الفهرس 
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Abstract
Negative symptoms appear to be common and sometimes severe among patients with schizophrenia. It may have direct negative effects on instrumental activities of daily living and quality of life. Functional outcome should be a priority target for therapeutic interventions in schizophrenia, as well as measuring treatment response, remission & good quality of life is essential that result in reclaiming control over health and life in general.
The present study aimed to assess the levels of the negative symptoms, instrumental activities of daily living and quality of life among patients with schizophrenia and to determine the relationship between negative symptoms and each of instrumental activities of daily living, and quality of life among those patients.
This study utilized a descriptive correlational research design. It was conducted at the outpatient clinic of El-Maamoura Hospital for Psychiatric Medicine in Alexandria, Egypt.
The study subjects comprised 200 patients diagnosed with schizophrenia with no co-morbidity, have a duration of illness for two years or more, aged not more than 50 years and able to communicate in coherent and relevant manner
Four tools were used for data collection:
Tool I: A socio-demographic and clinical data structured interview schedule:
This tool was developed by the researcher. It comprised two parts, the first part was developed to elicit data about the patients’ socio demographic characteristics such as sex, age, marital status, residence, occupation, educational level, cohabitation, monthly income and source of income. The second part concerned with patients’ clinical data as duration of illness, age at the beginning of illness, previous hospitalization, and number of previous psychiatric hospitalization, beginning of treatment, psychiatric medication, treatment currently prescribed and compliance with medication.
Tool II: Scale for the Assessment of Negative Symptoms of schizophrenia (SANS):
The Scale for the Assessment of Negative Symptoms of schizophrenia (SANS) was developed by Andreasen (1983) to assess negative symptoms in patients with schizophrenia. It contains 25 items that evaluate five groups of symptoms namely: affective flattening or blunting, alogia, avolition/apathy, anhedonia/asociality and inattention.
Tool III: World Health Organization Quality of Life Scale-Brief Version (WHOQoL-BREF):
The World Health Organization Quality of Life Scale-Brief Version (WHOQoL–BREF) was originally developed by World Health Organization (1998). The Arabic version of the WHOQoL–BREF scale that was adopted by Abd El-Fatahet al. (2020) was used in this study. The WHOQoL-BREF is a self-assessment scale and found as the most common suitable tool for assessment of QoL for patients with schizophrenia. The WHOQoL-BREF is composed of 26 items, of which 24 are divided into four domains: (I) physical health (seven items): (II) psychological well-being (six items) (III) social relationships (three items) and (IV) environmental health (eight items). The two extra items evaluate the individual’s general perception of quality of life and individual’s satisfaction with health.
Tool IV:Instrumental Activities of Daily Living (IADL) Scale:
The Instrumental activities of daily living (IADL) scale was developed by Lawton & Brody (1969). It measures patient’s competence in functional instrumental activities of daily living in the community. It consists of 8 items that provide self-reported information about functional skills necessary to live independently in the community. These items include ability to perform simple shopping, ability to use a telephone, meal preparation, keep the house tidy, do the laundry independently, travel to different places and the kind of transportation required, responsibility for taking their medications, and the ability to handle finances. Subjects are asked to score each domain according to their highest level of functioning in that category.
Method:
• An official Approval from the Research Ethics Committee, Faculty of Nursing, Alexandria University was obtained before conducting the study.
• A written official permission for conducting the study was obtained from the General Secretariat of Mental Health, Ministry of Health and the director of El-Maamoura hospital for Psychiatric Medicine in Alexandria.
• Tool 1: Socio-demographic and clinical data structured interview schedule for patients with schizophrenia was developed by the researcher.
• Tools II, III and IV were used and standardized in previous studies on Egyptian population and tested for content validity.
• A pilot study was carried out on 20 patients with schizophrenia, and it proved that the study tools were clear and applicable.
• Reliabilities of study tools II, III and IV were tested using the Cronbach’s alpha method on 20 patients with schizophrenia who met the inclusion criteria of the study subjects. Those patients were excluded from the actual study subjects.
• The researcher visited the outpatient clinic 4 days a week (Saturday, Monday, Tuesday, Wednesday).
• All patients who met inclusion criteria in the up mentioned setting were recruited. Each patient was met on individual basis: relationship was established, aim of study was explained and informed consent was obtained.
• Data were collected over a period of three months, starting from March 2022 to May 2022.
• The data were computerized and verified using the SPSS (Statistical Package for Social Science) to perform tabulation and statistical analysis.
The followings were the main results of the present study:
• The Socio-demographic characteristics of the studied patients (n=200):
- Male patients constituted the majority of the studied subjects (70.5%).
- Subjects age ranged between <25 and ≥45 years with a mean age of 35.06 ± 7.66 years. Patients in the age group ranging from 35 to 45 years constituted 40.5% of the studied subjects.
- One quarter of the studied patients (25.5%) had primary/preparatory education, 24.5% had technical/diploma education and only 7.5% had university education.
- More than half of the studied patients (55.5%) were single, 30.5% were married, while 13% were divorced.
- The majority of the studied patients (84%) lived in urban areas, 24% of the studied patients were not working, 32.5% were craft and commercial workers, while 23.5% were housewives and only 20% were unskilled workers.
