Mediating effects of empowerment on the relationship between global function and recovery among community-dwelling patients with schizophrenia: A cross-sectional study

Background: Functional degradation among community-dwelling patients with schizophrenia can negatively inuence their recovery. Given the importance of patient empowerment during recovery, the current study aimed to examine the mediating effects of patient empowerment on the relationship between global function and recovery among such patients. Methods: This cross-sectional study recruited community-dwelling patients with schizophrenia from northern and central Taiwan. Questionnaires with veried reliability and validity were provided and collected on site by trained nurses. The causal steps approach proposed by Baron and Kenny and the Sobel test were utilized to verify the mediation effect. Results: A total of 373 participants completed the survey. After controlling for factors associated with recovery, empowerment was determined to exert “full mediation” over the effects of global function on patient recovery, with the mediation effect reaching 85.9% and the Sobel test indicating signicant mediation. Conclusions: Although improving the global function of community-dwelling patients with schizophrenia could likely encourage recovery, the present study suggested that offering empowerment-oriented care services may be more effective than global function improvement on recovery among these patients.


Background
Schizophrenia is a complex chronic mental illness characterized by delusions, hallucination, or confusion in speech and behavior. Cognitive impairment has been shown to affect global functions, leading to employment di culties and social withdrawal, which consequently in uence their recovery [1][2][3].
Approximately 152,110 individuals in Taiwan have schizophrenia, creating medical expenses as high as 11.2 billion Taiwan dollars [4]. One study that tracked 200 schizophrenia cases for 20 years found that 57% of patients often have delusional symptoms that interfere with recovery [5]. Despite continuous treatment, 23.7% of cases developed negative symptoms [6], while 75% exhibited poor functional outcomes [7], which affect the degree of recovery and necessitate long-term continuous care [8,9].
Psychiatric consumers de ne recovery as the attainment of a meaningful and valued life rather than the absence of symptoms. Studies have also shown that recovery can be a care outcome [10][11][12]. Notably, global mental health care aims to improve recovery, with developed countries already having successfully developed related recovery programs and effectiveness evaluations [12][13][14]. Moreover, mental health services must be human-oriented, community-oriented, and recovery-oriented [15] considering that the extent of personal recovery can impact quality of life among community-dwelling patients with mentally illness [16,17]. However, follow-up studies and meta-analyses have reported that recovery rates among individuals suffering from mental illness only ranged from 13.5-37.9% [10,18,19]. Hence, promoting recovery among patients with mental illness is urgently needed.
Several systematic reviews and follow-up studies have identi ed the following in uence factors for recovery in patients with schizophrenia: gender, age, employment status, age of onset, illness duration, psychiatric symptoms, global function, side-effect, therapeutic alliance, insight, and medication adherence [8,11,[19][20][21]. Among such factors, global function has been identi ed as an important factor of recovery among patients with schizophrenia [8,20,22]. However, some systematic reviews have found that rehabilitation or psychoeducation programs developed to improve global function and achieve better recovery for individuals with schizophrenia were ineffective [23,24]. Schizophrenia is a debilitating chronic disease that impacts all major life areas. Given that substantial improvements may become di cult as the disease progresses, the empowerment concept has emerged as a novel approach to recovery-oriented interventions for community-dwelling patients with schizophrenia.
Empowerment plays a critical role in the recovery of patients with mental illness [8,22,24]. One systematic review that included 97 articles and rede ned the recovery model, called the CHIME model, identi ed empowerment as one of the elements for recovery [24]. Empowerment mainly entails promoting patient autonomy, independent decision making and responsibility, and self-management [25,26]. Evidence has shown that empowerment can play a mediating role in improving quality of life, hopelessness, or recovery among individuals with schizophrenia [27][28][29][30].
Although studies have suggested that empowerment is an element of recovery [8,28,31], few have explored the mediating effect of empowerment on global function needed for recovery. Even after prolonged functional rehabilitation, patients with schizophrenia nd it hard to improve global functions [23,24]. Assuming that empowerment functions as a mediator, it may therefore be able to hinder the negative impact of global function on recovery. Therefore, the current study aimed to explore the mediating effect of empowerment on global function among community-dwelling patients with schizophrenia. Based on the current literature, we hypothesized that empowerment could be a mediator of global function, consequently leading to personal recovery, among patients with schizophrenia.

Study design
This cross-sectional study utilized convenience sampling and determined the following control variables: basic demography (gender, age, education, employment status, and marriage), disease factors (age of onset, duration of illness, psychiatric symptoms, number of hospitalizations and global function), and therapeutic factors (drug side effects, therapeutic alliances, insight, and medication adherence). Global function was de ned as the independent variable (X), empowerment as the mediating variable (mediator; M), and recovery as the dependent variable (Y).

