Archives of Psychiatric Nursing 41 (2022) 51–61

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

The Transtheoretical Model based psychoeducation's effect on healthy

lifestyle behaviours in schizophrenia: A randomized controlled trial
Sercan Mansuroğlu a, *, F. Yasemin Kutlu b
a
Istanbul University-Cerrahpasa, Institute of Graduate Studies, Department of Mental Health and Psychiatric Nursing, Istanbul, Turkiye
b
Istanbul University-Cerrahpasa, Florence Nightingale Faculty of Nursing, Department of Mental Health and Psychiatric Nursing, Istanbul, Turkiye

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The study was conducted with the pretest-posttest randomized controlled trial design to detect the
Schizophrenia psychoeducation's effect, based on the Transtheoretical Model, on the healthy lifestyle behaviours of individuals
Transtheoretical Model with schizophrenia.
Healthy lifestyle
Methods: The data were collected from 82 participants, as 41 intervention and 41 control. The data were collected
Behavioural change
Mental health
via personal information form, behavioural change stage diagnosis form and healthy lifestyle scale II. 6-week
Psychiatric nurse psychoeducation, consisting of 6 modules, based on the Transtheoretical Model, was applied to the interven­
tion group. No interventions were applied to the control group. Pretests and posttests were applied to both
groups.
Results: When the healthy lifestyle scale II of intervention and control groups and final test results arranged
according to ANCOVA analysis are compared, average final test results were meaningfully positive for the
intervention group with taking control of the pretest and other covariants. When the pretest-posttest results in
terms of behavioural change of the intervention group are evaluated; a meaningful difference among nutrition,
physical exercises, spiritual self-improvement and stress management, which all are the stages of behavioural
change, was detected.
Conclusion: It was determined that psychoeducation on a healthy lifestyle, based on the Transtheoretical Model in
an individual with schizophrenia affected physical exercises, spiritual self-improvement and interpersonal re­
lationships sub-dimension in medium level, and had a drastic influence on health responsibility, nutrition, stress
management sub-dimensions and all healthy lifestyle behaviours. Progress in behavioural change stages was
detected.
Clinical trials ID: NCT05259748.

Introduction cause to be tended to decrease (World Health Organization, 2019). In­

Schizophrenia has been identified as a priority disorder because of its
association with high levels of disability and early mortality, human
rights violations, and loss of productivity (Patel, 2016). It is estimated
that there are approximately >21 million people diagnosed with
schizophrenia worldwide (World Health Organization, 2018). When the
prevalence of schizophrenia in Türkiye is accepted as 0.6 % and the
population is taken as 84 million, the current number of schizophrenic
patients is estimated to be 500,000 (Yaşar & Yıldız, 2021).
According to the World Health Organization, the life expectancy of
between 10 and 25 years of severe mental disorders among individuals
with schizophrenia than the general population to die prematurely and
dividuals diagnosed with schizophrenia generally have a worse physical
health compared to other populations, and this is an important factor in
increasing their risk of premature death (Crump et al., 2013; Nordentoft
et al., 2013; Walker et al., 2015). It is stated that physical diseases that
are common, cannot be prevented adequately, are not detected early
and are not treated effectively are caused by premature deaths in about
60 % of people with severe mental illness (Saxena & Maj, 2017). The
most important factor that individuals with Schizophrenia have a
shorter life expectancy is the physical factors, which include mainly
cardiovascular diseases (CVD), hypertension (HT), cerebrovascular
diseases (CeVD), respiratory system diseases, diabetes mellitus (DM),
obesity, metabolic syndrome and infections (Ohlsen et al., 2005; Uğur,

* Corresponding author.
E-mail addresses: sercanmansuroglu@gmail.com (S. Mansuroğlu), kutluy@iuc.edu.tr (F.Y. Kutlu).