- The majority of the studied patients (68.5%) did not have enough monthly income, 81.5% of the studied sample receive financial support from their relatives, while 2.5% claimed that their personal work is their source of income.
- The age of the studied patients at the beginning of illness ranged between 15-35 years. Nearly half of the studied patients (45%) were diagnosed with schizophrenia at the age group between 15 to less than 20 years, while 37.5 % were in age group between 20 to less than 25 at the beginning of illness with a mean age of 23.84 ± 6.16 years.
- Duration of illness ranged between less than 5 to 25 years and more with a mean age of 11.25 ± 6.52 years. More than one third of the studied patients (39%) had duration of illness ranged from 5 to less than 10 years and 21.5% had duration of illness for less than 5 years.
- The number of hospital admissions among the studied patients ranged from 1 to more than 4 times, one third of the studied patients (33.3%) had been hospitalized for two times, 28.1% of them were hospitalized for one time, whereas 43% of the studied patients were not previously hospitalized.
- 62.8% of studied patients received mixture of standard and atypical antipsychotics, 16.5% were treated with atypical antipsychotic, 12.4% received typical antipsychotic; while 8.2% of them received antipsychotic and other medications.
- The majority of the studied patients (71.5%) had no family history of mental illness.
• Negative symptoms among the studied patients:
- As for domains of negative symptoms, anhedonia / asociality and avolition / apathy had the highest mean percent scores (72.40 ± 20.37 and 66.57 ± 19.83 respectively) followed by affective flattening or blunting (58.47 ± 20.39) and alogia (56.78 ± 20.03); whereas attention has the lowest mean percent score (47.17 ± 21.19).
- More than half of the studied patients (61%) had moderate negative symptoms, 35% had severe negative symptoms, while only 3% had mild negative symptoms. The total mean score of negative symptoms is 60.86 ± 15.38.
• Instrumental activity of daily living among the studied patients:
- More than half of the studied patients (69%) were moderately dependent on others in their instrumental activities of daily living, while 27% were totally independent. the total mean score of IADL is 5.23 ± 1.89 and the mean percent score is 65.31 ± 23.63.
• Quality of life among the studied patients:
- As for domains of quality of life, the results revealed that environmental and physical health domains have the highest mean percent scores (45.55 ± 9.67, 42.41 ± 16.99 respectively), while social relations and psychological well-being domains have the lowest mean percent scores (37.79 ± 21.03, 34.13 ± 13.11). The mean scores related to general satisfaction of quality of life and general health recorded a 53.75 ± 26.02. The total mean score of overall quality of life is 41.80 ± 11.17.
- The majority of the studied schizophrenic patients (77%) had low quality of life, and 23% of them had moderate quality of life and no one had high quality of life.
- A high significant negative correlation was found between Negative Symptoms of Schizophrenia (SANS) and Instrumental Activities of Daily Living (IADL) (r = – 0.365).
- A high significant negative correlation was found between Negative Symptoms of Schizophrenia (SANS) and Quality of life (QoL) (r = –0.440).
- There is a higher significant positive correlation between Instrumental Activities of Daily Living (IADL) and Quality of life (QoL) (r = 0.393).
• The correlation between the studied patients’ negative symptoms and their instrumental activities of daily living;
- There is no significant correlation between affective flattening /blunting and housekeeping (r=-0.129, p=0.069) and between alogia and ability to use telephone & laundry (r=-0.105, p=0.137 and r=-0.085, p=0.230 respectively. There is no significant correlation between anhedonia /asociality and all domains of instrumental activities of daily living except responsibility for medications (r= -0.162, P=0.022). Also, there is no significant correlation between attention and laundry (r= -0.070, p=0.323).
- There is a significant negative correlation between avolition/apathy and all domains of instrumental activity of daily living (r=-0.346, p=<0.001)
• The correlation between the studied patient’s negative symptoms and their quality of life;
- There is no significant correlation between affective flattening /blunting and each of patient general perception and satisfaction of quality of life & general health and social relationships (r=-0.095, p=0.179 and r=-0.066, p=0.356).
- There is no significant correlation between alogia and all domains of quality of life except physical health (r= -0.191, P=0.007).
- There are significant negative correlations between avolition /Apathy, anhedonia/a-sociality & attention and all domains of Quality of Life.
- It was concluded that, the majority of the studied patients with schizophrenia experienced moderate to severe levels of negative symptoms, moderately dependent on others in their instrumental activities of daily living and had low quality of life. The level of negative symptoms among studied patients with schizophrenia is related negatively to their level of instrumental activities of daily living and quality of life.
Accordingly, the following are the main recommendations yielded by the study:
1- Assessment of negative symptoms and instrumental activities of daily living needs to be incorporated into routine clinical assessment of patients with schizophrenia, to consider appropriate psychiatric nursing care and interventions.
2- Integrating the relationship between instrumental activities of daily living and quality of life in nursing curriculum of psychiatric and mental health nursing.
3- Implementation of psycho-educational programs aiming to increase awareness of patients and their families about the negative symptoms and its effect on quality of life.
4- Mass and social media should have a role in increasing awareness and providing effective programs for helping the patients with schizophrenia to deal with the illness, enhance functional ability to improve their quality of life