Role of Health Locus of Control and Self-Efficacy on Level of Psychotropic Medication Adherence among Patients with Psychiatric Disorders

: Medication non-adherence is a major global issue among patients with psychiatric disorders. The most important elements related with medication non-adherence are health locus of control and self-efficacy. Aim of the study: To explore role of health locus of control and self-efficacy on level of psychotropic medication adherence among patients with psychiatric disorders. Subject: A convenience sample of 140 patients with psychiatric disorders was involved. Settings: The study was executed at the Inpatient Psychiatric Department in two settings; Tanta University Hospital and the Psychiatry, Neurology and Neurosurgery Center. Study design : A descriptive correlational research design was utilized. Study tools: Four tools were used: Tool I : Socio-demographic and Clinical Data Structured Questionnaire. Tool II: Medication Adherence Rating Scale. Tool III: Multidimensional Health Locus of Control (form C) . Tool IV: General Self-Efficacy Scale. Results: The study revealed that two thirds of the studied patients were non adherent to psychotropic medications and the half of them had moderate level of self-efficacy. Self-efficacy and health locus of control had statistically significant role in the prediction of psychotropic medication adherence among studied subjects. Conclusions: Self-efficacy and health locus of control are strong determinants in the occurrence of medication adherence among patients with psychiatric disorders. Recommendations : Developing programs for enhancing health locus of control and self-efficacy among patients with psychiatric disorders.


Introduction
Psychiatric disorder is often associated with significant personal distress, as well as social distress and functional disruptions in one's life (1) .Psychiatric illnesses are a global public health concern, affecting approximately 17.6% of the world's population and accounting for 14% of the global disease burden (2,3) .A significant portion of individuals (31.7%) with serious psychiatric disorders have long-term incapacity and dependency.One of the major challenges in treating psychiatric disorders is patient's non-adherence to psychotropic medications (4,5) .
The world health organization (WHO) defines medication non-adherence as cited in Hyvert et al (2023) as, "a case in which a person's behavior in taking medication does not correspond with agreed recommendations from health personnel" (6,7)   .Worldwide percentage of nonadherence to psychotropic medications was 20% to 60% among patients with psychiatric illness (8,9) .Additionally, on the national level, an Egyptian study carried by El-Azzab and Ali (2021) reported that almost two thirds of psychiatric patients did not take their prescribed psychotropic drugs as required.Non-adherence to psychotropic medication has a huge gloomy impact on patients, family and society.It can result in exacerbation of patients' illness, decrease the efficacy of treatment and may make patients less receptive to further treatment (10, 11) .Previous studies have demonstrated that medication adherence is a multifaceted phenomenon influenced by a variety of factors, such as those linked to the patient, the environment, the drug, the condition, and other aspects of the treatment. (12).In this respect the health locus of control and self-efficacy have been shown to be of special relevance related to medication adherence (13) .
The key factor of medication adherence in the context of chronic mental illness is self-efficacy.Self-efficacy is the belief in one's own capacity to carry out a certain behavior or group of related acts.( 14) .The feeling of self-efficacy has a high promise for lowering the prevalence of psychiatric disorders, chronic diseases, and improving psychotropic and other medication adherence.As per studies, patients with psychiatric disorders have strong selfefficacy comply to their medications more than patients with poor self-efficacy (14)(15)(16)(17) .
Another key factor rather than self-efficacy which affect medication adherence is health locus of control (HLOC).Health locus of control refers to the extent to which an individual perceives events in his or her health as being a consequence of his or her actions, and perceived control.A recent study reported that HLOC impact the outcome and possible recovery in psychosis (18,19) .There are two types of health locus of control; internal and external.While a person with a high external locus of control is more likely to believe that other factors are at play and is more vulnerable to psychosocial maladjustment.0) .Accordingly more external HLOC may diminish medication adherence and recovery in psychosis, whereas more internal HLOC may boost medication adherence, rehabilitation, better psychological adaptation to the disease and recovery (19)(20)(21) .

Significance of the problem:
The psychiatric disorder has a detrimental impact on patients' quality of life, medical costs, health outcomes, health resource use, and death rates.

Aim of the study
This study was aimed to:-Explore the role of health locus of control and self-efficacy on level of psychotropic medication adherence among patients with psychiatric disorders.

