Systematic review protocol

The effectiveness community-based care for primary caregiver and their families living
with schizophrenia.
Amar Akbar. G6138337 NRNS/D
Background
Schizophrenia is a severe mental disorder that usually has an onset in early adulthood and is
often associated with persistent or relapsing symptoms and a range of other adverse outcomes
(Chatterjee et al., 2011). Even though a low prevalence disorder, schizophrenia contributes an
estimated 1.1% of the total Disability Adjusted Life Years (DALY’s) and 9.5% of the total
DALY’s attributable to the neuropsychiatric disorders in South East Asia making it a priority
public health concern for the region (Pearce, McGovern, & Barrowclough, 2006).

The WHO’s mental health Gap Action Program (MHGAP) recommends that schizophrenia
management should include psychosocial interventions, including community-based
rehabilitation (CBR), where available, although evidence from low middle incomes country
(LMIC) settings is limited (Asher et al., 2015; WHO, 2011). CBR is a strategy that aims to
reduce disability and improve the quality of life and social inclusion of people with disabilities.
CBR echoes the ethos of psychosocial rehabilitation, particularly drawing on recovery values,
whilst reflecting the particular needs of low-income settings (Asher et al., 2016).

There is international consensus that care for people with schizophrenia should largely be
delivered in community settings for the best outcomes (WHO, 2011). While in high resource
countries, community care is the norm, in low income countries, the availability of community
services is the exception (Parabiaghi et al., 2007). Thus, for the majority of persons with
schizophrenia and their caregivers in low income countries, there is little access to any care
(Brooke-Sumner et al., 2015).

Addressing this ‘treatment gap’ by scaling up accessible, acceptable and effective community-
based services for persons with schizophrenia is an urgent public health (Asher et al., 2016;
Chatterjee et al., 2014). Scaling up of community services in low income countries faces
challenges like the paucity of specialist resources and the lack of evidence around the
effectiveness, costs and processes involved in delivering community-based interventions (Asher
et al., 2015). One method that specifically addresses the challenges of the lack of specialist
resources, accessibility and inequity in care provision is the Community Based Rehabilitation
(CBR) strategy for persons with disabilities a health and social intervention that is largely
implemented by appropriately trained, lay persons within community settings (Asher et al.,
2016). In addition, the CBR method has a strong focus on empowerment of service users, social
inclusion, livelihood support and equalizing of opportunities for people with disabilities; all of
these are of particular relevance to persons with schizophrenia (Chatterjee et al., 2014).

A non-randomized controlled study from rural India showed that CBR using trained lay
community workers was feasible and improved outcomes for people with schizophrenia,
compared with routine outpatient care (Chatterjee et al., 2014). A more recent study from the
same site has described the impact of specific components of the complex intervention on long-
term outcomes in people with schizophrenia (Chatterjee et al., 2011). These encouraging results
need to be rigorously tested through a randomized controlled trial. If demonstrated to be
clinically effective and affordable in comparison to usually available care (i.e. facility-based
care) alone, such interventions can be scaled up expand coverage and improve outcomes of
persons with schizophrenia and their caregivers in low income countries by using available and
low-cost human resources (Asher et al., 2015).

Objective
The objective of this review is to present the best available evidence related to community-based
care for people and their families living with schizophrenia. The specific review questions to be
addressed is:
What effect does community-based care of primary caregiver in taking care severe mental
illness?
Type of participant
This review will consider all studies that included primary caregiver (family, spouse, parents) in
severe mental illness (schizophrenia, psychotic disorder). Studies focusing on adult patient, and
not including informal or paid caregiver. For purposes of this review, primary caregiver means
that person that have most contact with the patient and living with the patient. Furthermore,
studies that not contain psychotic symptom will be excluded from the review
Type of intervention
Intervention of interest are community-based care for people and their families living with
schizophrenia. This review will be limited on psychoeducation and combine with community-
based care, any intervention that only have psychosocial or psychoeducational will be excluded.
Type of outcomes measures
The primary outcomes of interest are the difference in community-based care for people and
their families living with schizophrenia between experimental intervention and the control.
Type of studies
This review will consider any randomized controlled trials that evaluated effectiveness
community-based care for people and their families living with schizophrenia. In the absence of
RCTs, other research design such as non-randomized controlled trial and pre-post studies will be
considered for inclusion in narrative summary to enable the identification of current approaches
and possible future strategies. papers published in any years will included to the study.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search
strategy will be utilized in this review. An initial limited search of MEDLINE (via PubMed) and
CINAHL will be undertaken, followed by analysis of the text words contained in the title and
abstract, and of the index terms used to describe the article. A second search using all identified
keywords and index terms will then be undertaken across all included databases. Third, the
reference list of all identified reports and articles will be searched for additional studies. Only
studies published in English, for inclusion in this review.

Initial search term will be:

 Community-based care
 Psychoeducational
 Schizophrenia
 Severe mental illness
 Primary caregiver
The database to be searched will included:
 PUBMED/MEDLINE
 EBSCO/CINAHL/EMBASE
 PROQUEST
 SCIENCE DIRECT
The search unpublished studies will include:
Dissertation abstract international
All studies identified during database search will be assessed for relevant to the review based on
the information provided the title, abstract, and description. Full report will be retrieved for all
studies that meet inclusion criteria as follow as PRISMA.
Assessment of methodological quality
Methodological quality will be assessed using a checklist developed by Joanna Brigs Institute
(JBI) and based the work of Cochrane collaboration and review dissemination.
Data collection
Data will be extracted using a data extraction tool that was developed by JBI.
Data synthesis
Where possible, odds ratio (for categorical outcomes data) or standardized mean differences (for
continuous data) and their 95% confidence of interval will be calculated for each include studies.
If appropriate with available data, result from comparable group studies will be pooled in
statistical meta-analysis using Review manager / STATA. Heterogeneity between combined
study will be tested using standard chi squared test.
Pooling of data from studies will initially be based on comparable intervention. If possible, with
available data, subgroup analysis will be undertaken to determine the effectiveness community-
based care in primary caregiver of schizophrenia. Where statistical pooling is not appropriate or
possible, the finding will be summarized in narrative form.
References
Asher, L., De Silva, M., Hanlon, C., Weiss, H. A., Birhane, R., Ejigu, D. A., . . . Fekadu, A. (2016).
Community-based Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE):
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016-1427-9
Asher, L., Fekadu, A., Hanlon, C., Mideksa, G., Eaton, J., Patel, V., & De Silva, M. J. (2015). Development
of a Community-Based Rehabilitation Intervention for People with Schizophrenia in Ethiopia.
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Brooke-Sumner, C., Petersen, I., Asher, L., Mall, S., Egbe, C. O., & Lund, C. (2015). Systematic review of
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