INTRODUCTION:

Addressing medication adherence among schizophrenic patients has been a complicated process that requires multifactorial solutions. Some aspects of non-adherence were caused by personal factors, sociocultural issues, financial problems, stigma, care fragmentation and lack of insight. Previous studies explored factors related to poor compliance, such as knowledge, beliefs, and attitudes related to health conditions.

Poor knowledge about mental conditions, antipsychotic medications, and the desired treatment outcomes were considered as other reasons for non-adherence to treatment. It was investigated that patients discontinued the treatment when they felt better or they did not notice any improvement after taking medications^1-8. In another study, refusal to take medications was related to an unpleasant experience with side effects of drugs (42%), felt better after taking several prescribed medications (26%), forgotten to take doses of drugs (38%) and preferred using complementary therapies (29%)⁹.

More interestingly, however, medication adherence was related to the aspect of poor supervision from the environment. Schizophrenic patients may require support and supervision from health professionals, families, friends and neighbors while taking antipsychotic medications. They need to be surrounded by people with whom they are familiar who can provide emotional and social support as well as assisting them to manage the medications and cope with daily stress^10-11. A community could offer advice, suggest possible solutions and connect them to available resources that will benefit them to improve their conditions.

Medication adherence is a predictor of quality of life among schizophrenic patients generated in earlier studies, it can lead to exacerbation of symptoms, higher rates of relapse, higher risk of mortality, increased use of health services. Studies showed that poor compliance with treatment related to the frequent use of mental health hospitalizations and health care costs. This condition has been scrutinized and found to be a burden by many, families, community and health care system^12-17.

Several studies have shown to prevent recurrent relapse and non-adherence in schizophrenia. Medication and psychotherapies were known to be effective treatment for schizophrenia, but these did not resolve the underlying causes of the illness. Attempts to determine the best treatment for improving medication adherence has been identified multiple factors, some of which are empowering community to contribute collectively to supporting schizophrenic patients. Involving the community support systems, in addition to medical treatment can improve adherence to treatment. The community has the ability to change patients’ attitudes, insight, and behavior. The community should be able to understand the subtlety of mental illness and how to support schizophrenic patients, this is known as the community adaptability skills Helping to change the attitude and behavior of schizophrenic patients is a big part of the mission of community. Further, the community adaptation emerged as a strategy to build community resilience, the ability to adapt to changes. Studies suggested the need for widespread implementation of community-based practice model, in conjunction with conventional medical treatments to improve adherence among schizophrenic patients as well as reduce the burden of care, particularly in low-income and middle-income countries^18-20.At this stage, there is little available information on the topic of a community-based model for supporting medication adherence in schizophrenic patients. The development of a good practice model is required to meet the needs of current health and social wellbeing. Therefore, the objective of this study was to explore a community resilience model as a new way of optimizing medication adherence among schizophrenic patients.

MATERIAL AND METHODS:

A systematic review was written based on 99 data sources: Science Direct, Google Scholar, Proquest Health and Medical Complete, Proquest Psychology Journals and Proquest Science Journals from 2006 to 2019, search terms related to medication adherence in schizophrenia (compliance OR adherence) and community support (community support OR social support OR family support), yielding 51 articles that need to be screened. Articles were included if they directly described medication adherence and some form of community or social support. There were only 15 articles eligible to be reviewed (See Fig. 1).

Fig. 1: Flowchart of study inclusion protocol

RESULTS AND DISCUSSION:

The predictors of medication adherence in schizophrenic patients identified from the studies and reviews were grouped into several categories: socio-demographic factors, health and disease factors, individual factors, family factors, community factors, and medical treatment factors (See Table 1). Socio-demographic characteristics include age, sex, socioeconomic status, employment and level of education. Studies revealed that younger age and female were more likely to be noncompliance (P<0.01), younger age was especially unlikely to seek mental health services and believed that the illness was not so severe and harming others. Several studies have reported different results about the impact of gender on many aspects. Lack of employment, low-level of socioeconomic status and poor education were other factors related to adherence. The socioeconomic aspect was associated with adherence when it comes to treating chronic illnesses such as schizophrenia. This condition was very close to other variables, knowledge about schizophrenia and its treatment in particular with people who live in rural areas, they tend to have difficulties in managing adequate treatment as they live in limited geographical areas^21-25.