Research hypothesis:-
Patients with psychiatric disorders whom having high internal health locus of control and high self-efficacy will be more adherent to psychotropic medication.

Research design:-
A descriptive correlational research design was used in the current study.Setting:-The present study was conducted at Inpatient Psychiatric Department of the following settings: a. Tanta University Hospital.Its capacity is (42 beds) divided into two wards for men (26 beds) and two wards for women (16 beds).b.Psychiatry, Neurology and Neurosurgery Center.This center has a capacity of (61 beds) divided into two wards for men (50 beds) and one ward for women (11 beds).Both previously settings are affiliated to High Ministry of Education.

Subjects:
A convenience sample of 140 patients with psychiatric disorders was involved as the following; 80 patients from inpatients Psychiatric Department, and 60 patients from the other setting.The sample size was calculated using Epi-Info software statistical package.The criteria used for sample size calculation were as follows; 95% confidence level and expected outcome was 70% with margin of error was 5% as 900 patients were recruited yearly from the previously mentioned settings.According to the previously stated requirements, the sample size should be N >134; however, in order to improve the trustworthiness of the study results, the number of patients was increased to 140.Based on the following criteria, the subjects were chosen from the previous settings; -Having chronic medical illness that may affect a psychological state of patients.
-In acute stage of psychosis .
Tools of the study: -The data was collected by using the following tools:-Tool I: Socio-demographic and Clinical Data Structured Questionnaire: The questionnaire was developed by the researcher based on scientific review of literatures to assess and elicit data about socio-demographic characteristics (1)(2)(3)(4)(5)(6)(7) ; it consisted of 8 questions ; (gender , age in years , residence, marital status, level of education, occupation, income and living status) .As well as clinical data questionnaire; it contained 7 questions; (onset of illness (in years), duration of illness (in years), numbers of previous admissions, and insight of psychiatric illness, type of admission, clinical diagnosis and prescribed psychotropic medications).

Tool II: Medication Adherence Rating Scale (MARS):
It was adopted from Thompson et al., (2000) (22) .It was used for assessing medication adherence behaviors among patients with psychiatric disorders.It was a self-reported instrument consists of 10 statements like "I take my medication only when I am sick".It is a Likert type scale (yes \ no).Yes scores equal (0) and No scores equal (1).While there are 2 reverse statements (No.7and 8) like (By staying on medication, I can prevent getting sick.).

Scoring system:
Total score of MARS scale was ranged from zero to ten.The higher score indicated good adherence .The total score was categorized into three levels as the following; -Poor adherent ranged from (0-3) -Partial adherent ranged from (4-6) -Good adherent ranged from (7-10) Tool III : Multidimensional Health Locus of Control (MHLC) Scale (form C) -It was adopted from Wallston et al., (1994 ) (23) .It was a self reported scale that was used for assessing individuals' beliefs related to influences on their health.This scale was consisted of 18 in whether my condition improves, stays the same, or gets worse).

Scoring system:
After summing all responses on scale statement, total score were ranged from 18-108 and then according to total scores of each subscale, it classified into the following; -Internal locus of control: ranged from 6-36 -Chance locus of control score ranged from 6-36 -Doctors locus of control score ranged from 3-18 -Other people locus of control score ranged from 3-18 N.B: Total level of each subscale of MHLC scale come from multiplying total items of each subscale by numbers of likerts( likert that ranged from 1-6) Tool IV: General Self-Efficacy Scale (GSES) It was adopted from Schwarzer&Jerusalem (1995) (24) .This scale was intended to measure how confident a person was in their own abilities to adapt to unfamiliar or challenging circumstances and overcome any related challenges or failures.It consisted of 10-items.It is a four-point Likert scale ranging from 1 (not at all true) to 4 (completely true).Like statements (I can always manage to solve difficult problems if I try hard enough) or (If someone opposes me, I can find the means and ways to get what I want)

Scoring system:
Total Scores were ranged from 10-40 and classified into three levels as follow: -Low self-efficacy (10-20).

Method
The study was accomplished according to the following steps:a.The director of the study settings received an official letter from the dean of the nursing faculty seeking for their assistance and consent to collect data.The Pearson and Spearman correlation coefficients, r, were used to assess the correlation between the variables.The significance level used to interpret the findings of the significance tests (*) was set at P<0.05.Additionally, a very significant threshold of P<0.01 was used to evaluate the significance test results.(**) (25) .

