Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13000 Exploring outside-in empowerment approach to improve the family's ability to manage schizophrenia disorder Wahyu Endang Setyowati,1,2 Nursalam,3 Hanik Endang Nihayati,3 Dwi Indah Iswanti,4 Nia Agustiningsih,5 Intan Rismatul Azizah2,6 1Doctoral Program in Nursing, Universitas Airlangga, Surabaya; 2Faculty of Nursing, Universitas Islam Sultan Agung, Semarang; 3Department of Nursing, Faculty of Nursing, Universitas Airlangga, Surabaya; 4Department of Nursing, Faculty of Nursing and Health Science, Universitas Karya Husada Semarang, Semarang; 5Nursing Department, Sekolah Tinggi Ilmu Kesehatan Kepanjen, Malang; 6Master of Nursing Program, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Abstract Families often encounter a sense of despair and exhibit dimi- nished capability when providing care for schizophrenia patients, predominantly due to restricted knowledge and lack of formal trai- ning and support. Existing strategies to empower families have been insufficient in effectively dealing with schizophrenia care. This study objective was to explore the relationship between fam- ily knowledge, coping skills, and interaction within the framework of outside-in empowerment and their ability to care for individuals with schizophrenia. This explanatory research utilizes a cross-sec- tional design and involves a sample of 135 families, acting as caregivers for schizophrenia patients, selected through purposive sampling based on inclusion criteria. Regarding outside-in empo- werment, knowledge is evaluated using a questionnaire developed from the concept of schizophrenia care, coping skills are measured using the Family Coping Questionnaire (FCQ), and family inte- raction is assessed through the Brief Family Relationship Scale (BFRS). The family’s ability to manage schizophrenia is gauged using the Barthel Index and the Caregiving Tasks in Caring for an Adult with Mental Illness Scale (CTiCAMIS). All of the question- naire has been tested for validity and reliability.The data analysis involves multiple linear regression at a 95% significance level. The study reveals that knowledge (p=0.018 <0.005), coping skills (p=0.004 <0.005), and family interaction as part of outside- in empowerment significantly correlate with the family’s ability to manage schizophrenia (p=0.001 <0.005). Notably, the ability for family interaction (ß=0.392) is a predictor of the family’s capabi- lity to care for schizophrenia patients (p=0.042 <0.05). Enhancing family interactions is crucial to empower families in managing schizophrenia patients. This enhancement can be facilitated by fostering cohesion, minimizing conflicts, and effectively mana- ging the caregiving burden associated with schizophrenia. Introduction Families frequently experience feelings of inadequacy, failure, helplessness, fatigue, and uncertainty when caring for individuals diagnosed with schizophrenia.1 This often results in a challenging home environment, limiting the quality of care patients receive.2 Numerous studies report a generally low capacity among families to provide adequate schizophrenia care, compounded by a lack of accessible information and support specifically designed for fami- lies.3,4 Schizophrenia remains a global health concern with 21 mil- lion reported cases, equating to 0.24 cases per 1000 population.5 In Indonesia, the prevalence of schizophrenia escalated from 1.3 to 7 cases per 1000 population in 2018.6 In Central Java, the pre- valence rose from 2.3% (2013) to 9% (2018)7 with Semarang City Correspondence: Wahyu Endang Setyowati, Doctoral Program, Faculty of Nursing, Universitas Airlangga, Surabaya, 60115, Indonesia. E-mail: wahyu.endang@unissula.ac.id Key words: caregiving; family’s capability; outside-in empowerment; schiz- ophrenia. Ethics approval and consent to participate: this study received ethical clearance from the Health Research Ethics Committee of the Faculty of Nursing, Universitas Airlangga (Number 2637-KEPK), and from the Ethics Committee of Dr. Amino Gondohutomo Psychiatric Hospital, Central Java Province (Number 420/12375), and has obtained the respon- dents’ consent through informed consent, anonymity, confidentiality, fidelity, and autonomy. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published. Conflict of interest: the authors declare no conflict of interest. Funding: this research did not receive external funding. Contributions: WES, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; N, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; HEN, conceptualization, method- ology, formal analysis, validation, and writing – original draft, review & edit- ing. DII, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. NA, conceptualization, methodol- ogy, formal analysis, validation, and writing – original draft, review & edit- ing. IRA, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. Acknowledgement: the authors would like to express their gratitude to the families who participated as respondents and the nurses at the Outpatient Clinic of Dr. Amino Gondohutomo Psychiatric Hospital, Central Java Province. This research is part of a doctoral dissertation, and the insights gained have