https://doi.org/10.1016/j.apnu.2022.07.018
Received 12 March 2022; Received in revised form 15 June 2022; Accepted 9 July 2022
Available online 20 July 2022
0883-9417/© 2022 Elsevier Inc. All rights reserved.
S. Mansuroğlu and F.Y. Kutlu
2008; Öyekçin, 2009; Hardy & Gray, 2010; Collins et al., 2011; Strassnig
et al., 2017; Firth et al., 2019; Pan et al., 2020) and these can cause
serious health problems and deaths.
Defects in the physical health of individuals with schizophrenia are
associated with unhealthy living habits such as unbalanced and inade­
quate nutrition (Malhotra et al., 2016; Simonelli-Munoz et al., 2012),
sedentary lifestyle, and smoking and alcohol consumption (Fusar-Poli
et al., 2009) has been reported (Malhotra et al., 2016). In addition, the
medical side effects of medical treatments are also a risk factor associ­
ated with the negative impact of physical health (Choong et al., 2012;
Correll et al., 2015; Gothefors et al., 2010; Zhang et al., 2016).
The right to health means that a person can ask the state to protect
his health, to be treated when needed, to be healed, and to benefit from
the opportunities offered by the society. Therefore, everyone has the
right to live in physical and mental health. The state is also responsible
for ensuring that all its citizens live in physical and mental health and in
a way that is worthy of human dignity (Kol, 2015), but it is clear that
individuals with schizophrenia cannot access adequate care to meet
their physical health needs (De Hert, Cohen, Bobes, Cetkovich-Bakmas,
Leucht, Ndetei, et al., 2011; De Hert, Correll, Bobes, Cetkovich-Bakmas,
Cohen, Asai, et al., 2011b; De Hert, Correll, Bobes, Cetkovich-Bakmas,
Cohen, Asai, Leucht, and Leucht, 2011c). Therefore, what should be
done for schizophrenia patients in psychiatric care services is to focus on
physical health and prevent unhealthy lifestyle behaviours (Baller et al.,
2015; Stubbs et al., 2015).
Based on WHO's definition of bio-psycho-social and spiritual health,
a healthy lifestyle has a preventive and health-supporting effect on in­
dividuals (World Health Organization, 2006). Individuals with a diag­
nosis of schizophrenia stated that it takes time to change unhealthy
lifestyle habits and they make the decision to change after gaining
awareness about the health benefits of these changes (Lundström et al.,
2017).
A healthy lifestyle is that individuals control every behavior that
affects their health, increases their well-being and supports self-
development, and reflects this by choosing behaviours appropriate for
their personal health status while arranging their daily activities (İlhan
et al., 2010). Healthy lifestyle behaviours are presented as nutrition,
physical activity, interpersonal relationships, spiritual self-improvement
health responsibility and stress management (Bahar et al., 2008;
Cihangiroğlu & Deveci, 2011). Individuals should take their own re­
sponsibilities and develop healthy behaviours, and turn these habits into
the daily world (Cihangiroğlu & Deveci, 2011; Özyazıcıoğlu et al.,
2011). Many factors such as sedentary lifestyle, smoking, inadequate
and unbalanced eating habits, substance abuse and antipsychotic drug
use may be effective in the formation of physical health problems in
patients with schizophrenia (Burghardt & Ellingrod, 2013; Murphy
et al., 2019). Triggering lifestyle behavior change mainly depends on
factors such as gaining awareness of the harm caused by a certain
behavior to physical health and successful implementation and main­
tenance of this behavior change (Davis et al., 2015).
For individuals to develop a healthy lifestyle behavior, it is necessary
to primarily determine the lifestyle behaviours and then prevent the
illnesses caused by the lifestyle and deaths linked to these illnesses.
Current theory or models used to benefit from health programmes,
prepared for the development of healthy lifestyle behaviours, should be
deep-scaled. Theories and models are defined as a mental or schematic
representation of care that is formed systematically and that helps in­
dividuals organize their thoughts about what they do and put these
thoughts into practice (Mc Kenna & Slevin, 2008). A well-defined model
could contribute to the process of effective health improvement pro­
grammes for directive and content creation. One of the models mainly
used to develop a behavioural change in health and explain how to
obtain the most effective health behavioural change is the “Trans­
theoretical Model” (TTM) (Prochaska & Velicer, 1997; Shinitzky & Kub,
2001). Developed by Prochaska and DiClemente (1982), TTM is an
intentional behavioural change model that can offer a wide range of
52
Archives of Psychiatric Nursing 41 (2022) 51–61
research and service on various problematic behavioural change areas.
This model explains the stages of change: pre-contemplation, contem­
plation, preparation, action and maintenance (Erol & Erdoğan, 2007).
TTM, a behavior change model, shows how an individual move through
these five stages of change (Mohebbi et al., 2021; Li et al., 2020;
Rahimdel et al., 2019; Sharma, 2015).
The purpose of offering care for individuals with chronic mental
disorders like schizophrenia is to improve their skills to cope with the
disorder and prevent acute symptoms to increase and physical and
psychosocial health problems caused by the disorder's symptoms. In line
with this purpose, nursing attempts must focus on helping the individual
with mental disorder to learn or remember the healthy behaviours that
can ensure that they play their parts in the society satisfactorily (Oflaz,
2016). In this context, it can be said that mental health and psychiatry
nurses stands for a critical point in upgrading and improving health with
aimed behavioural changes and healthy lifestyle interventions (Bonfioli
et al., 2012).
In a study examining the healthy lifestyle behaviours of individuals
with a chronic mental disorder, it is reported that spiritual development
and interpersonal relationship sub-dimensions scores were higher than
healthy lifestyle behaviours of the participants, comparing to the other
sub-dimensions, and the physical activity point has the lowest score
(Gerçik, 2018). In another study that Erginer and Günüşen (2018)
analyzed 115 individuals with mental disorders in terms of physical
health status and healthy lifestyle behaviours, 49.6 % of individuals
with mental disorders have metabolic symptoms, 34.8 % of them smoke
approximately 1 pack of cigarettes, most of them have additional
various chronic diseases, 37.4 % have higher body mass index than
normal, and nutrition and physical activity scores are low, therefore,
they should have educational support for these topics. Parallel with the
results of this study, it is possible to say that mental health and psy­
chiatry nurses may help to prevent physical health problems of in­
dividuals with schizophrenia and a chronic mental disorder by
developing healthy lifestyle behaviours.
There are several studies in Türkiye on the development of healthy
lifestyle behaviours on chronic mental disorders (Çelik İnce & Partlak
Günüşen, 2021) and individuals with schizophrenia (Acıl et al., 2008)
for physical activity by applying for physical activity programmes.
However, national and international studies on the TTM, which is used
for the development of healthy lifestyle behaviours, are limited. When
the studies conducted on this subject are analyzed, it was detected that
mostly the effect of the TTM on quitting smoking was researched. Other
than that, there are several studies on stress management, compliance
with the medication, preventing depression, weight control, exercising
regularly and sleep problems (Alkar & Karanci, 2007; Aveyard et al.,
2006; Aveyard et al., 2009; Güngörmüş & Yılmaz Karabulutlu, 2012;
Hashemzadeh et al., 2019; Prochaska et al., 1994; Selçuk Tosun &
Zincir, 2016; Sharifirad et al., 2012; Spencer et al., 2006).
In the literature review, it is seen that intervention studies on the use
of TTM in schizophrenia patients, who are observed to exhibit frequent
unhealthy lifestyle behaviours, are scarce. The aim of this study is to
determine the effect of psychoeducation based on the Transtheoretical
Model on the healthy lifestyle behaviours of individuals with
schizophrenia.
The hypotheses of the study
Hypothesis 1. Individuals with schizophrenia who receive psycho­
education based on the Transtheoretical Model will progress according
to the behavior change stage identification form when compared to
those who do not receive this psychoeducation.
Hypothesis 2. Psychoeducation based on the Transtheoretical Model
is effective on the healthy lifestyle behaviours of individuals with
schizophrenia.
S. Mansuroğlu and F.Y. Kutlu
Materials and methods
Aim and design
This study is conducted in pretest-posttest randomized controlled
experimental research type.
Setting and time
The study was conducted in a Community Mental Health Center
(CMHC) in Hatay in Türkiye between April 2019–November 2020.
Sample
The population of the study are the individuals with schizophrenia
who registered in a CMHC and are under observation (N = 230). The
sample number is determined based on another similar study (Erbaba,
2018) with power analysis. In the evaluation completed according to the
healthy lifestyle behaviours score, the sample number needed to
participate in the study was determined to be at least 42 (intervention
group = 21 - control group = 21) in order for research results for Power:
0.80, β:0,20 and α:0,05 to have a meaningful effect. The data were
collected from 82 individuals with schizophrenia, as 41 intervention and
41 control groups.
➢ Inclusion criteria for the study
• Between the ages 18 and 65
• Being diagnosed with schizophrenia according to DSM-V
• Being literate
• Not having education and language problem that can block the
interview
• Being open to communication and cooperation
• Being in one of the three stages of the TTM: contemplation,
preparation and action
➢ Exclusion criteria from the study
