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147Perspect Psychiatr Care. 2019;55:147–152. wileyonlinelibrary.com/journal/ppc © 2018 Wiley Periodicals, Inc.
Received: 27 February 2017 Revised: 20 February 2018 Accepted: 24 February 2018
DOI: 10.1111/ppc.12276
O R I G I N A L A R T I C L E
The influence of adherence to antipsychotics medication on the quality of life among patients with schizophrenia in Indonesia
Lia Endriyani MSN1 Ching-Hui Chien RN, PhD1 Xuan-Yi Huang RN, MSN, DNSc1
Liu Chieh-Yu PhD2
1Department of Nursing, National Taipei Uni-
versity of Nursing and Health Sciences, Taipei,
Taiwan
2Graduate Institute of Nurse-Midwifery,
National Taipei University of Nursing and Health
Sciences,, Taipei, Taiwan
Correspondence
Xuan-YiHuang,RN,MSN,DNSc,Professor,
DepartmentofNursing,NationalTaipeiUniver-
sityofNursingandHealthSciences,Taiwan,365,
MingTeRoad,11219,Peitou,Taipei,Taiwan.
Email: [email protected]
Abstract Purpose: Investigating factors that can predict medication adherence and quality of life, as well as
the influence of adherence to medication on the quality of life among patients with schizophrenia.
Design and Methods: This study applies descriptive cross-sectional design. Participants were
determined from outpatient clinic in a psychiatric hospital in Indonesia. Several questionnaires
were used, including self-report, Glasgow Antipsychotics Side-effect Scale, drug attitude inven-
tory and SQOL-18.
Findings: Side-effect factor (p < .05) could influence medication adherence. Residential area
(p < .05) could significantly influence quality of life. There was also a correlation between medi-
cation adherence and quality of life (p < .05).
Practice Implications: Findings suggest to put more emphasis on assessing medication side
effects.
K E Y W O R D S
medication adherence, patients with schizophrenia, quality of life
1 INTRODUCTION
Schizophreniaisasevereformofmentalillnessthatisknowntoconsid-
erably influence a patient's physical, social, and cognitive functions.1,2
People who experience schizophrenia often suffer from significant dis-
advantages in their occupation, education, socioeconomic status,1 and
quality of life.3–5
Antipsychotic medication is an effective treatment for
schizophrenia.6 Antipsychotics were found to be statistically sig-
nificant indicators of quality of life.7 Recently, treatments increasingly
focus on improving the quality of life for patients with schizophrenia.
Finding a solution is particularly important to develop treatments
that help individuals with schizophrenia lead more fulfilling and
satisfying lives. Factors influencing quality of life are broadly grouped
into socio-demographic and clinical ones, such as marital status4 and
unemployment.8 The quality of life of patients with schizophrenia
can be influenced by unsatisfied needs,9 including the failure to meet
physical health needs, treatment of psychotic symptoms, or financial
need.10 Some studies have found that medication side effects are
one factor which could influence the quality of life for people with
schizophrenia.5,11,12 In addition, previous studies suggest that nonad-
herence to antipsychotic medications may result in poor quality of life
in patients with schizophrenia (Lasebikan & Owoaje, 2015).13
Nonadherence to antipsychotic medications is a major factor that
contributes to relapse and readmission.14,15 However, previous study
suggests that many patients with schizophrenia are reported to expe-
rience dissatisfaction with mental health care providers and that a lack
of access significantly predicted medication omission.16 Besides, poor
attitude toward antipsychotic medication is as predictors of nonadher-
ence to antipsychotic medications.17,18 In Indonesia, relapse patient
with schizophrenia show a high nonadherence toward medication.19
A qualitative study indicates that disobedience of treatment is associ-
ated with economic factors, endless conflict between couples, contin-
uous family conflict, and depression from unmet needs, and these are
also the leading causes of relapse and readmission among inpatients
with schizophrenia.20
The prevalence of schizophrenia is increasing, particularly in
developing countries.21 People with severe mental disorders receive
no treatment for their disorder in low-income and middle-income
countries for more than 70%.22 As a developing country, Indonesia
seems to have lower quality of daily life in outpatients of schizophre-
nia, owing to unmonitored patients and a lower priority on national
health programs. To our knowledge, the quality of life and medical
2 ENDRIYANI ET AL.148
adherence in patients with schizophrenia have been studied in many
countries such as Sweden,17 French,4 Nigeria,3,13 (Adelufosi et al.,
2012),33 and Thailand.5 However, there is a lack of studies investigat-
ing to fill in the knowledge of quality of life and medical adherence in
Indonesian patients with schizophrenia. Therefore, this study aims at
investigating the factors that can predict the medication adherence of
antipsychotics and quality of life, as well as investigating the influence
of medication adherence to antipsychotics on quality of life among
patients with schizophrenia in Indonesia.
