Attitudes towards and Beliefs about Schizophrenia in Xhosa Families with Affected Probands

O b jectiv e: T h e d e v e lo p m e n t o f e ffe c tiv e p sy ch o ed u catio n al p rogram s for the m anagem ent of schizophrenia requires an understanding of attitudes to­ wards and beliefs about the disorder in families of affected probands. In order to establish the need for adaptation of Western psychoeducational programs, these variables were investigated in X hosa speaking families in South Africa. Design: X hosa speaking family members of patients with DSM-IV schizophrenia were recruited on a voluntary ba­ sis, and interview ed with a structured belief and attitudes questionnaire adapted from previous studies in the West. Setting: The study population was drawn from both ur­ ban and rural Xhosa com m unities in South Africa. Subjects: 100 Xhosa speaking family members partici­ pated in the study. Results: Fam ily members most often recommended treat­ ment with psychotropic m edications (88%) and traditional healers (32%), and least often recom m ended psycho­ therapy (4%) and m editation (1%). O f the respondents who recom m ended traditional healing methods, 92% also recom m ended simultaneous use of allopathic treatment. Conclusion: A ttitudes towards and beliefs about schizo­ phrenia in fam ily members o f patients with schizophre­ nia may differ substantially from those described in previ­ ous work in the West. An understanding of local attitudes and beliefs is crucial for the successful development of local psychoeducational programs. Abstrak Doelwit: Ten einde suksesvolle psigo-opvoedkundige pro­ gram m e op te stel, moet die familie van die pasient se houding jeens en die begrip van die geestessiekte bekend wees. Die houding jeens en geloof oor skisofrenie is ondersoek in X hosa sprekende individue in Suid Afrika ten einde vas te stel of die bestaande Westerse programme gewysig behoort te word. Studie ontwerp: Xhosa sprekende familie lede van pasient met skisofrenie (DSM-IV) het vrywillig deelgeneem aan die studie. " n Gestruktureerde vraelys (aangepas vanuit vorige W esterse studies) oor houdings jeens en begrip van skisofrenie is deur elke deelnemer voltooi. Studie opset: Die studie populasie is afkomstig van beide stedelike en plattelandse Xhosa gem eenskappe in Suid Afrika. Deelnemers: 100 X hosa sprekende fam ilie lede het deelgeneem. Resultate: Psigotrope medikasie (88%) en tradisionele genesers (32%) was die m ees algem ene voorstelle vir behandeling van skisofrenie, terwyl psigoterapie (4%) …


Conclusion:
A ttitudes towards and beliefs about schizo phrenia in fam ily members o f patients with schizophre nia may differ substantially from those described in previ ous work in the West.An understanding of local attitudes and beliefs is crucial for the successful development of local psychoeducational programs.