• Patients in acute exacerbation period
• Having a neurocognitive disorder
• Having a mental retardation
• Being in one of the two stages of TTM: Precontemplation and
Maintenance.
Randomization
The files of 230 schizophrenia patients registered with the Commu­
nity Mental Health Center were evaluated by the researchers according
to the inclusion or exclusion criteria. As a result, 82 participants were
included in the randomization. In order to reduce selection bias in
determining the intervention and control groups, the numbers to be
included in the sample were determined with a number generator using
the www.random.org website.
Measurements
Personal Information Form: This form prepared by the researcher
using literature knowledge consists of total of 22 questions related to
their personal features, their disorder's specifications and lifestyles of
the individuals with schizophrenia in the study (Demirel Döngel et al.,
2018; Erginer & Günüşen, 2018; Gerçik, 2018; Holt et al., 2019;
İpekçioğlu & Kök Kendirlioğlu, 2019; Selçuk Tosun & Zincir, 2016;
Sungur et al., 2019).
Behavioural Change Stage Identification Form: It is formed using
behavioural change phases of the TTM and based to the literature by the
researcher in order to determine the behavioural chance stages of the
patients in the fields of taking responsibility for own health, nutrition,
physical exercise, spiritual development, interpersonal relationships and
stress management (Ay & Temel, 2008; Baysal, 2013; Tosun, 2015). In
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Archives of Psychiatric Nursing 41 (2022) 51–61
the TTM developed by psychologists Prochaska and DiClemente (1982),
it is stated that behavioural change is a process that develops stage by
stage and a framework in the classification of the behavior's stage (Van
Nes & Sawatzky, 2010). This study only focuses on the stages of change.
Stages of change deal with the time dimension of the model and include
five stages. The structure of the model consists of stages as pre-
contemplation, contemplation, preparation, action, maintenance (Erol
& Erdoğan, 2007; Nigg, 2001; Prapavessis et al., 2004). These stages also
explain the interests and the motivations of individuals towards change
with time of intention, attitude and behavioural change (Kim et al.,
2006). In this form, the question patterns directed to the participants are
related to healthy lifestyle behaviours (health responsibility, nutrition,
physical exercise, spiritual development, interpersonal relations and
stress management) specific to each change phase of TTM (pre-
contemplation, contemplation, preparation, action, maintenance). It
includes question patterns to determine what state they are in. The
participant is asked to choose the most appropriate sentence for each
sub-dimension of healthy lifestyle behaviours that describes the stages of
the transtheoretic model directed to him. This form only describes the
current status of the participant by numbers and percentages.
Healthy Lifestyle Behaviours Scale (HLBS II): It was developed to
measure behaviours of individuals that improve their well-being asso­
ciated with a healthy lifestyle by Walker et al. (1987). The scale was
reviewed in 1996 and renamed HLBS II. The scale consists of 52 items
and six subfactors and it is a 4-point Likert type scale (never (1),
sometimes (2), often (3), regularly (4)). The lowest and highest scores on
the scale are 52 and 208 respectively. It is considered that individuals'
healthy lifestyle behaviours increase with the increasing total score.
According to the results of the study on validity and reliability of HLBS II
and its subscales, conducted by Walker et al. (1995); Cronbach's Alpha is
0.94 in the whole scale and changes between 0.79 and 0.87 for six
subscales. The Turkish adaptation of the HLBS II was performed by
Bahar et al. (2008). As the result of the Turkish reliability and validity
study of the scale; Cronbach's Alpha is 0.92 in the whole scale and it was
found out to be 0.77 for the responsibility of health subscale; 0.79 for the
physical activity subscale; 0.68 for the nutrition subscale; 0.79 for the
spiritual development subscale; 0.80 for the interpersonal relationships
subscale; 0.64 for the stress management subscale. As to this study,
Cronbach's Alpha is determined to be 0.94 in the intervention group for
the whole scale, and for the sub-dimensions, in pretest to be respectively
0.67, 0.87, 0.73, 0.81, 0.76 and 0.76 whereas in posttest to be respec­
tively 0.71, 0.87, 0.71, 0.83, 0.78 and 0.74. As to the control group, it is
determined to be 0.95 for the whole scale, and for the sub-dimensions, in
pretest to be respectively 0.88, 0.88, 0.79, 0.85, 0.93 and 0.50 whereas
in posttest to be respectively 0.86, 0.89, 0.77, 0.82, 0.92 and 0.61.
Research procedures
The behavioural change identification form was applied to in­
dividuals with schizophrenia, who agreed to participate in the study,
and their stage of the TTM was detected. The participants meeting the
criteria in the participation stage (contemplation, preparation, action)
were assigned to the intervention and control groups with the
randomization. Pretests (personal information form, behavioural
change identification form, HLBS II) were applied to the intervention
and control groups before the psychoeducation. In addition to the
rehabilitation activities conducted in the CMHC, healthy lifestyle be­
haviours psychoeducation programme (HLBPP), based on the TTM, with
6 sessions (healthcare responsibility, nutrition, physical activity, spiri­
tual development, interpersonal relationships, stress management) was
applied to the intervention group for 6 weeks as three days in the
weekdays and two sessions in a day.
Psychoeducation was carried out by the researcher on the same day
but within different time zones. Each psychoeducation session took
90–120 min with the breaks taken considering the participants' mood.
After completing six sessions, the behavioural change identification
S. Mansuroğlu and F.Y. Kutlu
form and HLBS II were applied to the intervention group again. On the
other hand, the control group continued their rehabilitation practices
prepared for themselves in the CMHC. It was contacted with the control
group three times, two face to face and one via phone. In the third and
final meeting, when the intervention group's sessions are completed, the
behavioural change identification form and HLBS II were applied again
to the control group. All the participants remained in the study at the
end of it. The study was completed with 41 individuals in the inter­
vention group and 41 individuals in the control group, and all steps of
the study shown in the CONSORT flow diagram (Fig. 1).
Ethical considerations
The permission for the use of HLBS II was granted by the researcher
from those who conducted Turkish validity and reliability studies
thorough email. Permission was received from Mustafa Kemal Univer­
sity Faculty of Medicine Clinical Research Ethical Board (Date:
26.09.2019-Decree No. 06). Using this permission, an application was
made to Hatay Provincial the Health Directorate and institution
permission from Hatay State Hospital was obtained (Date: 23.10.2019).
The individuals with schizophrenia in the study and their families were
informed according to the Helsinki Declaration and written and verbal
approval were collected. This study has been registered with a Clinical
Trial Registry ID (Clinical Trials ID: NCT05259748).
Assessed for eligibility (n=230)
Not included (n = 148)
Refused to participate (n = 42)
Legal guardian did not consent to attend (n=27)
Did not meet inclusion criteria (n = 79)
-Over 65 years (n = 10)
- Illiterate (n = 14)
- Having a neurocognitive disorder (n = 12)
-Having mental retardation (n=5)
- Patients in acute exacerbation period (n = 6)
- Being in one of the two stages of TTM:
Precontemplation and Maintenance (n=32)
Randomized (n= 82)
Allocation
Intervention Group
Applying pretest (n=41)
Applying Healthy Lifestyle Behaviours
Psychoeducation Programme (n=41)
Completed the intervention (n=41)
Analysis
Applying posttests (n=41)
Analyzed (n=41)
Excluded from analysis (n=0)
Fig. 1. CONSORT flow diagram.
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Archives of Psychiatric Nursing 41 (2022) 51–61
Data analysis
SPSS v23.0, which is a statistical analysis programme, was used to
evaluate the findings of the study. It was benefited from descriptive
statistics such as frequency, percentage, arithmetic average, standard
deviation, minimum and maximum during data analysis. Parametric
tests were used for the data analysis. The chi-squared test was used for
relation analysis of two different categorized variables whereas the t-test
was used while comparing averages of two independent groups. To
determine the alteration of individuals' behavioural change stages
before and after receiving psychoeducation, the McNemar test was used.
Analysis of covariance (ANCOVA) while detecting the effect of the
intervention study in the researches designed in the entrepreneurial
pattern. In ANCOVA, to detect how big the effect of the independent
variable on the dependent variable the eta squared (effect size) was
calculated and the eta squared value (η2) was interpreted that it presents
which parts of the change explain the total variant that the independent
variable has on the dependent variable and it received a value between
0 and 1 (Büyüköztürk, 2011; Pallant, 2017).
Eta squared is interpreted as 0,01 as the minor effect, 0,06 as medium
effect and 0,14 as large effect (Cohen, 1992). All test results were
evaluated in terms of p < 0.05 meaningfulness level.
Results
Findings of personal and health characteristics of the individuals
with schizophrenia in the intervention and control groups are shown in
Power analysis=42
Control Group
Applying pretest (n=41)
No intervention
Phone interview (n=41)
Completed the control procedure (n = 41)
Applying posttests (n=41)
Analyzed (n=41)
Excluded from analysis (n=0)
S. Mansuroğlu and F.Y. Kutlu Archives of Psychiatric Nursing 41 (2022) 51–61

