The British Journal of Psychiatry (2006) 188: 286-287. doi: 10.1192/bjp.bp.104.007245
© 2006 The Royal College of Psychiatrists
Effect of a structured educational intervention on explanatory models of relatives of patients with schizophrenia
Randomised controlled trial
S. DAS, BSc
College of Nursing
B. SARAVANAN, DNB
Department of Psychiatry
K. P. KARUNAKARAN, Dip Nursing,
S. MANORANJITHAM, MSc and
P. EZHILARASU, MSc, PhD
College of Nursing
K. S. JACOB, MD, PhD
Department of Psychiatry, Christian Medical College, Vellore, India
Correspondence:
Professor K. S. Jacob, Department of Psychiatry, Christian Medical College,
Vellore 632 002, India. Fax: +91 416 2262268; e-mail:
ksjacob{at}cmcvellore.ac.in
Declaration of interest None.

ABSTRACT
We examined the effect of a structured educational programme
on explanatory
models of illness among the relatives of people
with schizophrenia, in a
randomised controlled trial. Participants
were assessed at baseline
(
n=100) and after 2 weeks (
n=75)
using a vignette from the
Short Explanatory Model Interview.
There was a reduction in non-biomedical
causal explanatory
models at follow-up among those who had completed the
structured
educational programme compared with the control group. There
was no
significant difference in non-biomedical treatment explanatory
models between
the two groups.

INTRODUCTION
By eliciting the explanatory models of patients and their relatives
in
routine clinical practice, mental health professionals can
better understand
the subjective experience of illness
(
Kleinman, 1980).
The past few
years have witnessed an increase in the
literature on beliefs about causes of
schizophrenia and its
treatment (
Angermeyer
& Matschinger, 1996;
Banerjee & Roy, 1998;
Kulhara et al, 2000),
but few studies have evaluated
the efficacy of interventions to change
explanatory models.
We used a randomised controlled design to examine the
effect
of a structured educational programme on explanatory models
of illness
among the relatives of people with schizophrenia.

METHOD
Out-patients who attended the Department of Psychiatry, Christian
Medical
College, Vellore, India for the first time and who
satisfied ICD10
(
World Health Organization,
1993) diagnostic
criteria for a research diagnosis of
schizophrenia were invited
to participate in the study with their relatives
(
Fig. 1).
Patients continued to
be managed by their psychiatrists. Informed
consent was obtained from the
relatives, who were then randomised
in blocks of four, using a computer
program, to a group that
would receive the structured educational intervention
or to
a control group. Progress through the trial is shown in
Fig. 1.
The Short Explanatory Model Interview (SEMI;
Lloyd et al, 1998)
formed the basis of the evaluation. A vignette describing a
typical patient
with chronic psychosis was presented (
Joel
et al, 2003). This was followed by open-ended questions
to
elicit the relatives beliefs about the perceived causes
and
consequences of the condition, and help-seeking behaviour.
A verbatim record
of the responses was made, and these were
later grouped into categories using
the procedure recommended
by the SEMI. The Tamil version of the instrument was
employed
(
Joel et al,
2003). Basic demographic and clinical information
was also
recorded. The assessments were conducted on day 1
(baseline) and after 2 weeks
of a structured educational programme
in the intervention group. The research
nurse who performed
the evaluations was masked to the intervention status of
the
participants.
We developed a structured educational programme which discussed the
different explanatory causal and treatment models prevalent in the region, and
we also presented the biomedical perspective without dismissing or directly
challenging local beliefs. This intervention had three components: exploring
explanatory models; psychoeducation, aimed at teaching the relatives about the
illness, symptoms, treatment and prognosis; and strategies to reduce the risk
of relapse. The education package covered the following topics in two
sessions: symptoms, beliefs about causation, psychosocial influences,
prevalence, biomedical model, diagnosis, treatments (including medication and
adherence), and coping strategies for families.
Sample size was calculated assuming that half of those who receive
education and one-fifth of those who do not would consider the illness to have
a medical cause by the end of the trial. For a power of 80% and 95% confidence
the minimum sample required was 72 (36 in each arm). To compensate for
possible loss to follow-up we recruited 100 participants.

