiatric symptoms, more monthly
household income and employment significantly increased
the level of QOL. Conversely, age of mental illness onset,
length of mental illness and health status did not significantly
affect the degree of QOL.

Discussion
This is one of the few studies that has investigated QOL and
its correlates (i.e. socio-demographic, clinical and psychosocial characteristics) in individuals with schizophrenia living
with their families in the community. Although these are
critical variables in the care of people with mental illness,
prior research has primarily focused on socio-demographic
and clinical factors as predictors (Chan et al. 2007, Xiang
et al. 2008, Meijer et al. 2009). Knowing the relative
contributions of multiple factors that influence QOL in
people diagnosed with schizophrenia can help provide insight
for preventions as well as interventions for improving
satisfaction with various aspects of life.
The mean scores for QOL and its four domains (i.e.
physical health, psychological health, social relationships and
environmental factors) in this study were lower than those for
the general population in Western countries (Bobes &
Carcia-Portilla 2006, Picardi et al. 2006, Evans et al. 2007)
and Eastern countries (Kunikata et al. 2005, Xiang et al.
2007, Yen et al. 2008). Further, our respondents reported
less satisfaction with their psychological and social relationships compared with other aspects of life, which is consistent

2372

with prior studies in Italy (Picardi et al. 2006), Hong Kong


(Chan et al. 2007) and Taiwan (Kao et al. 2011). Similar to
previous studies (Chan et al. 2007, Meijer et al. 2009, Kao
et al. 2011), more of our participants were single, unemployed and financially supported by their family and therefore may have a small social circle outside of their families.
In Taiwanese society, having offspring with mental illness
is regarded as a punishment for evil deeds in previous lives,
adhering to the belief that people inevitably reap what they
sow (Lin et al. 2008). Individuals with mental illness,
particularly with schizophrenia, are often perceived as scary,
frightening, unpredictable and dangerous (Hsiung et al.
2010). Given that face (miazi) is critically intertwined with
social stigma against the mentally ill, the diagnosis of
schizophrenia may result in a loss of face for the individuals
and their families (Huang et al. 2008a,b). Such public
misconceptions and social stigma attached to mental illness
has hindered patients and their families from seeking help
and getting access to appropriate mental health treatment.
Apart from the experience of distressing symptoms, pejorative stereotypes of mental illness may impede patients
opportunities for establishing social relationships, finding a
partner, entering the workforce and integrating into the
community. As a result, patients have less likelihood of
marriage, fewer opportunities for employment and income
loss that hampers a satisfactory QOL, particularly psychological health. The impact of the stigma associated with
mental illness on the QOL among people with schizophrenia
needs to be further investigated.
Regarding the association of socio-demographic characteristics and QOL, we found that people who were employed
and had a higher monthly household income perceived
greater satisfaction with their lives, suggesting that employment plays an important role in the daily life of an individual.
These findings were consistent with those of a study undertaken in Hong Kong (Chan & Yu 2004) and Brazil (de Souza
& Coutinho 2006). As Chan and Yu (2004) noted, work not
only provides financial remuneration but also enhances
individuals integration into society and promotes the perceptions of their worth. Contrary to findings in previous
studies (Chan & Yu 2004, de Souza & Coutinho 2006, Kao
et al. 2011), there was no significant association of QOL with
age, gender, education and marital status. This discrepancy
could be partly attributed to the variations of sample size,
study design, participants characteristics, settings and instruments of the assessments. Likewise, this lends support to
earlier findings indicating that socio-demographic variables
had no or only weakly significant association with the QOL
(Picardi et al. 2006, Xiang et al. 2008, Dimitriou et al.
2009).
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 23672376

Quality of life

In accordance with other studies, age of mental illness onset


(Kao et al. 2011), length of mental illness (Chan et al. 2007)
and symptom severity (de Souza & Coutinho 2006, Chan et al.
2007, Xiang et al. 2008) were significantly associated with
QOL. Patients with early onset of schizophrenia, longer
duration of mental illness and severe psychiatric symptoms
had a markedly diminished perception of their QOL. This
finding, partly, is in line with previous research that patients
with early onset of mental illness were likely to have an
unfavourable prognosis (Hafner 2000, Bender et al. 2001),
higher rates of chronicity (Bender et al. 2001) and increased
likelihood of dissatisfaction with their QOL (Kao et al. 2011).
As Larsen and Gerlach (1996) indicated, patients in a later
stage of schizophrenia tend to adapt and improve their QOL.
Furthermore, in the present study, patients with poor health
status and less mutuality reported poor QOL. Because no other
studies have examined this relationship, discussion and comparison of our findings are limited. A possible explanation is
the fact that patients with poor health status might induce more
conflicts and disharmony in the quality of relationships
between themselves and their family caregivers that adversely
influence satisfaction with QOL. The impact of health status
and mutuality on QOL in schizophrenia warrants further
investigations.
The significant relationships of QOL with mutuality,
symptom severity, monthly household income and employment status in this study indicated that these factors increased
the risk or vulnerability for unsatisfied perceptions of QOL.
To date, however, few studies have specifically addressed the
great value of mutuality in the level of psychosocial
functioning of patients with dementia (Ball et al. 2010) and
older adults with mildmoderate cognitive impairment
(Lyons et al. 2002, 2007). Nevertheless, it should be interpreted with caution that above-mentioned studies were
conducted in Western countries, and the findings may not
be applicable to a non-Western country such as Taiwan.
Further investigation is required to clarify this phenomenon.
Moreover, findings from this study also demonstrated that
mutuality, or the positive quality of the patientcaregiver
relationship as reported by the patients, is the most critical
determinant of QOL among several socio-demographic and
clinical factors. It is of interest that the increased mutuality
strongly enhanced patients QOL. Perception of assistance
from family members as supportive, apparently, alleviates
stress and facilitates managing the concerns of patients.
Accordingly, the components of mutuality (e.g. dyadic
conflicts, reciprocity, communication, interaction and cohesion) may appear to warrant much more attention to advance
our understanding of the importance of mutuality and its
impact on the QOL among individuals with schizophrenia.
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 23672376

