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\begin{document}


\def\RunningAuthor{Sara Sapharina G J and Neelakshi G.}
\firstPage{703}
\articleType{Original Article}
\receivedDate{15 Dec 2020}
\acceptedDate{18 Jan 2021}
\revisedDate{15 Jan 2021}
\journalVolume{2021, 12}
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\journalDoi{ijrps.v12i1.4166}
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\title{Relationship between Quality of life and Perceived stress among Caregivers of patient with Schizophrenia}
\author{Sara~Sapharina~G~J\textsuperscript{*}, 
            Neelakshi~G~\\[5pt]{Department of Psychiatric Nursing, Sri Ramachandra Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research (DU), Porur, Chennai-600116, Tamil Nadu, India}}

\begin{abstract}
Caring for the patient with mentally ill is a difficult and challenging task where the caregivers need to face the bio-psychosocial and financial problems during the process of care giving. Developing country like India, it is difficult to give care to the person with mental illness due to stigma and other cultural barriers which family need to undergo in turn it reflects on patient care. The family member who is taking care of mentally ill patient takes complete responsibility on their shoulder in meeting the daily activity needs of the patient, which is done meticulously with adequate supervision. In this study the majority of the caregivers had moderate stress 64(85.3\%) and 11(14.7\%) experienced high perceived stress and there is a low positive co-relationship between the perceived stress scores and Quality of life {\textendash}domain1 (physical health) 'r' value is 0.35 and domain 4 (environment) `r' value is 0.29 and it is statistically significant respectively. A statistically significant association between perceived stress categories with sample Characteristics like gender, place of residence, education and type of family (p \ensuremath{^{\prime}} \textless\ 0.05). The mental health care professionals to be involved actively in rehabilitating the mentally ill patients and considering the caregivers as a primary source of care providers and in order to help them to improve their quality of life and equipping them to be resilient so as to achieve good therapeutic success in their patients. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Caregivers,\newline Perceived Stress,\newline Quality of life,\newline Schizophrenia
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sara~Sapharina~G~J~\\ Phone:\ 9894279745~\\  Email:\ sarajojn.g@sriramachandra.edu.in
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
As the technology revolution improves and with huge awareness on human rights in terms of treatment and rehabilitating mentally ill had a great paradigm shift with the motive called home based treatment from hospital based treatment. Indeed caregivers undergo psychosomatic distress and avoid social relationship, poor quality life, financial constraints, low self-esteem as a result of care giving. The evolving concept towards community care and the de-institutionalization of a person with mental disorders has shifted to family based care to create a major support system to continue the care at home as well in the community. \unskip~\citep{990858:21295531} Psychological distress generally refers to a mental health problem characterized by a range of bio- psychological symptoms and an increased risk of morbidity and mortality. \unskip~\citep{990858:21295426} According to the \unskip~\cite{990858:21295537} transactional model of stress, according to him, stress is the result of a process whereby certain life events or experiences may be perceived by an individual as potentially threatening or harmful (primary appraisal), triggering a reaction (a secondary appraisal) that influences how the individual copes with the perceived threat or harm. The investigator decided to examine the quality of life and perceived stress among caregivers of patients with schizophrenia with the following objectives are to assess the level of quality of life and perceived stress, correlate quality of life and perceived stress and to associate the quality of life and perceived stress with selected background variables of caregivers of patients with schizophrenia.
    
\section{Materials and Methods}
A descriptive research design was adopted for this study conducted at the psychiatric ward and Psychiatric Outpatient department of Sri Ramachandra Hospital, Porur. The good infrastructure facilities available in the psychiatric ward and Psychiatric Outpatient department, which enabled the investigator to meet the participants easily. 75 caregivers of patient with schizophrenia were included in this study. The research was conducted using standardized questionnaires.

The participants included were between the age group of 21-50 years, available during the data collection, able to read and write in English and Tamil, willing to participate in this study, both male and female caregivers, not on special treatments like diabetes mellitus, hypertension and other disease and must have been with the patient for more than 6 months. Purposive sampling technique was used to select the samples for this study. A researcher began the recruitment process by obtaining the names and identification numbers of the caregiver who is staying in inpatient and caregiver, who is visiting the outpatient department.

Obtained written informed consent before the distribution of questionnaires. The participation was completely voluntary. Participants were given the freedom to withdraw from the study at any point of time. Assured Confidentiality will be maintained. The questionnaire consisted of three sections, namely socio demographic data, perceived stress scale and quality of life scale.