Table 1
Distribution of individual and illness characteristics of participants (n = 82).
Group Test statistics

Intervention (n = 41) Control (n = 41) Total (n = 82)

n (%) n (%) n (%) χ2 p

Gender Female 6 (14,6) 8 (19,5) 14 (17,1) 0,086 p > 0,05

Male 35 (85,4) 33 (80,5) 68 (82,9)
Marital status Married 12 (29,3) 15 (36,6) 27 (32,9) 0,221 p > 0,05
Single 29 (70,7) 26 (63,4) 55 (67,1)
Education Primary school 23 (56,1) 21 (51,2) 44 (53,7) 0,424 p > 0,05
High school 13 (31,7) 13 (31,7) 26 (31,7)
Undergraduate/graduate 5 (12,2) 7 (17,1) 12 (14,6)
Living With family 35 (85,4) 38 (92,7) 73 (89,0) 1,123 p > 0,05
Only 6 (14,6) 3 (7,3) 9 (11,0)
Financial situation Income less than expenses 20 (48,8) 18 (43,9) 38 (46,3) 5,005 p > 0,05
Income equals expense 17 (41,5) 23 (56,1) 40 (48,8)
Income equals expense 4 (9,8) 0 (,0) 4 (4,9)
Social security Yes 35 (85,4) 34 (82,9) 69 (84,1) 0,091 p > 0,05
No 6 (14,6) 7 (17,1) 13 (15,9)
Lifestyle definition Active 11 (26,8) 13 (31,7) 24 (29,3) 0,059 p > 0,05
Quiet 30 (73,2) 28 (68,3) 58 (70,7)
Additional chronic disease Yes 11 (26,8) 17 (41,5) 28 (34,1) 1,356 p > 0,05
No 30 (73,2) 25 (58,5) 55 (65,9)
Type of additional chronic disease Diabetes 2 (18,2) 2 (11,8) 4 (14,3) 7,457 p > 0,05
Hypertension 6 (54,5) 4 (23,5) 10 (35,7)
COPD 0 (0,0) 8 (47,1) 8 (28,6)
Other (asthma, FMF, solar retinopathy, goiter) 3 (27,3) 3 (17,6) 6 (21,4)
Regular doctor check Yes 37 (90,2) 12 (29,3) 49 (59,8) 31,755 p < 0,001
No 1 (2,4) 10 (24,4) 11 (13,4)
Partially 3 (7,3) 19 (46,3) 22 (26,8)
Adherence to treatment Yes 38 (92,7) 14 (34,1) 52 (63,4) 33,629 p < 0,001
No 1 (2,4) 0 (0,0) 1 (1,2)
Sometimes 2 (4,9) 27 (65,9) 29 (35,4)
Smoking Yes 22 (53,7) 30 (73,2) 52 (63,4) 3,920 p > 0,05
No 18 (43,9) 11 (26,8) 29 (35,4)
Stop using 1 (2,4) 0 (0,0) 1 (1,2)
Alcohol consumption Yes 2 (4,9) 7 (17,1) 9 (11,0) 2,173 p > 0,05
No 37 (90,2) 31 (75,6) 68 (82,9)
Stop using 2 (4,9) 3 (7,3) 5 (6,1)
Alcohol consumption frequency Once a week 0 (0,0) 1 (14,3) 1 (11,1) 9,000 p < 0,05
Twice a week 0 (0,0) 3 (42,9) 3 (33,3)
Three times a week 0 (0,0) 3 (42,9) 3 (33,3)
Social drinker 2 (100,0) 0 (0,0) 2 (22,3)
Substance use Yes 10 (24,4) 7 (17,1) 17 (20,7) 0,297 p > 0,05
No 31 (75,6) 34 (82,9) 65 (79,3)
Type of substance Cannabis 10 (100,0) 6 (85,7) 16 (94,1) 1,518 p > 0,05
Ecstasy 0 (0,0) 1 (14,3) 1 (5,9)
Regular exercise Yes 22 (53,7) 16 (39,0) 38 (46,3) 1,226 p > 0,05
No 19 (46,3) 25 (61,0) 44 (53,7)
Type of exercise Walking 21 (95,5) 11 (68,8) 32 (84,2) 8,387 p > 0,05
Swimming 0 (,0) 1 (6,3) 1 (2,6)
House-cleaning 0 (,0) 3 (18,8) 3 (7,9)
Fitness 0 (,0) 1 (6,3) 1 (2,6)
Warm up moves 1 (4,5) 0 (,0) 1 (2,6)
Exercise frequency Once a week 4 (18,2) 1 (6,3) 5 (13,2) 19,904 p < 0,001
Twice a week 5 (22,7) 0 (0,0) 5 (13,2)
Three a week 0 (,0) 9 (56,3) 9 (23,7)
Five a week 0 (,0) 1 (6,3) 1 (2,6)
Everyday 13 (59,1) 5 (31,3) 18 (47,3)
The way of nutrition Only 3 main meals 15 (36,6) 5 (12,2) 20 (24,4) 8,362 p < 0,05
Regular 3 snacks and 3 main meals 4 (9,8) 2 (4,9) 6 (7,3)
3 main meals regular, 3 regular breaks 8 (19,5) 14 (34,1) 22 (26,8)
2 main meals are regular, 3 breaks are irregular 14 (34,1) 20 (48,8) 34 (41,5)