Introduction
Schizophrenia is a prevalent and chronic disorder, which is accompanied by substantial impairment in function.The total costs o f this disorder, com prising both direct costs of treat ment and indirect costs of dysfunction, are therefore extremely high.Indeed, it has been estimated that in the United States, the treatment of patients with schizophrenia consumes 2.5% of the annual total health care allocations (Meltzer, 1999:3).Fortunately, there have been im portant advances in the m an agement of schizophrenia in recent decades.These include the introduction of novel psychopharm acological agents, as w ell as th e u se o f p s y c h o s o c ia l in te rv e n tio n s .Psychoeducational program s are increasingly used, with a growing recognition that fam ily members of patients with schizophrenia may play a useful role in helping to prevent re lapse (Goldstein, 1995:59).
The developm ent of successful psychoeducational programs must be based on an understanding of existing attitudes to wards and beliefs about disease.A number of studies docu ment widespread misconceptions about the etiology and treat ment of this disorder in the lay community (Angermeyer et al, 1993:114;Angermeyer and Matschinger, 1994:39;Angermeyer and Matschinger, 1996:199;W ahass& Kent. 1997:175;Jorm et al, 1997:143;Jo rm et al, 1997:182).Attending to patients and family m em bers' explanatory models of disease (Kleinman, 1988), and education in o rd er to change m isconceptions (Becker, 1975:10), may prove useful in destigmatizing schizo phrenia and in improving com pliance with treatment.
A recent set of studies in Germany (Angermeyer et al, 1993:114;A ngerm eyer and M atschinger, 1994:39;A ngerm eyer and Matschinger, 1996:199), for example, found that laypersons re gard schizophrenia as caused mainly by psychosocial stressors, biological factors and intra-psychic factors.The treatment options most favored were «talking it over»(>75%), relaxation (>50%) and psychotherapy (>50%).Psychotropic drugs were recom mended by less than 25% o f the lay public.These re sults reinforce the need for psychoeducation, and for focusing on information about pharm acological interventions.
Similarly, in South Africa local beliefs about the causes and treatment of schizophrenia help determine health-seeking path ways and may be an im portant locus for psychoeducational intervention.Certainly, anecdotal impressions would indicate a strong belief in supernatural causes o f illness, and a reliance on traditional healers for its treatment (Buhrmann, 1982:163;Buhrmann, 1984).This study aims to elicit the attitudes to wards and beliefs about schizophrenia in family members of affected probands.

Methods
Patients with schizophrenia were voluntarily recruited from inand outpatient services in the urban areas of the Western Cape and the rural areas of the Eastern Cape in South Africa, as part of a larger genetics study.Potential subjects had to be of Xhosa ethnicity (all of the grandparents of X hosa origin).Mental health workers identified possible participants, and candidates were then screened for suitability after obtaining w ritte n in fo rm e d c o n se n t.They were diagnosed on the basis of DSM -IV criteria using a structured clinical interview, the Diagnostics Interview for Ge netics Studies (DIGS) (APA, 1994).The study population was comprised o f 100 Xhosa speaking family members of these probands.One caregiver or close family member who voluntarily agreed to take part in the study was interviewed by a trained psychiat ric nurse who visited the family at home and administered a structured questionnaire.This questionnaire (English version) was based on the work of Angermeyer and M atshinger et al (Angerm eyer et al, 1993:114;Angerm eyer and Matschinger, 1994:39;Angermeyer and Matschinger, 1996:199) 2]), and course of schizophrenia (chronic versus curable, need for continued medication use and com pli ance).The role of traditional healing m ethods was assessed by means o f the addition of two options to the treatment sec tion, namely the use of traditional healers' services and tradi tional rituals.

Results
One hundred Xhosa family members participated in the study.76% of the study population was female.Mean age (±SD) of the participants was 61.1 (± 13.0) years (range 24-87).The mean level of scholastic achievement was 6.0 (±3.5) years, with only 2% o f participants having completed high school.Subjects were mostly commonly mothers (59.2%) or fathers (21.4%) of probands with schizophrenia.
Forty-one percent of respondents believed that the natural course of schizophrenia is one of remissions with the possibil ity o f relapse, while 24.2% believed that the disorder can be cured without medication.28% o f respondents stated that if optimal treatment is given then cure is possible, with 30.3% holding that optimal treatment led to remission with the possi bility of relapse.

