Subjective Life Satisfaction and Objective Living Conditions of Patients With Schizophrenia in Nigeria

Quality of life is considered an important outcome in the treatment of schizophrenia, but it has not been clearly conceptualized and its measurement has not been clearly defined. Studies have demonstrated discrepancies between subjective quality of life and objective living conditions ( 1 , 2 ). Although much research has examined the quality of life of patients with schizophrenia in Western cultures, little is known about the quality of life of this patient group in sub-Saharan Africa. A literature search found only two studies ( 3 , 4 ), and none focused on possible differences between subjective life satisfaction and objective living conditions of these patients.

This study aimed to explore the level of life satisfaction among patients with schizophrenia in Nigeria and its relationship with their objective living situations.

Methods

Adult patients with schizophrenia were consecutively recruited from March to May 2006 from the outpatient psychiatric clinics of the Obafemi Awolowo University Teaching Hospitals Complex in Ile-Ife, Nigeria. Patients taking antipsychotic medications for at least one year who had no evidence of intellectual disability and whose most recent hospital admission was more than six months prior were included in the study. Ethical approval and informed consents were obtained.

Information about sociodemographic characteristics was obtained, and subjective quality of life was assessed with the brief version of the World Health Organization Quality of Life Scale (WHOQOL-BREF) ( 6 ). The WHOQOL-BREF was scored according to the instruction manual. Each of the 26 items was rated from 1 to 5, with higher scores indicating better quality of life. One item each was for "overall quality of life" and "overall health." The other 24 items were then averaged to form four domains: physical (possible score range 7–35), psychological (range 6–30), social (range 3–15), and environmental (range 8–40).

Objective living conditions were also assessed. The Instrumental Activities of Daily Living Scale (IADL-7) was used to measure activities of daily living, with a possible summary score of 0, low function, to 8, high function. Self-esteem was measured with the Rosenberg Self-Esteem Scale (RSES-8); possible scores range between 1 and 30, with higher scores indicating better self-esteem.

Results were calculated as frequencies and means with standard deviations. Variables with small cell sizes were dichotomized. Associations were assessed with t tests and Spearman's correlations. Tests were two-tailed, and the criterion level of significance was set at .05.

Results

Of the 100 participants recruited, one had incomplete data, and data for 99 patients were analyzed. The mean age of the participants was 35.3±7.9 years. Fifty-six participants were aged 34 years or less; 58 were male; 41 were divorced, separated, or widowed; 59 were Christians; and 71 were from the Yoruba ethnic group. Fifty-three had less than six years of formal education. Sixty-six were unemployed, 65 earned less than N5,000 (about $40 USD) per month (the average monthly income in Nigeria is about $250). Eighty were living with their relatives or friends.

On the WHOQOL-BREF the mean±SD raw scores were 2.8±1.1 for overall quality of life and 2.9±1.1 for overall health. Raw scores for the domains were as follows: physical, 22.7±8.3; psychological, 21.9±6.7; social, 7.8±3.6; and environmental, 22.7±9.7. Items with the highest scores were "satisfaction with self" (3.6±1.2), "life meaningful" (3.2±1.2), "enjoying life" (3.2±1.3), and "overall quality of life" (2.8±1.1). Those with the lowest scores were "personal relationships" (2.1±1.1), "transport" (2.2±1.1), "enough money" (2.3±1.1), and "capacity to work" (2.5±1.1).

On the objective measures, 58 participants rated their leisure activities as inadequate, 57 rated their relationships with the same gender as difficult, and 90 rated their relationships with the opposite gender as difficult. Only seven reported having regular sexual intercourse, and 82 reported having "very few" friends. Level of social support from friends was rated poor by 70 participants. The condition of the living place was rated good by 53 participants. Only ten had a means of transport (car or bicycle; two had a car), and 89 relied on walking or commercial transport. The mean number of hours of sleep reported was 5.4±3.2. The mean IADL-7 score for the group was 4.5±2.3, and the RSES-8 score was 14.3±5.7. The average distance to the nearest mental health facility was 15.0±7.2 km.

Table 1 shows the association between the 12 satisfaction measures from the WHOQOL-BREF and the corresponding measures of living conditions. Significant associations were found for only four of the items, including sleep, daily activities, personal relationships with the same gender, and condition of the living place.

Enlarge table

Discussion

This study is the first to examine the quality of life of patients with schizophrenia in Nigeria and the association between objective and subjective measures of their quality of life. Although there are differences in living circumstances between sub-Saharan Africa and Western or Asian settings, our study had findings similar to those in Western and Asian settings—good satisfaction with life in the face of objectively poor circumstances. For example, in India, patients who had schizophrenia had similar WHOQOL-BREF scores for physical (25.2±4.3), psychological (20.7±4.1), social (10.2±2.6), and environmental (30.1±3.8) domains ( 9 ). Although a large percentage of our patients reported high levels of satisfaction with life and found life meaningful, levels of satisfaction with personal relationships, transportation, and money were low. Overall, the objective living situations of these patients were quite unfavorable; the group had high rates of unemployment; about half were single, divorced, or widowed; and participants reported limited social relationships.

In agreement with studies from Western cultures ( 2 ), the study also found little correlation between subjective quality of life and objective living situation. Patients with schizophrenia appeared to report better subjective quality of life than would be expected from their living circumstances, regardless of country of residence. Reasons for this remarkable difference might be that the measures of subjective and objective quality of life assess different constructs ( 10 ), or patients with schizophrenia may be more satisfied because they have lowered their level of aspiration and compare themselves only with those in their own group.

One clinical implication of our study is that poor quality of life among the patients in our sample may be best addressed by efforts to improve work opportunities and transportation options in the community. Advocacy and research grants could be used to implement a bicycle share program or vocational rehabilitation program.

Our study had limitations. It was conducted in a single setting and was cross-sectional, with a moderate sample size. In addition, a generic instrument was used to measure quality of life. Participants were regular outpatients in contact with mental health services, which may have led them to rate their quality of life as higher than persons with schizophrenia not in regular treatment. Also, some factors that have been consistently linked with subjective quality of life, particularly mood, were not assessed in this study. Finally, a control group without schizophrenia was not used.

Conclusions

We have shown that in contrast to their poor living conditions, in Nigeria most patients with schizophrenia expressed a high level of satisfaction with the quality of their life, with only a moderate correlation between subjective and objective measures. Efforts to improve quality of life for these patients should focus on improving work opportunities and transportation options. Also, a larger, longitudinal, multicenter study will be needed to identify changes in needs and quality of life of these patients.

Acknowledgments and disclosures

The authors report no competing interests.