Mean ± SD Mean ± SD t* p

Age 38,7 ± 9,9 39,6 ± 11,1 − 0,389 p > 0,05

Diagnosis age 24,8 ± 6,7 25,0 ± 3,2 − 0,106 p > 0,05
Diagnosis time (years) 14,1 ± 7,3 14,1 ± 10,0 0,025 p > 0,05
Number of hospitalizations 4,7 ± 5,4 4,8 ± 4,5 − 0,112 p > 0,05
Additional disease duration (years) 11,5 ± 11,7 10,5 ± 5,3 0,289 p > 0,05
Smoking duration (years) 16,5 ± 9,0 18,8 ± 10,2 − 0,857 p > 0,05
Cigarettes (day/piece) 25,0 ± 12,9 30,7 ± 14,6 − 1,450 p > 0,05
Height (cm) 173,6 ± 8,5 173,4 ± 8,3 0,092 p > 0,05
Weight (kg) 86,8 ± 17,8 75,9 ± 10,6 3,360 p < 0,001
Waist measurement (cm) 104,1 ± 12,5 92,1 ± 10,2 4,768 p < 0,001

55
S. Mansuroğlu and F.Y. Kutlu Archives of Psychiatric Nursing 41 (2022) 51–61

χ2 = Chi-Square Test, COPD: Chronic Obstructive Pulmonary Disease, FMF: Familial Mediterranean fever.
χ2 = Chi-Square Test, *independent sample t-test, SD: standard deviation.
Note: The test statistics shown in bold in the table show that the applied test gives meaningful results.

Table 1.
Table 3
The findings related to the pretest-posttest results regarding the
Post-test and corrected post-test means of HLBS II and sub-dimensions of in­
behavioural change stages of the individuals with schizophrenia in the
dividuals diagnosed with schizophrenia in the intervention and control group (n
intervention and control groups are shown in Table 2. When the com­ = 82).
parison between groups is evaluated using chi-squared, the groups are
Group n Post-test Corrected
observed to be similar other than physical, exercise and spiritual
mean
development stages of behavioural change (p > 0.05). When the pretest-
X SD X SE.
posttest results of the individuals with schizophrenia are evaluated using
the McNemar relation test, a significant difference was detected between Responsibility of Intervention 41 25,24 4,66 24,00 0,25
nutrition, physical exercise, spiritual development and stress manage­ health Control 41 20,49 4,50 21,73 0,25
Physical activity Intervention 41 18,02 6,05 16,26 0,30
ment (p < 0.05). Control 41 13,51 4,28 15,28 0,30
As a result of the test process of the necessary hypothesis for Nutrition Intervention 41 23,63 4,52 22,87 0,30
Covariance (ANCOVA) analysis to be applied, for determining the effect Control 41 20,20 3,47 20,36 0,30
of the independent variable on the dependent variable; the hypothesis of Spiritual Intervention 41 26,24 5,77 23,69 0,20
development Control 41 20,20 3,99 22,75 0,20
the normal distribution of the groups was achieved according to the
Interpersonal Intervention 41 24,51 5,38 22,50 0,20
Kolmogorov-Smirnov test, completed to observe the groups normal relationships Control 41 19,80 5,07 21,82 0,20
distribution (p > 0.05). According to the result of the Levene test which Stress management Intervention 41 22,90 4,59 21,00 0,27
was performed to test the homogeneity of the variances, no difference Control 41 17,20 2,82 19,09 0,27
was observed between groups (p > 0.05). According to the results of the HLBS II total Intervention 41 140,56 24,99 130,07 1,31
Control 41 111,39 20,21 121,88 1,31
Pearson Correlation Test, another hypothesis of the ANCOVA test, which
was applied to test whether there is a direct relationship between the X: average, SD: standard deviation, SE: standard error.
covariant variable and dependent variable, a statistically significant
relationship was found between covariant variables and the dependent pretest score were statistically stabilized, a significant difference ac­
variable (p < 0.05; r > 0.30). Finally, the homogeneity of the regression cording to the covariance results were observed between the healthcare
lines was tested and it was seen that the equality of the regression lines responsibility posttest average score of the patients in the intervention
was obtained (p > 0.05). group and the posttest average score of the patients in the control group
Without the effect of covariant variables, corrected posttest averages (F(1,79): 38.658; p < 0.001). This difference is in favour of patients in the
(
of ANCOVA analysis results of HLBS II of the patients and its sub- intervention group Xintervention: 25.24; Xcontrol: 20.49). Also, the crite­
dimensions are presented in Table 3. ANCOVA analysis results, _

completed after the necessary hypothesis was achieved, are shown in rion of study η2 (eta squared) was calculated as 0.32. When pretest
Table 4. scores were stabilized, 32 % of the variance in the posttest scores was
After the ANCOVA analysis, when the healthcare responsibility explained with the group variable. Basing on this finding, without the
effect of pretest, it can be said that the HLBPP based solely on the TTM