RESULTS
A total of 100 patients and 100 relatives (one first-degree
relative per
patient) were contacted, all of whom agreed to
take part in the study. The
majority of the participants were
male (56%), married (91%) and literate
(80%), with a mean age
of 45.3 years (s.d.=15.7). Most of the participants
(60%) regarded
the condition of the patient described in the vignette as a
disease. Nearly all of the relatives who were interviewed (94%)
felt that help
should be sought from a doctor or hospital.
However, a significant proportion
of the relatives also attributed
the patients condition to previous
deeds (43%) or to
punishment by God (43%), and felt that visiting temples and
places of worship could solve the problem (33%). A minority
of participants
attributed the patients condition to
black magic (33%) or evil spirits
(10%), and felt that help
should be sought from a traditional healer (5%) or a
shaman
(9%). The majority of participants held more than one explanatory
model
of illness, and many believed that there was at least
one non-biomedical
explanation for the patients psychosis.
The differences between the
baseline socio-demographic variables
and the explanatory models of the two
groups were not statistically
significant.
The 25 participants lost to follow-up (see
Fig. 1) did not differ
significantly from those assessed at 2 weeks with regard to socio-demographic
variables, explanatory models at baseline, or treatment arm.
Intent-to-treat analysis of all participants (with the last observation
carried forward for those who were lost to follow-up) showed that the
intervention group had a statistically significant reduction in the total
number of non-biomedical causal models of psychosis compared with the group of
relatives who did not receive additional education (mean=0.88 (s.d.=0.96)
v. 1.32 (1.15); P=0.08). The two groups also showed a
significant difference with regard to change in non-medical causal models from
baseline after adjusting for age, gender and literacy (mean=70.58 (s.d.=1.21)
v. 0.14 (1.16); P=0.003). There were significant differences
between the two groups at follow-up in the number attributing the condition to
black magic (8 v. 16; P=0.08) and the number believing that
visiting a place of worship would effect a cure (7 v. 14;
P=0.04). However, there were no differences between the two groups
with regard to non-medical treatment models of illness (see data supplement to
online version of this paper). Similar results were obtained when the data for
participants who completed the trial were analysed.

DISCUSSION
This study evaluated an educational intervention for psychosis
and assessed
its effect in the immediate follow-up period.
Limitations included the
drop-out rate of 25% and the lack
of long-term assessment. However, the
participants who were
lost to follow-up did not differ significantly in terms
of
baseline variables from those who remained in the trial. Also,
the results
of an intent-to-treat analysis and analysis of
those who completed the trial
were similar.
The baseline data suggest that the relatives of patients with psychosis
have multiple, diverse and contradictory explanatory models of illness.
Participants held simultaneous beliefs in naturalistic explanations (e.g.
disease) and personalistic explanations (e.g. supernatural causation, sin and
punishment, karma). They also suggested that help could be sought from a range
of different sources (e.g. doctor, temple or place of worship, traditional
healer). Other studies of explanatory models of psychosis have reported
similar findings (Joel et al,
2003), and the issues surrounding the simultaneous holding of
multiple beliefs have been discussed in the literature (Saravanan et
al, 2004,
2005).
The educational intervention programme used in this study discussed the
local explanations for psychosis, and presented the biomedical explanatory
model as an alternative. The indigenous beliefs of the participants were not
challenged. The programme did not claim exclusivity or superiority of
biomedical beliefs, but discussed issues relating to symptoms, disease models,
medication and regular treatment. Although such issues are often raised in
routine clinical practice (and the control group may also have received such
information), psychoeducation does not follow a structured format, and
psychiatrists tend to dismiss local explanations and to favour biomedical
concepts.
The relatives who received the educational intervention showed some change
in their explanatory models in the immediate follow-up period. However, many
of the indigenous explanatory models persisted, especially those related to
treatment. The results of this study suggest that although some explanatory
models can be changed, others may be more resistant to modification. In the
developing world, people with mental disorders often visit places of worship,
traditional healers and psychiatric hospitals in search of both relief from
symptoms and cure (Jacob,
1999). However, it is acknowledged that holding non-biomedical
beliefs about psychosis can delay the recognition of disease, prevent early
institution of treatment with medication, and interfere with adherence to
treatment, resulting in a poor outcome. Health education packages should
discuss the advantages of medication, but should not dismiss alternative
explanations of illness, as these may also help to restore mental health.
Further research is needed to identify the components of the ideal health
education package and maximise its effectiveness in changing explanatory
models and thereby preventing
relapse.

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Received for publication December 1, 2004.
Revision received February 17, 2005.
Accepted for publication March 31, 2005.
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