This research was approved by Institutional ethical committee of Sri Ramachandra institute of Higher Education and Research (DU) and permission was obtained from the Head of the Department of Psychiatry of Sri Ramachandra Hospital to conduct the study. The collected data were analyzed using descriptive and inferential statistics based on the objectives. Descriptive methods used were frequency, percentage, mean and standard deviation. Inferential statistics like Chi square and correlation coefficient.

\textbf{Background variables}

This section included information about the caregivers: age, gender, religion, marital status, place of residence, educational qualification, occupation, duration of care giving, and relationship with the patient, social support, medical expenses.

\textbf{Quality of life scale (QoL)}

The brief version of the World Health Organisation Quality of Life instrument \unskip~\cite{990858:21295427} was used to assess caregiver's QoL. This tool consists of 26 items with four domains includes physical health, psychological, social relationships and environment and also has two items for assessing overall QoL and general health. All items are constructed on variations of a 5-point Likert Scale, with scores from one to five, enquiring on ``how much'', ``how completely, ``how often'', ``how good'' or ``how satisfied'' the individual felt. Higher the score indicates High quality of life.

\textbf{Perceived Stress Scale}

To assess the stress of the caregivers Perceived Stress Scale (PSS) was used and the tool consists of 14 items (0 = Never; 1 = Almost Never; 2 = Sometimes; 3 = Fairly often; 4 = Very often) Scores 0{\textendash}18 show that there is a low stress, 19{\textendash}37 moderate stress, 38{\textendash}56high perceived stress.
    
\section{Results and Discussion}
The study results showed that most of the caregivers 24(32\%) were above 50 years and majority 66(88\%) were female caregivers. In connection with the place of residence 36(48\%) of them from urban and having secondary education 34(45.3\%). With regard to occupation 47(62.7\%) of were homemakers and 52(69\%) were from a nuclear family, Majority of primary caregivers were parents 38 (50.7\%). The medical expenses for the patient were taken care of by only caregivers 57(76\%). Most of the patients were male 40(53.3\%).


\begin{table}[!htbp]
\caption{\boldmath {Frequency and Percentage Distribution of sample based on perceived stress categories} }
\label{tw-f7d8e73c6e23}
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Perceived stress & \cAlignHack f & \cAlignHack \%\\
\tblmidrule 
\cAlignHack Moderate stress &
  \cAlignHack 64 &
  \cAlignHack 85.3\\
\cAlignHack High Perceived stress &
  \cAlignHack 11 &
  \cAlignHack 14.7\\
\tblbottomrule 
\end{tabulary}\par 
\end{table}
As shown in Table~\ref{tw-f7d8e73c6e23}, the majority of the caregivers had moderate stress 64(85.3\%) and 11(14.7\%) experienced high perceived stress. The mean (SD) for Perceived stress scores 31.61(9.43) and the QOL domains were as follows physical health 46.97(9.76)