Results:
Table 1 clarifies socio-demographic characteristics of studied patients.About two thirds of the studied patients (65.7%) were males.Less than half of studied patients (41.4%) aged 30 to less than 40 years old with Mean ±SD 40.2411.474.About half of the studied patients (47.1%) were married.More than half of the studied patients (60.7%) had secondary school, 64.3% were not working and 52.9% were living in urban areas.Relating to income and living status, 65% had enough income and most of studied patients (92.9%) were living with their family.Table 3 shows correlation between medication adherence and total scores of multidimensional health locus of control and general self-efficacy of studied patients.It was obvious that there was a positive statistical significant correlation between general self-efficacy and medication adherence of studied patients where r= 0.134, p= 0.014.It was noticed that there was highly positive statistical significant correlation between internal health locus of control of studied patients and medication adherence where r= 0.663, p= 0.000.But, there was highly negative statistical significant correlation between external health locus of control and medication adherence among studied patients where r= -0.476, p= 0.000.This indicated that with increasing selfefficacy and internal health locus of control, there are subsequently increases in medication adherence of studied patients.
Table 4 presents role of medication adherence on internal and external locus of control and general self-efficacy among studied patients by simple linear regression analysis.Results showed that both internal locus of control and general self-efficacy of the studied patients had significant positive role on occurrence of medication adherence (β= 0.663; P=0.000 & β= 0.134; P=0.000) respectively.While results showed that external locus of control of the studied patients had significant negative role on occurrence of medication adherence (β= -0.476; P=0.000).This indicates that both internal locus of control and general self-efficacy can significantly predict occurrence of medication adherence.At the same time, external locus of control can significantly predict poor medication adherence.