Participants
This study was conducted at the community psychiatric department of two psychiatric hospitals in Taiwan. Participants were community-dwelling patients with schizophrenia. Those who satis ed the DSM-5 criteria for schizophrenia, were able to communicate in Mandarin and Taiwanese, did not take abused substances, and resided within mental rehabilitation institutions were included as research subjects.
To estimate the sample size using G power 3.1.9.4 [32], we set F test to "Linear multiple regression: Fixed model, R2 deviation from zero" and R2 to 0.35 based on a previous study [29]. Thereafter, we calculated the effect size f2 to be 0.54, with α being set to .05, β to .80, and the number of predictors to 15.
Ultimately, our calculation showed that at least 150 samples need to be included, while 373 participants were needed for su cient statistical power.

Procedure
This study had been reviewed and approved by the Human Test Review Committee of the studied hospitals before data collection from September 1, 2016 to April 30, 2017. During the indicated period, the researcher rst explained the purpose of the research and asked the participants to ll out the questionnaire by themselves after obtaining consent. The researcher also participated in the collection of questionnaire. Data were only collected once per participant, with data collection lasting approximately 30 min. Those who wished to terminate participation midway through the study were allowed to do so to avoid answering deviations related to forced participation

Measures
The basic data sheet includes the participants' general and illness information, including gender, age, education, employment, marriage, age of onset, duration of illness, and number of hospitalizations. The remaining variables were measured using the following structured questionnaires with good reliability and validity.

Global Assessment of Functioning (GAF)
The global assessment of functioning is an assessment tool proposed by the American Psychiatric Association. The single-term GAF uses a 0-100 Likert scale to measure the overall psychosocial and employment function, with higher scores indicating better functioning. The infraclass correlation coe cient of the GAF was 0.89-0.95 and showed good reliability, with higher scores indicating better function [33,34].

Empowerment scale
The empowerment scale is a self-lled scale developed by Rogers et al. in 1997 [35] that uses a Likert scale, with 1 point indicating strong agreement and 4 points indicating strong disagreement, over a total of 25 questions. After the reverse scoring the questions, higher scores indicated higher empowerment.
Taiwanese scholars have translated and veri ed the reliability and validity of this scale in patients with mental illnesses and have revised it into a 13-question Chinese version of covering three factors, namely self-e cacy, community action, and emotional control. The total explanatory variation was 59%, while the Cronbach's α value was .87 [36]. The Cronbach's α value obtained herein was .81.

Questionnaire on Process of Recovery (QPR)
The QPR is a self-lled scale developed by Neil et al. in 2009 [37] that uses a Likert scale ranging from 0 to 4, with a total of 22 questions. The total score can range from 0 to 88, with higher scores indicating better recovery. The scale covers three factors, namely self-empowerment, effective interpersonal relationships, and life reconstruction, with the Chinese version of the QPR having a Cronbach's α of .90 and a total explanatory variation of 70.2% [38]. The Cronbach's α obtained herein was .96.

Brief Psychiatric Rating Scale (BPRS)
The 16-item BPRS was developed by Overall and Gorham in 1962 [39] to measure the psychiatric symptoms and psychopathology, with good construct validity and retest reliability (r = 0.78, p < .001) [40].
The Chinese version of BPRS is scored from 0 to 6 points, with a total score ranging from 0 to 96 points. Higher scores indicate more psychiatric symptoms [41]. The Cronbach's α value obtained herein was .76.

Medication Adherence Rating Scale (MARS)
MARS is a 10-question self-administered questionnaire developed by Thompson et al. (2000) [42] that is scored between 0 and 10 points, with higher scores indicating better medication. Kao and Liu (2010) had translated this scale into Chinese, with a Cronbach's α value of .72, retest reliability after two weeks of .80 (p < .01), and total explained variance of 49.7% [43]. The Cronbach's α value obtained herein was .70.
Glasgow Antipsychotic Side-effect Scale (GASS) GASS is a 22-item questionnaire developed by Waddell and Taylor in 2008 [44] that uses a Likert scale ranging from 0 to 3 points, with a total score of 0-63 points. Higher scores indicate more serious drug side effects. This scale had a Cronbach's α of .79 [45], while its construct validity was associated with the LUNSERS [44]. The Cronbach's α value obtained herein was .89.
Working Alliance Inventory-Short (WAI-s) The 12-item Working Alliance Inventory-Short (WAI-S) uses a 7-point Likert scale to measure therapeutic alliance, with higher scores indicating better therapeutic alliance [46]. WAI-S had a Cronbach's α of .90 and total explained variance of 73.4%, indicating good reliability and validity [47].
The Schedule for assessment Insight in Psychosis (SIP) The SIP is a 9-item questionnaire developed by Yen et al. [48] that uses a Likert scale ranging from 1 to 4 points, with a total score of 9-36 points. Higher scores indicate better sense of disease. This scale had a Cronbach's α of .92, which was related to the Scale to Assess Unawareness of Mental Disorder and Schedule for the Assessment for Insight, with good reliability and validity [48]. The Cronbach's α value obtained herein was .89.