Quality of life of individuals with schizophrenia

In the sociocultural context of Chinese communities, given


that strong emphasis is placed on the interdependence of
family members, families play a vital role in caregiving and
maintenance of harmonious relationships. Patients are more
likely to live with and depend more on their families in their
own community to meet their needs. However, the mutuality
may deteriorate in the family caregiving experience as the
demands of care become increasingly unpredictable (Lyons
et al. 2007). Family caregivers may not be equipped with the
knowledge and skills needed to manage their relatives
psychiatric symptoms, which results in conflicts or a less
satisfying relationship. To provide family caregivers with an
educational programme on symptom management is extremely critical. In addition, the mutuality may be greatly
influenced by the past and present; however, it has vital
consequences for both patients and their family caregivers.
Given that the patients perspective on the mutuality with the
family caregivers is a critical contributor to QOL, further
research on the extent of care-dyadic congruence over
mutuality is of great importance.

Limitations
The results of this study should be interpreted with caution
because of several methodological limitations. First, the study
was cross-sectional; therefore, the results cannot be used to
infer causality. Given that the degree of mutuality and QOL
may change over time, the extent of QOL and its determinants need to be investigated longitudinally, to show subtle
changes throughout the course of schizophrenia. Secondly,
the study only recruited outpatients with schizophrenia living
with their families in the community, precluding generalisation to all patients with schizophrenia. Therefore, replication
of the current findings with inpatients is necessary. Finally, a
potential limitation of the study was the use of WHOQOLBREF, a generic questionnaire that may not have been
sensitive enough to detect subtle changes of QOL in persons
with schizophrenia. More specific instruments with sensitive
gradations such as the Schizophrenia Quality of Life Scale
Revision 4 (SQLS-R4; Kuo et al. 2007) should be used for
future studies.

Conclusion
Schizophrenia is a taxing and demanding illness that interrupts the QOL in affected individuals and their families. The
findings of this study underline the deleterious effect of low
mutuality, high symptom severity, low monthly household
income and unemployment status on QOL in patients
with schizophrenia living with their families in Taiwan.

2373

C-Y Hsiao et al.

Additionally, this study further expands the existing caregiving literature on the importance of patients mutuality with
their family caregivers and its impact on the satisfaction of
QOL in schizophrenia. Apparently, the emphasis on holistic
care needs to go further by looking at information not only
on the psychopathological symptoms but also on psychosocial characteristics. Knowledge gained from this study is
critical for health care professionals to incorporate families
and communities into treatment programmes and, in turn,
enhance patients capabilities of social integration and
satisfaction with their lives.

Relevance to clinical practice


Findings from this study pointed out how socio-demographic
and clinical characteristics, health status and mutuality play a
vital role in determining QOL for individuals with schizophrenia, while psychiatric symptoms, though correlated with
QOL, are not the most critical elements that account for
QOL. Special attention should be given to the importance of
mutuality in the improvement of QOL in schizophrenia.
Knowledge of the assessment of mutuality and its association
with QOL represents a unique opportunity for the development of targeted interventions to promote communication,
reciprocity and sense of family orientation between the
patient and family caregiver about the caregiving circumstance and their respective needs. Such interventions would
improve mutuality that not only improves patients life
satisfaction but also facilitates family adaption to living with
schizophrenia.
Traditional Chinese cultural values and the social stigma
attached to mental illness clearly make living with a highly

stigmatised disease, such as schizophrenia, extremely difficult


not only for patients but for also their families. Clearly, such
stigmatisation hampers the opportunities for employment and
societal integration and consequently, has an overall negative
impact on the QOL of those suffering from schizophrenia. Poor
QOL in individuals with schizophrenia may result in increased
demands on their families. To provide holistic care to patients,
health care providers need to not only focus on the reduction of
psychiatric symptoms but also facilitate patients psychosocial
functioning to integrate into the community. Efforts should
also emphasise engaging patients and families in the task of
developing coping strategies to counteract the negative influences of stigma and enhance psychosocial functioning (e.g.
greater health status and positive mutuality) to adapt to daily
life stressors and demands.

Acknowledgements
We would like to express our sincere appreciation to the
research participants for their corporation. Sincere thanks to
Chung Shan Medical University Hospital, Taiwan for funding this study (CSH-2010-A-011).

Contributions
Study design: CYH, CCC; data collection and analysis: CYH,
MHH CJT, SHC, CCC and manuscript preparation: CYH,
MHH, CJT, SHC, CCC.

Conflict of interest
No conflicts of interest.

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