significantly contributed to the completion of this academic work. Received: 2 September 2024. Accepted: 24 October 2024. Early view: 6 December 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13000 doi:10.4081/hls.2024.13000 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13000] [page 1] witnessing the highest incidence rate among other cities, at 0.79 per 1000 population in 2018.8 This surge in schizophrenia cases is attributable to various factors, including the family’s inability to provide care for schizophrenia patients during relapse symptoms and their lack of active involvement in home care.9 A primary issue contributing to this gap is families’ sense of helplessness and limited empowerment regarding their roles in schizophrenia management. Key barriers include inadequate fami- ly-centered empowerment initiatives, insufficient education on preventive strategies,3,4 weak family function enhancement pro- grams, and lack of ongoing family support systems, Moreover, families often face difficulties in recognizing early disease sym- ptoms, lack collaboration with service providers,3,4 and there is a paucity of interventions focusing on caregiver or family welfare.10 Although psychiatric nurses in hospitals and community health centers have initiated mental health promotion, these efforts often fall short due to insufficient family involvement and empower- ment. Current practices focus more on responding to individual cases than on enabling families to maintain long-term, effective management strategies.11 Therefore, this study objective was to examine the relationship between family empowerment—specifi- cally knowledge, coping skills, and family interactions—and fami- lies’ abilities to manage schizophrenia, offering insights into how outside-in empowerment could improve family-centered care and long-term patient outcomes. Materials and Methods Study design This study utilizes an explanatory design with a cross-sectional approach. It investigates the relationship between the outside-in empowerment (which includes knowledge, coping skills, and family interaction) , and family interaction and the family’s ability to care for schizophrenia patients at a single point in time. This care includes fulfilling Activities of Daily Living (ADL), facilita- ting social interaction, and fostering productive skills. Participants The study focuses on the entire population of families with schizophrenia patients who have received treatment and are cur- rently under outpatient monitoring at Dr. Amino Gondohutomo Psychiatric Hospital in Central Java Province, specifically those residing in Semarang City. The population size in 2022 is approxi- mately 1,911. Following the rule of thumb, the sample size was determined to be 135 families. These samples were chosen using purposive sampling based on several inclusion criteria: core family members cohabitating with the patient, providing daily home care for schizophrenia patients, possessing at least 1 year of experience in caring for schizophrenia patients, being aged between 20-60 years, and having a family member with schizophrenia who has received treatment more than three times and is under monitoring at Dr. Amino Gondohutomo Psychiatric Hospital in Central Java Province. Data collections Data collection took place at Dr. Amino Gondohutomo Psychiatric Hospital’s Psychogeriatric and Adult Polyclinic in Central Java Province, from September 20th to October 3rd, 2022. A checklist was used to gather respondent demographic characteri- stics. The research variables of Outside-in empowerment, which include knowledge, coping skills, and family interaction, as well as the family’s ability to care for schizophrenia, were evaluated using questionnaires. The knowledge questionnaire, derived from the concept of schizophrenia care,12,13 encompasses: disease process, signs and symptoms, triggering and supporting factors, care methods, and relapse prevention, with a total of 7 questions. Scores were assi- gned based on the number of marked answers, with each mark sco- ring 1, and so forth, resulting in a total score range of 7-28. The Coping Skills questionnaire employed the Family Coping Questionnaire (FCQ) by (14). The FCQ is a 9-statement scale sco- red from 1 (never) to 4 (always), with a score range of 9-36. It con- sists of seven subscales: information, positive communication, social interest, coercion, avoidance, resignation, and patient’s social involvement. The Brief Family Relationship Scale (BFRS), adopted from,15 was used for the family interaction questionnaire. This scale measures the relationship between caregivers and fami- ly members with schizophrenia. The BFRS consists of three sub- scales: cohesion, expressiveness, and conflict. It includes 10 state- ments measured with a 4-point Likert scale (1=never to 4=always) and a score range of 10-40. Social interaction support was measured using 5 items adapted from the Caregiving Tasks in Caring for an Adult with Mental Illness Scale (CTiCAMIS), with scores ranging from 5 to 20. Finally, a questionnaire on supporting productive skills, developed by the researcher based on theoretical concepts,16 included 3 items, with scores ranging from 3 to 12. All instruments