Table 2
Comparison of pre-test-post-test results regarding behavior change stages of individuals diagnosed with schizophrenia in the intervention and control group (n = 82).
Intervention (n = 41) Test value Control (n = 41) Test value

Pre-test Post-test Pre-test Post-test

n (%) n (%) χ2 n (%) n (%) χ2

Healthcare responsibility Contemplation 2 (4,9) 1 (2,4) 0,927 20 (48,8) 20 (48,8) 0,000
Preparation 7 (17,1) 10 (24,4) p > 0,05 9 (22) 9 (22) p > 0,05
Action 32 (78) 30 (73,2) 12 (29,3) 12 (29,3)
McNemar test p > 0,05 p > 0,05
Nutrition Contemplation 17 (41,5) 3 (7,3) 13,518 16 (39) 16 (39) 0,000
Preparation 18 (43,9) 25 (61) p < 0,001 15 (36,6) 15 (36,6) p > 0,05
Action 6 (14,6) 13 (31,7) 10 (24,4) 10 (24,4)
McNemar test p < 0,001 p > 0,05
Physical activity Contemplation 19 (46,3) 6 (14,6) 11,300 19 (46,3) 19 (46,3) 0,000
Preparation 10 (24,4) 22 (53,7) p < 0,001 15 (36,6) 15 (36,6) p > 0,05
Action 12 (29,3) 13 (31,7) 7 (17,1) 7 (17,1)
McNemar test p < 0,05 p > 0,05
Spiritual development Contemplation 12 (29,3) 2 (4,9) 9,529 16 (39) 16 (39) 0,000
Preparation 10 (24,4) 18 (43,9) p < 0,01 10 (24,4) 10 (24,4) p > 0,05
Action 19 (46,3) 21 (51,2) 15 (36,6) 15 (36,6)
McNemar test p < 0,05 p > 0,05
Interpersonal relationships Contemplation 8 (19,5) 4 (9,8) 1,578 12 (29,3) 12 (29,3) 0,000
Preparation 21 (51,2) 23 (56,1) p > 0,05 15 (36,6) 15 (36,6) p > 0,05
Action 12 (29,3) 14 (34,1) 14 (34,1) 14 (34,1)
McNemar test p > 0,05 p > 0,05
Stress management Contemplation 12 (29,3) 4 (9,8) 5,320 17 (41,5) 17 (41,5) 0,000
Preparation 23 (56,1) 27 (65,9) p > 0,05 23 (56,1) 23 (56,1) p > 0,05
Action 6 (14,6) 10 (24,4) 1 (2,4) 1 (2,4)
McNemar test p < 0,01 p > 0,05

χ2 = Chi-Square Test.
Note: The test statistics shown in bold in the table show that the applied test gives meaningful results.

56
S. Mansuroğlu and F.Y. Kutlu Archives of Psychiatric Nursing 41 (2022) 51–61

Table 4
ANCOVA results of the adjusted post-test scores of HLBS II and sub-dimensions of individuals diagnosed with schizophrenia in the intervention and control group (n =
82).
Resources Sum of squares Df Average of squares F p η2
Responsibility of health Pre-test 1479,601 1 1479,601 589,739 0,000 0,88
Group 96,991 1 96,991 38,658 0,000* 0,32
Error 198,204 79 2,509
Total 45,015 82
Physical activity Pre-test 1931,997 1 1931,997 575,471 0,000 0,88
Group 17,451 1 17,451 5,198 0,025*** 0,06
Error 265,222 79 3,357
Total 23,003 82
Nutrition Pre-test 1012,712 1 1012,712 280,481 0,000 0,78
Group 72,068 1 72,068 19,960 0,000* 0,20
Error 285,24 79 3,611
Total 40,921 82
Spiritual development Pre-test 1857,578 1 1857,578 1353,489 0,000 0,95
Group 13,948 1 13,948 10,163 0,002** 0,11
Error 108,422 79 1,372
Total 46,926 82
Interpersonal relationships Pre-test 2062,826 1 2062,826 1337,329 0,000 0,94
Group 8,332 1 8,332 5,402 0,023*** 0,06
Error 121,857 79 1,542
Total 42,901 82
Stress management Pre-test 958,988 1 958,988 373,09 0,000 0,83
Group 57,597 1 57,597 22,408 0,000* 0,22
Error 203,061 79 2,57
Total 34,790 82
HLBS II total Pre-test 37981,965 1 37981,965 898,406 0,000 0,92
Regular physician check-up 0,275 1 0,275 0,007 0,936 0,00
Adherence to treatment 2,460 1 2,460 0,058 0,810 0,00
Frequency of alcohol use 165,881 1 165,881 3,926 0,051 0,05
Frequency of exercise 5,043 1 5,043 0,119 0,731 0,00
Nutritional status 3,197 1 3,197 0,076 0,784 0,00
Weight (kg) 57,337 1 57,337 1,357 0,248 0,02
Waist circumference (cm) 42,546 1 42,546 1,007 0,319 0,01
Group 587,997 1 587,997 13,917 0,000* 0,16
Error 3042,058 72 42,251
Total 1,360,094 82

Df: Degrees of Freedom, η2: Eta-square (effect size).

Note: the test statistics shown in bold in the table show that the applied test gives meaningful results.
*
p < 0,001.
**
p < 0,01.
***
p < 0,05.

