Evaluation of a Peer-Led Self-Management Programme (PLSMP) for people with schizophrenia

Compared to the control group, participants who complete the peer-led self-management program will report significantly lower psychotic symptom scores at 12 months’ follow up. Outcome will be assessed at baseline, immediate after the intervention (posttest 1), six months (posttest 2) and 12 months (posttest3) after the intervention. Individual interviews will be conducted for trainers and participants 12 months after the intervention.

Primary Outcome Measure: Clinician-Rated Scale
Positive And Negative Syndrome Scale (PANSS). It is a 30-item rating scale that is specifically developed to assess individuals with schizophrenia. It is based upon the premises that schizophrenia has two distinct syndromes: positive and negative. The positive syndrome includes those productive features such as delusions and hallucinations, while the negative syndrome includes those features which are lacking/poorly developed in individuals with schizophrenia, such as social withdrawal and flattened or blunted affect. The Inter-class correlation coefficiency is r=0.88-0.98 in the subscales.

Outcome will be assessed at baseline, immediate after the intervention (posttest 1), six months (posttest 2) and 12 months (posttest3) after the intervention. Individual interviews will be conducted for trainers and participants 12 months after the intervention.

Clinician-Rated Scales
1. Specific level of Functioning Scale (SLOF). It will be used to assess social functioning and daily living skills of participants. It is a 43-item behavioural rating scale designed for use in people mentally ill in the community. The internal consistency reliability of the subscales ranged from á=0.68-0.92.
2. Schizophrenia Cognition Rating Scale (SCoRS), which is a 20-item interview-based assessment. It aims to assess cognitive processes that are commonly affected in schizophrenia patients which include attention, memory, reasoning and problem solving, working memory, language production and motor skills. All items are rated on a 4-point scale. Validation in Singapore found good intra-class correlation coefficient: r=0.984. Ratings from three sources (subject, informant and interviewer) correlated significantly with each other (r = 0.684–0.846, df = 143, P < 0.001). The convergent validity of SCoRs was assessed by comparing with the Brief Assessment of Cognition in Schizophrenia (BACS) The SCoRS global rating score was significantly correlated with Brief Assessment of Cognition in Schizophrenia BACS composite score and scores on majority of the BACS sub-tests.
3. Cogstate Schizophrenia Battery will be used to assess participants’ cognition level through its computerized task based assessment. It was specifically designed to assess people with schizophrenia in the domains of speed of processing, attention/vigilance, working memory, visual learning, verbal learning, reasoning/problem solving and social cognition. It was well validated with Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) (r=0.83). An introduction brochure for Cogstate Schizophrenia Battery is attached.

Self–Rated Questionnaires
1. Modified Empowerment Scale (ES) which contains 28 items of 5-point Likert scales. The higher the score, the better the empowerment level is. It is a consumer-constructed scale to measure personal empowerment among mental health consumers (Cronbach’s á=0.86).
2. Modified Recovery Assessment Scale-Revised (RAS-R). This will be used to measure perceived recovery and hopefulness. The RAS-R is a 24-item instrument with 5-point Likert scale designed to measure recovery from mental illness. The items on the scale categorized into five subscales: personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others and no domination by symptoms . In addition to subscales, a total score can be calculated as a measure of overall recovery. The higher the scores, the better perceived recovery and hopefulness are. Psychometric evaluation have reported Cronbach’s á=0.93(64).
3. Modified Multidimensional Scale of Perceived Social Support scale (MSPSS). It consists of 12 5-Likert scales. It measures participants’ perceived social support with family (Cronbach’s á=0.9), friends (Cronbach’s á=0.9), and significant others (Cronbach’s á=0.91). The higher the scores the better the social support is.
4. Drug Attitude Inventory (DAI). It is a 10-item self-report scale that predicts drug adherence. The DAI contains two subscales: subjective positive and subjective negative. The scale is equally balanced for items to be scored true and false. "Positive" answers will be as follows and score as plus one: "Negative" answers score as minus one. The final score for each person at each time is the positive score minus the negative score. A positive total final score means a positive subjective response (adherent). A negative total score means a negative subjective response (non-adherent). This instrument has been used in the study venue to measure patient drug adherence and demonstrated good validity and a test-retest reliability of r=0.82.
Apart from DAI, the pill count record will be documented. It is a routine procedure carried out by the Centre staff. Information will be retrieved from the residence’s casenotes.
5. World Health Organization Quality of Life Scale-Brief Version (WHOQoL-BREF, which aims to assess participants’ quality of life. This is a 28-item transcultural research tools with an aim to allow valid international comparisons of the nature of mental disorders and their management. Though it is not a disease-specific instrument, it has been used in studies of persons with schizophrenia in Singapore and Hong Kong and found it as a valid and reliable tool. This WHOQoL-BREF is structured in four domains: Physical health, psychological, social relationship and environment. Subjects were asked to comment on their satisfactory level of each item during the past month on a 5-point Likert scale (1=very dissatisfied to 5=very satisfied).

Hospital Readmission Rate and Psychiatric Consultation Number
They will be tracked through the centres’ record on psychiatric treatment. For participants who will be discharged to their own homes, the researchers will monitor the number of admission to psychiatric hospital and psychiatric consultation numbers through participants and families self-reported history during the study period. The 12-month readmission rates and psychiatric consultation numbers will be compared between control and intervention groups.

Semi-structured Interviews
Semi-structured interviews for peer trainers will explore their perception on the effect of delivery peer-led programme on their own psycho-social wellbeing and development, and how they perceive their effort in helping the peers in their recovery. Semi-structured interview questions are:
1. Please tell me about your experience in conducting PLSMP to peers.
2. Please tell me how you think the delivery of the peer session have an effect on you. Please use examples to illustrate.
3. Please tell me how you think your participation as peer trainer has an effect on your peer participants.

Semi-structured interviews for participant will aim to explore participants’ perspective on the programme and to seek opinion for improvement. The interviews will be guided by an interview schedule and will be audio-recorded. Examples of the interview questions are:
1. Please tell me your experience in the programme.
2. Please tell me what was most helpful about the programme.
3. Please tell me what was least helpful about the programme.
4. Please tell me what is like working with a consumer provider.
5. Please tell me what has been the biggest change for you.
6. Please tell me what other aspects you would like this programme to improve.