Discussion
One of the major challenges in treating psychiatric disorders is patient's nonadherence to psychotropic medications.Adherence to psychopharmacological treatment is a frequent issue in clinical healthcare because, evidently, compliance with prescriptions is a prerequisite for treatment efficacy (3) .Self-efficacy and health locus of control are ones of potentially important predictors of psychotropic medication adherence (15,19) .So, alongside with this, the present study was conducted to explore the role of health locus of control and self-efficacy on level of psychotropic medication adherence among patients with psychiatric disorders.Concerning psychotropic medication adherence level, unfortunately approximately majority of studied patients had partial and poor adherence, while, only one third had good adherence.It denotes that the majority of studied patients were non adherent to psychotropic medications.This may be owing to the fact that the majority of studied patients stated during data collection that patients leave medications due to some following reasons: " they may belief the medication does not work", "did not need for their medications when discharged from hospital with improvement" side effects of medication are undesirable for them such as patients feel tired of medications or less concentrated or the medication make sleepy most of the time".Also, the patient reported that" they don't adhere because of certain social factors as "lack of social support "family didn't support them they feel stigmatized when taking psychotropic medications".Additionally, most of the studied patients didn't adhere to medications because they didn't have insight and this actually supported with the results of the present study.Such result was actually in line with the study of Şahin et al (2018) which conducted at Turkey on individuals with schizophrenia and showed that 71.7% of the patients weren't adherent to psychotropic medication (26) .Also, at the national level, the current findings in the same direction with certain Egyptian studies as the study of Wahba et al (2021) conducted at "psychiatric outpatient clinics at Port Said and Demira Mental Health Hospital" and(x) represented that the majority of the patients with psychiatric disorders didn't adhere to the medications (27) .Also the study of El-Serogy et al (2021) conducted at "psychiatric hospital at Assiut university", estimated that a half of patients with schizophrenia who react greatly to medications are noncompliant with their medication regimen (28) .With summarizing the previous findings, this signposts that the level of adherence to psychotropic medications was very low among individuals with psychiatric disorders at international and national levels (29) .Regarding health locus of control, the current findings of the present study demonstrated that the studied patients were found to have high mean score on external health locus of control than internal one.Such high score of external locus of control may be attributed to that the most patients stated during data collection that other people play a big role in their condition to Vol. 32.No. 4 (Suppl 2) ,November 2023 be improved or get worse.Also studied patients mentioned that "their condition is a matter of fate".Additionally the studied patients stated that "they can't change their situation through their own efforts whatever happened", "they feel hopeless or powerless in the face of difficult situations".These results was certainly supported by the Egyptian study carried by Mahmoud et al (2021) conducted at "psychiatric outpatient clinics at Port Said Psychiatric Health Hospital" stated that patients with psychiatric disorders have higher scores on external health locus of control than internal (30) As regard self-efficacy among studied patients, the result of the current study for surprising illustrated that, the half of studied patients had moderate level of self-efficacy.These high levels of self-efficacy among studied patients may be due half of the studied subjects had schizophrenia and one quarter of them had bipolar disorders.Without doubt both diagnoses have main manifestation of delusional grandiosity and inflated self-esteem that provide the patients with sense of false powerful ability to front any problem and solve any difficult situation.Also during data collection, patients stated that' they wanted to be discharged from hospital and showed that they are well and think that the researcher will report their physicians with their improvement because of high self-efficacy.As a result of patient's point of view, they answer perfectly on researcher's questionnaire of general self-efficacy.This finding matched with the study of Chan et al (2023) which found that 75 % of patients with psychiatric disorders had high levels of self-efficacy (31) .However this result wasn't compatible with the study of Tian,Y et al (2023) which reported that only 30% of patient with psychiatric disorders had high level of self-efficacy (32) .Self-efficacy and health locus of control are the potentially important predictors of psychotropic medication adherence (16,20) .The current result demonstrated that internal health locus of control of the studied patients and general self-efficacy had significant positive role on occurrence of medication adherence.This may be due to that those only studied patients with higher internal health locus of control are more likely to take responsibility for their actions and sustain on it and their health status is the result of their actions and behaviors so adhere more to the medication for better health.Additionally, patients with high internal locus of control feel confident in the face of challenges.So patients were able to confront difficult situations independently and handle the medication problems without frustration or blaming outside forces for their circumstances.Also these current findings may be owing to that studied patients with high self-efficacy will be more motivated to adhere with their psychotropic medications, as patients convinced that their personal abilities allow them to govern their actions.Also patients with high selfefficacy have the ability to assess and solve their problems independently.So this ability helps patients to properly assess any problems with their medications and detect the alternative solutions rather than discontinuing the medications.In the same side, those patients able to adapt and cope with the difficult Vol. 32.No. 4 (Suppl 2) ,November 2023 events.So this enables the patients to comply with their psychotropic medications regardless high medication cost, medication complexity and side effects.These findings agreed with the result of Na´fra´di, L et al (2017) who suggested that high levels of self-efficacy and internal health locus of control among patients with psychiatric disorders are consistently found to promote medication adherence (12) .However, this finding was in contrast with results by Abd ElRahman Rabea et al (2023) reported that a high level of Internal HLOC promotes critical non-adherence to medication regimen (33) .

Conclusion & Recommendations Conclusion
Self-efficacy and health locus of control are strong determinants in the occurrence of medication adherence among patients with psychiatric disorders.Such supported by results of the present study of presence of significant positive role of internal locus of control and general self-efficacy of the studied patients on occurrence of medication adherence.On the contrast, the current results showed that external locus of control of the studied patients had significant negative role on occurrence of medication adherence.These findings indicate that both internal locus of control and general self-efficacy can significantly predict occurrence of medication adherence.At the same time, external locus of control can significantly predict poor medication adherence.

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Patients whom are at least 18 years old.-Patients with psychiatric disorders.-Thepatients were able to engage in the study and communicate well.

Figure 2
Figure2demonstrates total mean scores of internal and external health locus of control among studied patients.It was found that total mean score of external health locus of control of studied patients (51.71± 8.761) was more than mean internal health locus of control (21.01±7.691).

Figure 3
Figure 3 describes levels of general selfefficacy among studied patients.It emphasized that (50%) of the studied patients had moderate self-efficacy.While more one quarter (28%) had high sense of self-efficacy and only 21.4% of the studied patients had low sense of selfefficacy.

Figure 2 :Figure 3 :
Figure 2: Total Mean Scores of Internal and External Health Locus of control among Studied Patients(n=140)

Table ( 4): Role of Multidimensional Health Locus of Control and General Self-Efficacy on Level of Medication Adherence among Studied Patients by Simple Linear Regression Analysis.
* Significant at level P<0.05 ** Highly significant at level P < 0.01.Vol.32.No. 4 (Suppl 2) ,November 2023