2 METHOD
2.1 Design and sample
This descriptive cross sectional research design study was conducted
in the outpatient department at the hospital in Indonesia. Adherence
toward medication of antipsychotic was an independent variable while
dependent variable of this study was schizophrenic patient's quality of
life. Data were collected between August and September 2014 from
patients with schizophrenia who visited the outpatient clinic in a psy-
chiatric hospital in Indonesia. Data were collected by using purposive
sampling technique in order to control the sample focusing on inclu-
sion criteria, while the number of samples was small. Several inclusion
criteria for subject selection were (1) a diagnosis of schizophrenia
according to the Diagnostic and Statistical Manual of Mental Disorders
(DSM IV), which had been adapted in Indonesia to Pedoman Peng-
golongan Penyakit dan Diagnosis Gangguan Jiwa (PPDGJ III), (2) aged
between 18 and 65 years, (3) clinically stable (not acutely ill or had not
been recently hospitalized at least for the past 3 months), (4) speaking
Indonesian language, (5) score of Global Assessment of Function
(GAF) Scale > 70, (6) prescribed one or more type of oral antipsychotic
medication, and (7) provided consent to participate in the study.
Those who had incoherent communication and associated diagnosis of
mental retardation, organic brain diseases, or substance abuse were
excluded. We approached 161 respondents who were listed on the
psychiatric consultation appointment during August and September
2014. There were 139 respondents who met inclusion criteria.
Approval from the Institutional Review Board (IRB) in the Hospi-
tal was attained prior to conducting this study. Approval letters and
ethical clearance letters had been given to researchers to execute this
study. Consent forms were given to each participant in the study and
respondentswereensuredanonymity.Participantsscheduledappoint-
ments for their interviews organized by the researcher and patient
either during waiting time for psychiatrist consultation or after consul-
tation while waiting for the pharmacist. The whole interview, including
filling out the questionnaires, took about 15–25 min, depending on the
patient.
2.2 Measures
Socio-demographics data and history of illness and medication data
were collected using self-designed list. The items include age, gender,
marital status, educational level, employment status, income, religion,
residential area, length of illness, hospitalization experience, onset of
schizophrenia, resource of support, and route of description.
The side effects of antipsychotics treatment assessed by using Glas-
gow Antipsychotics Side-effect Scale (GASS), which was developed by
Waddell and Taylor in 2008.23 The GASS was shown to have good dis-
criminating power and construct validity, along with good re-test reli-
ability, and is put forward as a short, helpful, and a valid clinical tool.
This tool contains 22 items of question. The total score of GASS indi-
cates existence of side effects, where 0–21 indicate absent/ mild side
effects; 22–42 indicate moderate side effects; 43 and over indicate
severe side effects. The instrument reliability after translation back
translation process into Bahasa Indonesia (Indonesia language) is 0.81
and its content validity is 0.91.
The drug attitude inventory (DAI-10) consists of 10 yes/no state-
ments reflecting patients’ experiences, attitudes, and beliefs about
medication. The total score is calculated as a sum of each item score.
A positive score indicates a positive subjective response (adherent)
and a negative total score indicates a negative subjective response
(nonadherent). The DAI-10 is a brief form of the DAI-30, which was
developed to assess how the subjective attitude toward antipsychotic
medication of people with schizophrenia may affect adherence with
treatment. The scale reliability is 0.77.24 The reliability of the instru-
ment after translation back translation process to target language is
0.67 and its content validity is 0.90.