significantly improved the healthcare responsibility sub-dimension, one
of the healthy lifestyle behaviours of individuals with schizophrenia,
and it has 32 % (great) influence on the healthcare responsibility levels
(Table 4).
When the physical exercises pretest score was statistically stabilized,
a significant difference between the physical exercises posttest average
score of the patients in the intervention group and the patients in the
control group was detected according to the covariance analysis results
(F(1,79): 5.198; p < 0.05). This difference is in favour of the patients in
(
the intervention group Xintervention: 18.02; Xcontrol: 13.51). Also, the
_ _
criterion of study η2 (eta squared) was calculated as 0.06 and 6 % of the
variance in the posttest scores were explained by the group variable.
Basing on this finding, without the effect of pretest, it can be said that the
HLBPP based solely on the TTM significantly improved the physical
exercise sub-dimension, one of the healthy lifestyle behaviours of in­
dividuals with schizophrenia, and it has 6 % (medium) influence on the
physical exercises levels (Table 4).
When the nutrition pretest score was statistically stabilized, a sig­
nificant difference between the physical exercises posttest average score
of the patients in the intervention group and the patients in the control
group was detected according to the covariance analysis results (F(1,79):
19.960, p < 0.001). This difference is in favour of the patients in the
(
intervention group Xtest: 23.63; Xcontrol: 20.20). Also, the criterion of
_ _
study η2 (eta squared) was calculated as 0.20 and 20 % of the variance in
the posttest scores were explained by the group variable. Basing on this
finding, without the effect of pretest, it can be said that the HLBPP based
solely on the TTM significantly improved the nutrition sub-dimension,
one of the healthy lifestyle behaviours of individuals with schizo­
phrenia, and it has 20 % (great) influence on the nutrition levels
(Table 4).
When the spiritual development pretest score was statistically sta­
bilized, a significant difference between the physical exercises posttest
average score of the patients in the intervention group and the patients
in the control group was detected according to the covariance analysis
results (F(1,79): 10.163; p < 0.01). This difference is in favour of the
(
patients in the intervention group Xintervention: 26.24; Xcontrol: 20.20).
_ _
Also, the criterion of study η2 (eta squared) was calculated as 0.11 and
11 % of the variance in the posttest scores were explained by the group
variable. Basing on this finding, without the effect of pretest, it can be
said that the HLBPP based solely on the TTM significantly improved the
spiritual development sub-dimension, one of the healthy lifestyle be­
haviours of individuals with schizophrenia, and it has 11 % (medium)
influence on the spiritual development levels (Table 4).
When the interpersonal relationships pretest score was statistically
stabilized, a significant difference between the physical exercises post­
test average score of the patients in the intervention group and the pa­
tients in the control group was detected according to the covariance
analysis results (F(1,79):5.402; p < 0.05). This difference is in favour of
(
the patients in the intervention group Xintervention: 24.51; Xcontrol:
_ _
19,80). Also, the criterion of study η2 (eta squared) was calculated as