Health and disease - duration of illness, the severity of symptoms and Body Mass Index (BMI) were other predictors for adherence in schizophrenic patients. Shorter duration of illness and the severity of symptoms determined the duration of therapy for schizophrenia outpatients (P<0.01)²¹. Higher BMI was found more often in noncompliance patients, so it was recommended that the patients should be aware of the negative consequences of having bad lifestyles and habits as it could also increase the chances of having other medical conditions²².

The attitude of schizophrenia patients towards medication or treatment may directly or indirectly impact the course of illness. Studies showed that a positive attitude towards the prescribed medications may alleviate the impact of illness and it was also associated with good insight and awareness of the mental illness. The presence of good insight was linked to a better ability to understand and perceive the illness as well as the importance of medications and other types of treatment^{3,4,11,21,25-27}. Developing behaviors for taking routine medications were needed to improve treatment outcomes and functional status²³.

In Parihar’s study, more than fifty percent of community members have poor insight about mental illness. Poor knowledge about mental illness was related to adherence to treatment, they suggest that community participation leads to a better understanding of the mental illness.²⁸ Public stigma is linked to improper treatment adherence, as it prevents schizophrenic patients from seeking professional treatment.

A higher level of stigma was also felt by schizophrenic patients with poor insight. Better insight was associated with increased hope, self-esteem and active participation in community events. On top of that, a high level of perceived stigma has devastating effects on daily life and may cause a lack of engagement in medical treatment^26,29.

Schizophrenia treatment was quite complex and required commitment to achieve long term goals as it has dramatic changes to patients’ life. Social support from family and community provides practical and emotional helps to encourage patients to follow the treatment and manage stresses of living with illness. Living in rural areas has a strong connection between access to health services and medication adherence^25-27,30-33.

Medical treatment factors - side effects of drugs, hospital admission frequency, treatment needed, antipsychotic types, treated symptoms and supervision were also important predictors of medication adherence. It was reported that schizophrenic patients felt at least “somewhat bothered” and bored with the side effects of drugs, such as thinking and memory problems (32.2%), inability to sleep (28.4%), feeling tense, and uneasy (28.2%), gaining weight (25.8%), tiredness (25.1%), low sexual desire (20.6%), feeling dizzy (17.8%), being constipated (16.2%), uncontrollable shaking of extremities (13.1%) and sexual impairment (12.6%). Longer frequency of admissions, the awareness of treatment needed, treated symptoms and antipsychotic types have a significant correlation with adherence to prescribed drugs (P<0.01). Studies found that medication adherence rates were higher among schizophrenic patients receiving atypical antipsychotics than typical drugs. Patients need to be motivated to take antipsychotic medications, they need ongoing support from health professionals, families, friends and community to increase their self-esteem. They need adequate supervision and guidance about how to follow the treatment recommendations^{3,4,12,22,23,27,31-33}.

Table 1: Predictor of Medication Adherence in Schizophrenic Patients

Predictor Medication Adherence	Item
Socio-demographic factors	Age, sex^21,25
	Socioeconomic status²²
	Employment^23,25
	Level of education²⁵
Health and Disease factors	Illness duration, severity of symptoms²¹
Health and Disease factors	BMI²²
Individual factors	Attitudes, beliefs, insight^{3,4,11,21,25-27}
	Routine medications, functional status²³
	Stigma²⁶
Family factors	Family support ^26,27,30
Community factors	Residential areas²²
Community factors	Social support ^23,25,27
Medical treatment factors	Side effects of drugs, hospital admission frequency, treatment needed, antipsychotic types^3,4,21,25,27
	Treated symptoms²⁵
	Supervision^11,25

Social support can help schizophrenic patients to maintain their quality of life during long-term treatment. Family, friends, and community can help them to find and sustain both practical and emotional support. A community could encourage patients to seek help, support them to continue following the treatment, and guide them to take medication on time and improve their social lives.