The S-QoL 18 is a short form of S-QoL 41, which is a self-
administered questionnaire that assesses quality of life among peo-
ple with schizophrenia (Boyer, et al., 2010).34 The S-QoL 18 evalu-
ates eight dimensions: psychological well-being, self-esteem, family
and friend relationships, resilience, physical well-being, autonomy, and
sentimental life. The reliability of instrument after translation back
translation process to target language is 0.83 and its content validity
is 0.91.
2.3 Statistical analysis
Data were analyzed by utilizing IBM SPSS version 20.0. Data were ana-
lyzed by using chi square and Fischer's exact test. The frequency was
generated to describe socio-demographic, status of illness, and med-
ication status. Fisher's exact test and Chi square test were used to
analyze the relationship between adherence to antipsychotics medi-
cation and quality of life. Furthermore, the significant predicting vari-
ables such as residential area and side effects had been entered into a
logistic regression model to identify the key predictors of quality of life
among patients with schizophrenia.
3 RESULTS
This study suggests that there was no significant difference among all
subdimensions of socio-demographic factors in medication adherence
(Table 1). Only did the side effects subdimension (p < .05) from medi-
cation factor show significant differences (Table 2). Most participants
(92.4%) who adhered to medication felt absence to mild side effects
fromtheirtreatmentduringtheweek.Inadditiontoabsenttomildside
ENDRIYANI ET AL. 3149
TABLE 1 Difference socio-demographics factor in medication adherence and quality of life (n = 139)
Medication adherence Quality of life
Variables Nonadherent n (%) Adherent n (%) 𝝌2 p-value Lower QoL n (%) Higher QoL n (%) 𝝌2 p-value
Age − 1.000 49 (72.1) 52 (66.7) 0.478 .489
18–39 y/o 5 (71.4) 91 (68.9) 17 (27.9) 26 (33.3)
40–65 y/o 2 (28.3) 41 (31.1)
Gender − .439 35 (57.4) 48 (61.5) 0.246 .620
Male 3 (42.9) 52 (39.4) 26 (42.6) 30 (38.5)
Female 4 (57.1) 80 (60.6) 59
Marital status − 1.000 0.018 .892
Single 5 (71.4) 83 (62.9) 39 (63.9) 49 (62.8)
Married 2 (28.6) 49 (37.1) 22 (36.1) 29 (37.2)
Education level − .244 0.652 .419
Basic education 5 (71.4) 58 (43.9) 30 (49.2) 33 (42.3)
Higher education 2 (28.3) 74 (56.1) 31 (50.8) 45 (57.7)
Employment status − .248 0.998 .318
Unemployed 5 (71.4) 59 (44.7) 31 (50.8) 33 (42.3)
Employed 2 (28.3) 73 (55.3) 30 (49.2) 45 (57.7)
Income − 1.000 0.108 .742
Below standard salary 6 (85.7) 114 (86.4) 52 (85.2) 68 (87.2)
Above standard salary 1 (14.3) 18 (13.6) 9 (14.8) 10 (12.8)
Residential area − .427 4.082 .043*
Magelang region 3 (42.9) 83 (62.9) 32 (52.5) 54 (69.2)
Other regions 4 (57.1) 49 (37.1) 29 (47.5) 24 (30.8)
*p < .05.
effects, moderate to severe side effects existed in patient groups who
did not adhere to their medication.
Residential area was the only subdimension of the socio-
demographic factors that showed statistical significance (𝜒2 = 4.082, p = .043) in quality of life (Table 1). Using our framework, we propose medication adherence as an added factor that could influence quality
of life. The findings show people who live in surrounding areas of
Magelang have a higher quality of life scores compared to other
regions. Higher quality of life scores indicate that people who live
in Magelang regions have a better quality of life rather than others
regions. The results show medication adherence significantly influence
quality of life (p < .05) (Table 2).
Finally, both the residential area subdimension and medication
adherence were added into a logistical regression model. Although the
side effect is the only subdimension that influence medication adher-
ence, which does not enter to multivariate analysis. The residential
area subdimension (B = 0.668, OR = 1.949, p = .065) and medication adherence (B = 2.041, OR = 7.699, p = .064) did not add enough to be significant in the quality of life among patients with schizophrenia
(Table 3).