57
S. Mansuroğlu and F.Y. Kutlu
0.06 and 6 % of the variance in the posttest scores were explained by the
group variable. Basing on this finding, without the effect of pretest, it
can be said that the HLBPP based solely on the TTM significantly
improved the physical exercise sub-dimension, one of the healthy life­
style behaviours of individuals with schizophrenia, and it has 6 %
(medium) influence on the interpersonal relationships levels (Table 4).
When the stress management pretest score was statistically stabi­
lized, a significant difference between the physical exercises posttest
average score of the patients in the intervention group and the patients
in the control group was detected according to the covariance analysis
results (F(1,79):22.408; p < 0.001). This difference is in favour of the
(
patients in the intervention group Xintervention: 22.90; Xcontrol: 17.20).
_ _
Also, the criterion of study η2 (eta squared) was calculated as 0.22 and
22 % of the variance in the posttest scores were explained by the group
variable. Basing on this finding, without the effect of pretest, it can be
said that the HLBPP based solely on the TTM significantly improved the
physical exercise sub-dimension, one of the healthy lifestyle behaviours
of individuals with schizophrenia, and it has 22 % (great) influence on
the stress management levels (Table 4).
When the healthy lifestyle behaviours pretest score, along with
regular doctor check, adherence to treatment, alcohol consumption
frequency, exercise frequency, the way of nutrition, weight (kg), waist
measurement (cm) variables were statistically stabilized, a significant
difference between the healthy lifestyle behaviours posttest average
score of the patients in the intervention group and the patients in the
control group was detected according to the covariance analysis results
(F(1,79):13.917; p < 0.001). This difference is in favour of the patients in
(
the intervention group Xintervention: 140.56; Xcontrol: 111.39). Also, the
_ _
criterion of study η2 (eta squared) was calculated as 0.16 and 16 % of the
variance in the posttest scores were explained by the group variable.
Basing on this finding, without the effect of pretest along with the other
variables, it can be said that the HLBPP based solely on the TTM
significantly improved the healthy lifestyle behaviours of individuals
with schizophrenia, and it has 16 % (great) influence on the healthy
lifestyle behaviours levels (Table 4).
Discussion
This study is a clinical psychoeducational study based on the
Transtheoretical Model, and it was observed that it had a positive effect
on healthy lifestyle behaviours in individuals with schizophrenia and
that the participants in the experimental group made positive progress
in the stages of behavior change. The results of the study support these
two hypotheses: H1: “Individuals with schizophrenia who receive psy­
choeducation based on the Transtheoretical Model will progress ac­
cording to the behavior change stage identification form when
compared to those who do not receive this psychoeducation.” and “H2:
Psychoeducation based on the Transtheoretical Model is effective on the
healthy lifestyle behaviours of individuals with schizophrenia.”
When the demographic, personal and disease-related characteristics
of individuals diagnosed with schizophrenia were examined, it was seen
that the findings obtained in the study were similar to those of previous
studies in the literature with the same sample group (Gandhi et al.,
2019; Meepring et al., 2018; Costa et al., 2018; Vancampfort et al., 2017;
Vancampfort et al., 2016).
When the pretest and posttest results of the intervention and control
groups in the TTM change stages are evaluated, it was observed that the
intervention group made progress in the stages of nutrition, physical
exercise, spiritual development and stress management, but they could
not progress in the stages of health responsibility and interpersonal re­
lations. It may be speculated that longer-term interventions or follow-up
are needed to observe an average to minimize the change in individuals
in terms of health responsibility and interpersonal relations. In a study
examining the effect of the interview based on the TTM on smoking
58
Archives of Psychiatric Nursing 41 (2022) 51–61
behavior in the psychiatric patient group, it was reported that positive
progress was detected in the change stages of the individuals partici­
pating in the study (Gümüş Ersoy, 2019). Gong et al. (2015), it was seen
that the training given for TTM-based physical exercise is effective in
protecting health and reducing risk factors. Increases were observed in
the transitions between healthy behavior change stages of TTM-based
motivational interviewing conducted by Selçuk-Tosun and Zincir
(2019). It was observed that the use of the TTM-based interventions in
different chronic diseases and sample groups was also effective in
making progress in the stages of change (Çavuşoğlu, 2018; Erkal Aksoy
& Özentürk, 2021; Li et al., 2020; Tanyeri, 2019; Yalçınöz Baysal, 2013).
TTM-based interventions deal dynamically with behavioural changes in
the change processes of goals and approaches determined during the
behavior change stages of individuals (Chen et al., 2012). These results
show that TTM-based interventions show positive developments in
behavior change in individuals, just like in this study. Considering the
effectiveness of TTM in chronic diseases, it may be recommended to
increase the level of evidence by using TTM in intervention studies for
individuals with severe mental illness.
Compared to the control group, greater progress was made in the
intervention group in the stages of change, and it is thought that the
HLBPP grounded on the TTM was effective in these posttest average
scores of the intervention and control group patients are corrected by the
ANCOVA analysis of the HLBS II and its sub-dimensions. When they are
compared, the sub-dimensions of healthy lifestyle behaviours and the
total posttest average scores showed a significant difference in favour of
the intervention group. When the effect of covariates is removed, HLBPP
based on the TTM shows moderate effect in the sub-dimensions of
physical exercise, spiritual development and interpersonal relations in
individuals with a diagnosis of schizophrenia in the psychoeducation
programme, and health responsibility, nutrition, stress management
sub-dimensions and the total of HLBS II can be said to have had a great
influence.
When the national and international literature is analyzed, the
findings have been discussed under limitations since it has been detected
that HLBS II and an intervention programme based on the TTM are
limited. Lifestyle interventions appear to have positive outcomes in
patients with mental illness in the general population (Daumit et al.,
2013). Most previous studies have looked at the general population with
chronic disease and have applied similar strategies, focusing mostly on
physical activity and nutrition only (Stubbs et al., 2016). The results of
this study were not only limited to the dimensions of nutrition and
physical exercise, but also other healthy lifestyle behaviours (health
responsibility, spiritual development, interpersonal relations and stress
management) of the participants were also evaluated. It can be said that
this situation increases the importance of the study. It has been sug­
gested that the proof level should be increased with the studies that
could deal with this subject. As the result of the previous studies, it was
emphasized that lifestyle change of individuals with chronic mental
disorders must be performed with the aim of minimizing the risk of
cardiovascular diseases and mortality (De Hert, Cohen, Bobes,
Cetkovich-Bakmas, Leucht, Ndetei, et al., 2011; De Hert, Correll, Bobes,
Cetkovich-Bakmas, Cohen, Asai, et al., 2011b; De Hert, Correll, Bobes,
Cetkovich-Bakmas, Cohen, Asai, Leucht, and Leucht, 2011c; Ratliff
et al., 2012; Dipasquale et al., 2013; Erginer & Günüşen, 2018; Jakobsen
et al., 2018; Çelik İnce & Partlak Günüşen, 2021).
According to the results of the protecting and improving physical
health programme applied with individuals with chronic mental disor­
ders (Çelik İnce & Partlak Günüşen, 2021), it was detected that, − in a
way that is similar to the results of the health responsibility sub-
dimension of the study-, there is a statistically significant increase in
the healthcare responsibility, physical activity and nutrition sub-
dimensions score but there is no significant difference on the other
sub-dimensions. In the same study mentioned, for the control group, on
the other hand, a significant increase was reported only in the spiritual
development sub-dimension.
S. Mansuroğlu and F.Y. Kutlu
It was stated that physical exercise intervention programmes,
managed by professionals, practised with individuals with chronic
mental disorders help individuals to lose weight and decreases the body
mass index (Dodd et al., 2011). In these activity programmes, in­
dividuals were observed to feel mentally better, become easygoing and
feel closer to the therapeutic interventions, and have positive outcomes
such as strengthening their sense of physical self, increasing social
functionality, decreasing anxiety, having more quality sleeps (Silva
et al., 2015; Loh et al., 2015). The intervention programmes applied to
increase the physical activity and healthy nutrition levels of individuals
with chronic mental disorders also have positive outcomes (Van Citters
et al., 2010; Malchow et al., 2013; Gomes et al., 2014; Masa-Font et al.,
2015; Göhner et al., 2015; Vancampfort et al., 2017; Petzold et al.,
2018). These data support the findings of this study. When the literature
is examined, individuals with schizophrenia generally healthy lifestyle
behaviours, and in particular, health responsibility, interpersonal re­
lations, spiritual development and stress management intervention
studies that examine the levels of limited, due to the planned activities
related to the aforementioned areas it is thought that the level of proof
should be increased.
Importance of the study
Promoting healthy lifestyle behavior choices and early interventions
are key to ensuring equal access to health care, as well as improving or
improving physical health conditions (National Mental Health Com­
mission, 2016). With the results of this study, it is thought that it will
make a great contribution to recommend the use of a proven model in
nursing initiatives that will be planned for individuals diagnosed with
schizophrenia. By using this model, psychiatric nurses will be able to
make a more systematic and holistic approach to individuals diagnosed
with schizophrenia. In addition, the results of the research will
contribute to better planning of nursing initiatives in the field of mental
health, organizing corporate policies to protect and improve mental
health, and helping people with psychiatric diagnoses to live a better
quality life in society by acquiring healthy lifestyle behaviours.
Limitations of the study
Lack of observation and the application of posttest to the participants
by the researcher and the lack of pre-application of the study are among
the limitations. Also, these findings are limited to this sample group, it
cannot be generalized.
Conclusion
Psychoeducation based on the Transtheoretical Model is determined
to be effective on the healthy lifestyle behaviours of individuals with
schizophrenia and to be helpful to improve a healthy lifestyle. Different
models are used for individuals with mental disorders to create a
behavioural change. Transtheoretical Model is a model that directs the
individual to the stage of change, that they are in, to prompt behavioural
change. This study contributed to the literature by presenting the
effectiveness of the model on individuals with schizophrenia. Also, the
results obtained in the study and the psychoeducation based on the
Transtheoretical Model will enable mental health and psychiatry nurses
to use their independent roles and to take part in practices as group
leaders. Studies similar to this one and psychotherapeutic practices with
the leadership of mental health and psychiatry nurses will help them to
show their competencies.
Funding statement
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
59
Archives of Psychiatric Nursing 41 (2022) 51–61
Declaration of competing interest
The authors declare that they have no conflict of interest.
Acknowledgement
We thank the individuals with schizophrenia who have taken part in
the study. We would also like to state that all of the data in this study
were based on a doctoral thesis prepared by Sercan Mansuroglu under
the supervision of Prof. Dr. F. Yasemin Kutlu, Institute of Graduate
Studies, Istanbul University-Cerrahpaşa, Istanbul, TÜRKİYE.
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