Statistical analyses
SPSS software package (New York: IBM) was used for data analysis. Frequencies, percentages, averages, and standard deviations were used to describe the distribution of each variable, while the scale of the main variable was converted into a score percentage (mean score/total score of the scale * 100%) to describe the variability of the results. The independent-samples t-test, ANOVA, and Pearson correlation were used to analyze the relationship between the independent variable and recovery. Hierarchical regression was used to analyze the in uence and explanatory value of the independent variables for recovery.
The Baron and Kenny path analysis and Sobel test was adopted to verify the mediating effect of empowerment [49].

Demographic characteristics and relationships with recovery
A total of 373 community-dwelling patients with schizophrenia (average age, 46.61 years; 58.2% males) participated herein. Details regarding their demographic characteristics are presented in Table 1.

Discussion
The current study included a large sample of community-dwelling patients with schizophrenia to explore the relationships between global function, empowerment, and recovery. Converting the scale used herein into a percentage shows an empowerment level of 55.4% and a recovery level of 69.1%, which are slightly higher than those presented in other studies [10,19]. This may have been related to differences in the research populations considering that the current study included participants who availed of various community care services, such as outpatient clinics, day wards, or home treatment services, and excluded those not receiving community care services. In other words, the present study supports providing proper community care services, which can stabilize mental illness, reduce overall dysfunction, and reduce the negative impact of the disease on the recovery of community-dwelling patients with schizophrenia [51]. Therefore, community care is important for promoting recovery from mental disorders in community settings.
Our results identi ed employment, psychiatric symptoms, global function, side effects, therapeutic alliances, insight, medication adherence, and empowerment as recovery associated factors. Although such ndings are consistent with previous related literature [8,28], prior studies only explored the impact of a single factor [8,28] on recovery. Nonetheless, the current the study incorporates a framework of multiple comprehensive factors, such as individuals, diseases, and treatments for analysis, which may contribute to the current knowledge regarding factors related to recovery from schizophrenia. The aforementioned results imply that establishing a therapeutic alliance with the clients is an important factor for recovery. Despite the importance of strengthening adherence to medication, attention should still be given to patient's discomfort during the process of medication administration. Developing and using empowerment-oriented care services may effectively in uence and improve recovery rates among community-dwelling patients with schizophrenia.
The results of the current study, like others, support the concept that global function is related to recovery [8]. However, in actual situations where global function is di cult to modify immediately, our research has veri ed that empowerment can completely mediate the in uence of global function on recovery.
Despite the relationship between global function and degree of empowerment, limited general cognitive function can affect the degree of empowerment given its requirement of self-re ection, which consequently affects recovery owing to the close relationship between degree of empowerment and recovery [26,30,31,52]. The current study veri ed that empowerment is indeed an important element for recovery, despite the negative impact of global function on recovery [8,28]. Traditionally, mental health practices had emphasized strategies for enhancing the global function of patients. However, we believe that shifting toward relevant strategies for empowering patients is necessary and may be more effective for patient recovery than enhancing global functions.
The current study recommended that nursing education convey the importance of empowerment through which nursing students can learn the concept and coverage of empowerment-oriented care, including self-maintenance during illness and life and familial-societal connections [25]. The results presented herein provide clinical professionals with an alternative approach to care. Transitioning to an empowerment-oriented care strategy can effectively reduce the negative impact of poor global function on recovery. The empowerment strategy that assist in achieving recovery [31,53].

Limitations
To our knowledge, this has been the rst study to focus on the mediating effect of empowerment on the relationship between global function and recovery in schizophrenia after accounting for multiple related factors. Nonetheless, some research limitations of the study are worth noting. First, given the crosssectional, descriptive design that lacked causal inference, our results should be interpreted with caution. Second, the main dependent recovery variable was the self-evaluated recovery scale, which may differ from the actual recovery status that contains speci c indicators. Future longitudinal studies are thus needed to identify variables at different time points, thereby deepening our knowledge regarding the mediating effect of empowerment on the relationship between global function and recovery.

Conclusions
The current study identi ed employment, psychiatric symptoms, global function, drug side effects, therapeutic alliance, insight, medication adherence, and empowerment as factors related to recovery. Moreover, the empowerment mediating model con rmed that empowerment can reduce the negative impact of global functional decline on psychiatric recovery. The present study suggests that developing and applying empowerment-oriented community care may be more effective in promoting psychiatric recovery than focusing on global functions among community-dwelling patients with schizophrenia. Despite attempting to include all active variables affecting recovery, some may have still been missed. Future investigations on the relationships between empowerment and recovery might include additional variables. Developing empowerment-and recovery-oriented services for community-dwelling patients with schizophrenia and then utilizing carefully designed randomized controlled trials to investigate the effectiveness of such programs on improving psychiatric recovery are also essential.

Availability of data and materials
Datasets used and analyzed herein are available from the corresponding author upon reasonable request.

Competing interests
The authors declare no competing interests.

Funding
This study was funded by the Ministry of Health and Welfare planning project of Taiwan (Grant No. 10647).

Authors' contributions
Each author made substantial contributions to this study. WI and WL designed the study framework, analyzed data, interpreted the result, and wrote a rst draft of the manuscript. SK supervised data collection. KT and WI had substantively revised the article. All authors have read the nal version of the manuscript and approve of its submission.