4 DISCUSSION
The findings show that side effects are the only subdimension that can
influence the medication adherence. The residential subdimension of
the socio-demographic factor shows a significant result of influencing
quality of life. There is also a significant relationship between medica-
tion adherence and quality of life. However, the findings show residen-
tial area and medication adherence do not significantly predict quality
of life.
The previous study suggests that medication adherence to antipsy-
chotics has two different and indirect pathways that correlate with
quality of life,12 whereas another study reports no direct relationship
could be distinguished between subjective quality of life and adher-
ence to medication.25 The indirect relationship of medication adher-
ence and quality of life supported by Puschner et al.26 suggests that,
in a follow-up study of medication side effects, the identified indirect
effect could be adherence to a baseline measure affecting quality of
life. However, the results of the current study suggest side effects do
not share a relationship with quality of life as in previous studies5,12,26
that broke the indirect relationship link between medication adher-
ence and quality of life.12 The current study also indicates that adher-
ence to antipsychotics medication had direct relationship to quality of
life that has different results to previous studies.12,26
Side effects are a crucial component of drug acceptability and
adherence. The results of this study concern on side effects found
significant associations with medication adherence. This study sug-
gests that people who experience absent to mild side effects tend to
comply with their medication. In accordance with other studies, side
effects are one of the predictors of medication adherence.18,27 A study
2 ENDRIYANI ET AL.150
TABLE 2 Difference history of illness and medication factor in medication adherence and quality of life (n = 139)
Medication adherence Quality of life
Variables Nonadherent n (%) Adherent n (%) 𝝌2 p-value Lower QoL Higher QoL 𝝌2 p-value
History of illness − .234 0.484 .487
One until 10 years 3 (42.9) 88 (66.7) 38 (62.3) 53 (67.9)
More than 10 years 4 (57.1) 44 (33.3) 23 (37.7) 25 (32.1)
Hospitalized experience − .251 0.113 .737
Less than three times 3 (42.9) 86 (65.2) 40 (65.6) 49 (62.8)
≥ 3 times 4 (57.1) 49 (34.8) 21 (34.4) 29 (37.2)
Onset − .158 0.527 .468
Under 20 y/o 3 (42.9) 26 (19.7 ) 11 (18.0) 18 (23.1)
≥ 20 y/o 4 (57.1) 106 (80.3) 50 (82.0) 60 (76.9)
Support − 1.000 0.028 .866
Themselves 1 (14.3) 18 (13.6) 8 (19.1) 11 (14.1)
Family 6 (85.7) 114 (86.4) 53 (86.9) 67 (85.9)
Side effects − .018a 1.815 .178
Absent to mild 4 (57.1) 122 (92.4) 53 (86.9) 73 (93.6)
Moderate to severe 3 (42.9) 10 (7.6) 8 (19.1) 5 (6.4)
Medication adherencea − − − .043b
Adherent − − 55 (57.9) 77 (98.7)
Nonadherent − − 6 (9.8) 1 (1.3)
aMedication adherence was also added as factor that could influence quality of life. bp < .05.
TABLE 3 The predicting factors of quality of life in patient with schizophrenia (n = 139)
Quality of life
Variable 𝜷 SE OR p-value
Constant −2.117 1.105 0.120 .055
Residential area
Other region versus Magelang region 0.668 0.361 1.949 .065
Medication adherence
Adherent versus nonadherent 2.041 1.102 7.699 .064
OR = odds ratio; 𝛽 = unstandardized coefficient; SE = standard error.
finds that patients experiencing side effects are statistically and sig-
nificantly more likely than others to be nonadherent.27 The burden of
side effects has been extensively explored as a predictor of poor med-
ication adherence.28 It makes sense, therefore, that patients experi-
encing uncomfortable side effects for the first time may stop taking
medication.
There is always a chance of forgetfulness in taking medication.29
Because this study did not assess the patients of their “never” forget
of taking medication in their self-reported statement, forgetfulness in
taking antipsychotics medication may contribute to the lower adher-
ence rate. The possibility of patients getting tired with their medica-
tionafterbeingadherentforsometimescanalsolowertheiradherence
rate. A stable condition and lowered the dose of medication can lead to
an assumption of possibility avoiding their medication.