Discussion
Our findings indicate that in a Xhosa speaking sample witch craft or possession by evil spirits was the most commonly endorsed view o f the cause of illness.This view differs mark edly from th at found in a series o f stu d ies in G erm an (Angerm eyer et al, 1993:114;A ngerm eyer and Matschinger, 1994:39;A ngerm eyer and Matschinger, 1996:199) where psy chosocial stressors, biological factors, and intra-psychic fac tors were the m ost commonly believed causes o f schizophre nia, and from sim ilar sets of findings in other Westernized cul-Laypersons' explanatory models of disease are o f course inti m ately related to cultural beliefs.The Xhosa belief system includes an acceptance of the phenomena of witchcraft and possession by evil spirits, and the notion that ancestors play an important role in protecting the community from such spir its (B uhrm ann, 1982:163;Buhrm ann, 1984;T shotsho & Strumpher, 1996:63-66).The ancestors require appeasement with rituals, and neglecting such rituals is held to lead to with drawal of ancestral protection and the possible onset of mental illness.Thus it is not surprising that respondents emphasized the role o f witchcraft and evil spirits in the etiology o f schizo- tures (Wahass & Kent, 1997:175;Jo rm e ta l, 1997:143;Jorm et al, 1997:182).Similarly, Xhosa family members most commonly supported psychotropic m edications and traditional healing methods (for exam ple, rituals such as beer brewing and the slaughter of cattle), in contradiction to the more negative per ceptions o f m edication in W esternized cultures (Angermeyer et al, 1993:114;A ngerm eyer and M atschinger, 1994:39; Angerm eyer and M atschinger, 1996:199; Wahass & Kent, 1997:175;Jorm etal, 1997:143;Jorm etal, 1997:182).
phrenia, and the role of traditional rituals in its treatment.Nevertheless, several other causes and treatments o f schizo phrenia were listed by respondents, indicating the complexity of explanatory models in this community.Endorsem ent of stressful life-events (38%), broken homes (25%) and lack of parental affection (31%) as causes of schizophrenia is rem inis cent of Western lay and biomedical explanatory m odels o f the disorder (3-8).Similarly, not only was psychotropic m edica tion the most commonly recommended form o f treatment, but the vast majority of respondents supporting traditional heal ers also supported the sim ultaneous use of psychotropic medi cation.Indeed, our impression was that respondents' explanatory mod els of schizophrenia relied on multiple theories and observa tions.Many felt that traditional healers' methods protected individuals from invasion by «bad spirits», but that Western treatments prevented the symptoms from getting worse.The often being treated with depot preparations).
A num ber of important limitations of this study deserve em phasis.Family members were relatively elderly and poorly edu cated; findings are unlikely to be readily generalizable to younger more educated respondents.This is partly reflected by the num ber of «unsure» responses to concepts such a m edi tation, signs o f the zodiac and even psychotherapy.Further more, the fact that interviewers were nurses may have biased A number o f worrying perceptions were noted in respondents.
Overall, there was only partial support for a biomedical model of schizophrenia as a disease o f the brain, with 46% o f re spondents endorsing this opinion, but 42% believing the op posite.Similarly, patients were to some extent stigmatized as dirty, unpredictable, and dangerous.Furthermore, 28% o f respondents believed that schizophrenia can be cured by treatm ent, a b e lie f that is likely to be overoptimistic.Non-com pliance was only seen as a problem one month after medication discontinuation (although this may partly be explained by the fact that probands in this study were respondents away from endorsing traditional beliefs and to wards endorsing the importance o f psychotropic medication.N evertheless, our impression was that respondents were open and frank about their agreements and disagreements with the standard biomedical model.Clinicians who work with Xhosa speaking patients with schizophrenia and their families would do well to be aware of traditional attitudes and beliefs towards this illness, and to make an effort to determine their explana tory models.Psychoeducational programs need to address such explanatory models, and clinicians need to negotiate a shared biomedical model (Kleinman, 1988;Becker and Maiman, 1975;Stein, 1993:322-329).Such a negotiation is likely to pro mote to foster the therapeutic alliance and to promote adher ence to treatment.

:
Die houding jeens en begrip van skisofrenie verskil beduidend van die in vorige W esterse studies.A andag b eh o o rt gegee te w ord aan die inhoud van W esterse psigo-opvoedkundige program m e voordat dit geïnisieer word in Suid Afrika.
in Germany.It allowed for yes, no or unsure responses and focused on respondents' views of the causes (17 options, multiple choices possible [Table 1]), treatment (9 possible options, multiple choices allowed [Table

Table 2 :
Preferred treatment methods