\begin{table*}[!htbp]
\caption{\boldmath {Mean and SD of perceived stress scores and Quality of life {\textendash} BREF Scale} }
\label{tw-6e98532cdef7}
\centering 
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Variables & \cAlignHack Mean\ensuremath{\pm}SD\\
\tblmidrule 
\cAlignHack Perceived stress scores &
  \cAlignHack 31.61\ensuremath{\pm}9.43\\
\cAlignHack Quality of life {\textendash}Domain 1 (Physical Health) &
  \cAlignHack 46.97\ensuremath{\pm}9.76\\
\cAlignHack Quality of life {\textendash}Domain 2 (Psychological) &
  \cAlignHack 39.08\ensuremath{\pm}13.32\\
\cAlignHack Quality of life {\textendash}Domain 3 (Social Relationship) &
  \cAlignHack 36.33\ensuremath{\pm}18.8\\
\cAlignHack Quality of life {\textendash}Domain 1 (Environmental) &
  \cAlignHack 40.16\ensuremath{\pm}13.5\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{SD: Standard Deviation}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Co-relation between the perceived stress scores and Quality of life{\textendash}Domain 1 } (Physical Health) among participants }
\label{tw-a2396b5e5de0}
\centering 
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\tbltoprule \rowcolor{kwdboxcolor}Variable & \cAlignHack Mean & \cAlignHack Standard deviation & \cAlignHack Pearson's Correlation and coefficient (r) value & \cAlignHack p value\\
\tblmidrule 
Perceived stress scores  &
  \cAlignHack 31.61 &
  \cAlignHack 9.43 &
  \multicolumn{1}{p{\dimexpr(.2198\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{\cAlignHack 0.35 }} &
  \multicolumn{1}{p{\dimexpr(.10639999999999997\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{\cAlignHack 0.002\ensuremath{^{*}}}}\\
Quality of life{\textendash}Domain 1  \mbox{}\protect\newline (Physical Health)  &
  \cAlignHack 46.97 &
  \cAlignHack 9.76 &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{\ensuremath{^{*}}significant relationship (p'{\textless}0.05)}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Co-relation between the perceived stress scores and Quality of life{\textendash}Domain 2 } (Psychological Health) among participants}
\label{tw-966a616fdde5}
\centering 
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\tbltoprule \rowcolor{kwdboxcolor}Variable & \cAlignHack Mean & \cAlignHack Standard deviation & \cAlignHack Pearson's Correlation and coefficient (r) value & \cAlignHack p value\\
\tblmidrule 
Perceived stress scores  &
  \cAlignHack 31.61 &
  \cAlignHack 9.43 &
  \multicolumn{1}{p{\dimexpr(.23419999999999998\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{\cAlignHack 0.15}} &
  \multicolumn{1}{p{\dimexpr(.12620000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{\cAlignHack 0.192\ensuremath{^{*}}}}\\
Quality of life {\textendash}Domain 1  \mbox{}\protect\newline (Psychological)  &
  \cAlignHack 39.08 &
  \cAlignHack 13.32 &
   &
  \\
\tblbottomrule 
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\begin{tablenotes}\footnotesize 
    
\item{\ensuremath{^{*}}significant relationship (p'{\textless}0.05)}
\end{tablenotes}
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\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Co-relation between the perceived stress scores and Quality of life{\textendash}Domain 4} (Environment) among participants}
\label{tw-f61bb8e6c693}
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\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.40129999999999995\linewidth-2\tabcolsep}p{\dimexpr.11920000000000003\linewidth-2\tabcolsep}p{\dimexpr.1407\linewidth-2\tabcolsep}p{\dimexpr.2269\linewidth-2\tabcolsep}p{\dimexpr.1119\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Variable & \cAlignHack Mean & \cAlignHack Standard deviation & \cAlignHack Pearson's Correlation and coefficient (r) value & \cAlignHack p value\\
\tblmidrule 
Perceived stress scores  &
  \cAlignHack 31.61 &
  \cAlignHack 9.43 &
  \multicolumn{1}{p{\dimexpr(.2269\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{\cAlignHack 0.29 }} &
  \multicolumn{1}{p{\dimexpr(.1119\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{\cAlignHack 0.01\ensuremath{^{*}}}}\\
Quality of life {\textendash}Domain 4 (Environment)  &
  \cAlignHack 40.16 &
  \cAlignHack 13.50 &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{\ensuremath{^{*}}significant relationship (p'{\textless}0.0)}
\end{tablenotes}
\end{threeparttable}

\end{table*}
psychological 39.08(13.32), social relationships 36.33(18.8) and environment 40.16(13.5) respectively. The highest mean scores for the respondents were in the physical domain, followed by an environmental, psychological and social domain. (Table~\ref{tw-6e98532cdef7}) 

The data presented in Table~\ref{tw-a2396b5e5de0} shows the Co-relation between the perceived stress scores and Quality of life {\textendash}Domain1 (Physical Health) among participants and it reveals that there is a low positive co-relationship between the perceived stress scores and Quality of life {\textendash}Domain1 (Physical Health) `r' value is 0.35 and it is statistically significant. The data depicted in Table~\ref{tw-966a616fdde5} shows the Co-relation between Co-relation between the perceived stress scores and Quality of life {\textendash}Domain 1 (Psychological Health) among participants and it reveals that there is a slight positive co-relationship between the perceived stress scores and Quality of life {\textendash}Domain 2 (Psychological) `r' value is 0.15 and it is not statistically significant. The data shown in Table~\ref{tw-f61bb8e6c693} shows the Co-relation between Co-relation between the perceived stress scores and Quality of life {\textendash}Domain 4 (Environment) among participants and it reveals that there is a slight positive co-relationship between the perceived stress scores and Quality of life {\textendash}Domain 4 (Environment) `r' value is 0.29 and it is statistically significant.