Living in a nurturing and therapeutic environment could be a dream for schizophrenic patients. Such an environment was an important step in attaining their recovery. Beebe et al. stated that the community was the treatment success for schizophrenic patients was determined by initial and ongoing contact between community members and patients. A community may positively affect the way patients manage their pressures of life and facilitate adaptive coping skills³¹. Schizophrenic patients who are adequately supported by the community tend to feel a greater sense of belonging and acceptance, less lonely and have a greater quality of life.

The key to recovery from schizophrenia includes a sense of hope, self-acceptance, sense of belonging and confidence. The ability to recover from schizophrenia and other stressors during illness course is a critical element of community taskforce program. The importance of community support, especially to schizophrenic patients suggested that a supportive environment was particularly helpful for improving medication adherence. Developing community resilience was not easy, several steps should be reinforced: 1) communities must identify the problems and its exact nature needs to be evaluated; 2) improve social and economic resources; 3) involve society members to participate in supporting schizophrenia patients; 4) connect with local support organizations; 5) establish community supports, and 6) implement strategies which fit into the needs of community. Promoting the community resilience model in the context of schizophrenia recovery has a positive impact on the global function of schizophrenic patients. Community resilience was a strategy to support and encourage healthy habits for individuals, families, and communities with regards to the recovery of schizophrenia patients^34-37. The community-based model involved multi-sector partnerships and emphasizes its members to participate in interventions.

Engaging communities to support each other, coping with emotional, social and the pressures of daily life can foster greater community resilience. The essential components of community resilience model have been shown as an effective method for supporting medication adherence in several studies: 1) Community resources – socioeconomic capital, social support; 2) Community coping strategies – mental health services, health policy and integrated care services; 3) Community adaptation – psychological and sociocultural adaptation; 4) Community resilience, and 5) Medication adherence. The underlying principles for community resilience are focused on getting stronger, helping others, being socially organized, keeping connected, learning to reflect and share ideas, being locally interdependent and reasonably profitable (See Fig 2)^38-42.

Fig. 2: Framework of Community Resilience Model for Supporting Medication Adherence of Schizophrenic Patients^38-42

Community resilience defines as community ability to adapt to the sources of daily stress, in this context, the community has certain resources (socioeconomic capital and social support) to help schizophrenia patients to manage the prolonged medical treatment. Community could improve strategies for coping with the behaviors of schizophrenic patients by integrating mental health services with local health policy and other services which met the needs of patients. Adaptive community includes the aspects of psychological adaptation and sociocultural adaptation. Psychological adaptation refers to community adjustment or changes in behavior to support medication adherence in schizophrenic patients. Sociocultural adaptation could be identified as providing motivational support and having the commitment to take part in community interventions.

A resilient community within this framework provides an opportunity for other community members to come together to support schizophrenia patients to comply with the prescribed medications and other treatments. Previous studies examined the role of social relationships in achieving and maintaining recovery of schizophrenia patients⁴³. Factors related to recovery were positive thoughts (35%), prescribed treatment (24%), and social relationships (18%)⁴². Community resilience involves collective thoughts, behaviors, and actions that can be learned through experience. Facing life challenges makes us more powerful and stronger, as positive thoughts related to resilience⁴⁴. Resilient communities help schizophrenia patients to cope and get through hard times, in particular, compromising adherence to treatment. Helping others was recognized as another stage of the resilience process, in which people give their support, reinforcement, shared learning, feel connected, and optimism. Socially organized means that the community organized special activities to help schizophrenic patients to be more productive in life. Community support can improve resilience to stress, help protect against the negative effects of stigma on mental health. Locally interdependent means as helping schizophrenia patients reach their full potential and abilities, and provide life skills training to improve their productivity. A reasonable profit outlines acknowledgement of schizophrenia patients to make a future plan for a successful treatment. Community resilience implies that people have connected with each other, socially organized in which communities have ability to meet their needs with regards to help schizophrenia patients adhere to their treatment regimens^45-47.

CONCLUSION:

These findings could potentially inform the development of community resilience model for optimizing medication adherence among schizophrenic patients.

ACKNOWLEDGEMENT:

The authors are grateful to Faculty of Public Health, Universitas Airlangga for providing tremendous support to the study.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 14.01.2020 Modified on 29.02.2020

Research J. Pharm. and Tech. 2020; 13(11):5083-5087.

DOI: 10.5958/0974-360X.2020.00890.2