Residential area includes the living environment, distance from
healthcare facilities, and accessibility of mental health care. As men-
tioned in a previous study related to quality of life of chronic
schizophrenia in communities, residential status reveals people with
chronic schizophrenia living in communities faced many challenges in
their daily life.30 Public misconceptions and social stigma attached to
mental illness have hindered patient and families from seeking help
and accessing appropriate mental health treatment. Access to health
services is a basic human right. In Indonesia, as in many other develop-
ing countries, access to mental health services is far from adequate for
most of the population.31
The health service system requires outpatients to regularly see
their psychiatrists on a voluntary basis. Alternatively, patients’ care-
givers are allowed to attend clinics and purchase psychiatric drugs
on the patients’ behalf in particular cases, such as when they live far
away from the clinic, weather conditions, or disabling medical con-
ditions, as long as they bring the prescription from the psychiatrist.
For patients with relatively severe symptoms or who are experienc-
ing extra-pyramidal syndrome, patients need to attend or refer to the
hospital, which has better facilities compared to the otherwise limited
community services. The current issue related to the policy of national
health insurance is that all outpatients, including patients with mental
ENDRIYANI ET AL. 3151
illness, should attend by themselves in order to claim insurance, other-
wise the caregiver or family should pay out-of-pocket. This generates
further problems that the government needs to address when review-
ing the policy for people with mental illness.
Other authors have reported that patients with mental illness who
live in the community tend to display relatively high satisfaction levels
for particular parts of their life, such as living situation and safety.32
Residing close to the healthcare center has advantages for people
who live in surrounding areas. Another issue regarding living close
to healthcare centers, especially psychiatric hospitals, is that the sur-
rounding communities have the added benefit of further understand-
ing mental disorders and display more respect toward people with
mental disorders.
5 CONCLUSION
To date, no study currently exists in Indonesia that investigates the
predictors among medication adherence and quality of life and the
influence of medication adherence to antipsychotics on quality of life
among patients with schizophrenia. Though schizophrenia has often
been considered a chronic disease with poor outcomes, this study indi-
cates positive outcomes, where only a few study participants did not
adhere to their treatment. Moreover, quality of life showed strong
results. However, to obtain a better understanding of medication
adherence and quality of life of patients with schizophrenia, it is neces-
sary to use interviews, including questionnaires, and to conduct quali-
tative experiments.
6 LIMITATIONS
Several limitations are considered in this study. The cross sectional
study could not capture the adherence behavior of patients over time,
as this approach is useful for identifying associations among variables.
The use of subjective or self-reported questionnaires may not cover
some important aspects related to treatment, as well as in quality
of life, which is best measured with qualitative studies to gain more
in-depth information. All measures in this study are of western ori-
gin translated into the target language. There were some points that
clashed with cultural issues such as the fact that it is uncommon to
show feeling and expression deliberately and ask about the satisfac-
tion of people's love life and it requires further adjusting. Moreover, in
this study, the score of GAF scale > 70 is one of the criteria for sub-
ject selection. However, their general functioning is well and may take
their medications also well. Therefore, it suggests that future study can
include patients with a low score of GAF scale for investigating the
situation.
7 IMPLICATIONS FOR NURSING PRACTICE
The results suggest side effects are important matters requiring
attention by healthcare providers in terms of adherence by patients
to medication. The medication can also influence the quality of life
among patient with schizophrenia. This study also suggests residential
status as a proxy for patient environment of living can be modified in
order to improve quality of life. The information included in this study
also expects to serve as a springboard for developing assessments
and interventions for both medication adherence and quality of life in
patients with mental illness, particularly schizophrenia.
CONFLICT OF INTEREST STATEMENT
The authors report no actual or potential conflict of interest.
ORCID
Xuan-Yi Huang RN, MSN, DNSc
http://orcid.org/0000-0002-5446-7453
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How to cite this article: Endriyani L, Chien C-H, Huang
X-Y, Chieh-Yu L. The influence of adherence to antipsy-
chotics medication on the quality of life among patients with
schizophrenia in Indonesia. Perspect Psychiatr Care. 2018;1–6.
https://doi.org/10.1111/ppc.122762019;55:147–152. https://doi.org/10.1111/ppc.12276
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