There is a statistically significant association between perceived stress categories with sample Characteristics like gender (c2= 7.24 df=1, = 0.02*), place of residence (c2= 6.04, df=2, = 0.04*), education (c2= 14.8 df=4, = 0.005*) and type of family (c2= 6.59, df=1, = 0.01*)

The current study examined the association between QoL and perceived stress among caregivers of patients with schizophrenia. Most of the caregivers 24(32\%) were above 50 years and majority 66(88\%) were female caregivers. The similar study done by \unskip~\cite{990858:21295531} had a same similar demographic background in their study with the mean age of the caregivers was 49.7 years ranging from 21 to 82 years, with a preponderance of females (67.6\%). Majority of primary caregivers were parents (34.8\%) of the ill relative. \unskip~\cite{990858:21295531}

In this study majority of the caregivers had moderate stress 64(85.3\%) and 11(14.7\%) experienced high perceived stress. Whereas the study done by \unskip~\cite{990858:21295534} reported that 46\% of them had moderate stress and only 17\% of them experienced severe stress.

The mean (SD) for perceived stress scores 31.61(9.43) and the QOL domains were as follows physical health 46.97(9.76), psychological 39.08(13.32), social relationships 36.33(18.8) and environment 40.16(13.5) respectively.  \unskip~\citet{990858:21295532} in their study reported that the mean scores on the WHOQOL-BREF in the Physical, Psychological, Social and Environment domains were 15.0 (SD = 3.7), 13.3 (SD = 4.2), 11.0 (SD = 4.7) and 13.5 (SD = 3.1), respectively. This study supports that the physical domain has the highest mean score compare with the other domains of QoL. \unskip~\citep{990858:21295532}

The highest mean scores for the respondents were in the physical domain, followed by an environmental, psychological and social domain. The mean QOL scores of this study are almost similar to the study conducted in Malaysia by \unskip~\cite{990858:21295536}, which was 64.9(SD=14.4).

The Co-relation between the perceived stress scores and Quality of life {\textendash}Domain1 (Physical Health) among participants and it reveals that there is a low positive co-relationship between the perceived stress scores and Quality of life {\textendash}Domain1 (Physical Health) `r' value is 0.35 and it is statistically significant. 

There is a statistically significant association between perceived stress categories with sample characteristics like gender (c2= 7.24, = 0.02*), place of residence (c2= 6.04, = 0.04*), education (c2= 14.8, = 0.005*) and type of family (c2= 6.59, = 0.01*). \unskip~\cite{990858:21295535}, done a study and supports that there is a significant association between this variable like education (p=0.04) and caregiver's stress at p{\textgreater}0.05. \unskip~\citep{990858:21295535}

Although study done in Malaysia by \unskip~\cite{990858:21295536} shows that the mean QOL score of the caregivers with secondary school education is higher than those with primary school and this is statistically significant (p-value 0.017) and other variables gender (t=1.12, p-value=0.263), marital status (F=0.20, p-value=0.894), occupation (F=2.26, p-value=0.107) were not statistically significant. However, in this study, there is a statistically significant association between perceived stress categories with sample Characteristics like gender, place of residence, education and type of family. \unskip~\citep{990858:21295533}

\textbf{Recommendation for Future Study}
  
  \begin{enumerate}
  \item \relax Interventional based studies can be done to strengthen the overall health of caregivers.
  \item \relax A comparative study can be done to caregivers of the patient from a rural and urban background.
  \item \relax A qualitative study can be conducted to explore a psychosocial aspect of caregivers of patient with schizophrenia.
  \end{enumerate}
  
    
\section{Conclusions}
As the effect of deinstitutionalization, the shift of psychiatric care to the community, many individuals with mental illness depend upon their family members for the support may be due to the absence of sufficient community-based services. Even today, with the presence of multiple community-based services, the family members, particularly parents, often step in to fill the gaps in the service system. This study also contributes further evidence to plan nurse led interventions to address the caregiver bio-psycho social demands, handle financial constraints and emotions as well. Considering this as a primary need of the caregiver it is imperative that health care providers take the initiative to address the stress and quality of the caregivers which directly impede the quality of care which they provide for their loved one.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.
    

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