were validated and tested for reliability with a sample of 30 respondents. The description of outside-in empower- ment and family interaction questionnaire presented in Table 1. The knowledge component included aspects such as disease pro- cess, symptoms, triggers/supports, care methods, and relapse pre- vention, with a validity range of 0.503–0.934 and a Cronbach’s alpha of 0.882. Coping skills were measured across various domains (information, positive communication, social interest, coercion, avoidance, resignation, and patient social involvement) with validity scores of 0.419–0.895 and reliability at 0.929. Family interaction, covering cohesion, expressiveness, and conflict, sho- wed validity scores from 0.429 to 0.915 and reliability of 0.929. The family’s caregiving ability was evaluated through fulfilling ADL needs (validity 0.472–0.824; reliability 0.912), assisting with social interaction (validity 0.448–0.648; reliability 0.777), and aiding in productive skills (validity 0.618–0.771; reliability 0.861). All variables exceeded the r-table threshold of 0.361, indicating robust instrument construction. Data analysis A descriptive analysis was performed on the demographic cha- racteristics of respondents, sub-variables of outside-in empower- ment, such as knowledge, coping skills, and family interaction, and the variable of the family’s ability to manage schizophrenia patients. These are represented as percentages based on the fin- dings from each research variable. An inferential analysis in the form of a Pearson correlation with a 95% significance level was applied to analyze the relationship between knowledge, coping skills, and family interaction variables with the family’s ability to manage schizophrenia patients. The outcomes of this bivariate relationship analysis were used as a basis for testing the four varia- bles multivariately using multiple regression with an alpha level of 5% (0.05). Ethical consideration This study received ethical clearance from the Health Research Ethics Committee of the Faculty of Nursing, Universitas Airlangga Special issue Pathways of Change [page 2] [Healthcare in Low-resource Settings 2025;13(s1):13000] (Number 2637-KEPK), and from the Ethics Committee of Dr. Amino Gondohutomo Psychiatric Hospital, Central Java Province (Number 420/12375). Results Based on Table 2, the demographic characteristics of families caring for schizophrenia patients are predominantly male (50.4%), middle-aged (51.1%), with high school/vocational school educa- tion (38.5%), working as private employees (37.8%), and earning less than the Semarang City Minimum Wage (65.9%). Siblings constitute the most common caregiver relationship (39.3%). Occupation and income are the characteristics most closely related to the family’s ability to care for schizophrenia (p=0.002 <0.005). Table 3 demonstrates that the majority of families are modera- tely able to meet the ADL needs (37.0%) of schizophrenia patients but still struggle in assisting with social interaction (53.3%) and productive skills (48.9%). Table 4 illustrates that a significant number of families still lack knowledge about caring for schizophrenia patients, with defi- Special issue Pathways of Change Table 1. Questionnaire research variables. Variable Indicator Favorable Unfavorable Validity Reliability (r-table =0.361) (Cronbach alpha) Outside-in empowerment Knowledge Disease process 1 0.503-0.934 0.882 Signs and symptoms 2 Triggers and supports 3 Care methods 4-6 Preventing relapse 7 Coping skills Information 8 0.419-0.895 0.929 Positive communication 9 Social interest 10 Coercion 11-12 Avoidance 13-14 Resignation 15 Patient's social involvement 17 Family interaction Cohesion 18-21 0.429-0.915 0.929 Expressive 22,23 Conflict 24-27 Family's ability to care for schizophrenia Fulfilling ADL needs 1-10 0.472-0.824 0.912 Assisting with social interaction 11-15 0.448-0.648 0.777 Aiding in productive skills 16-18 0.618-0.771 0.861 Table 2. Description of the demographic characteristics of families caring for schizophrenia patients (n=135). Family characteristics Indicator f % p Gender Man 68 50.4 0.507 Woman 67 49.6 Age Early Adulthood (20-30 years) 20 14.8 0.022 Middle Adult (31-55 years) 69 51.1 Pre-Elderly (55-60 years) 46 34.1 Education Not completed in primary school 1 7.7 0.913 Elementary school 28 20.7 Junior high school 29 21.5 Senior High School 52 38.5 College 25 18.5 Employment Government employees 6 4.4 0.002 Pension 9 6.7 Self-employed 24 17.8 Private sector employee 51 37.8 Housewife 31 23.0 laborer 9 6.7 Unemployed 5 3.7 Family outcome < Regional minimum wage 89 65.9 0.002 = Regional minimum wage 14 10.4 > Regional minimum wage 32 23.7 [Healthcare in Low-resource Settings 2025;13(s1):13000] [page 3] ciencies in understanding the disease process (34.8%), recognizing signs and symptoms of the disease (53.3%), identifying trigge- ring/supporting factors (57.0%), and implementing patient care methods (52.6%). The coping skills of families caring for schizo- phrenia patients are partially maladaptive, with 34.8% demonstra- ting low social involvement. On the other hand, family interaction in caring for schizophrenia patients is generally adequate in esta- blishing cohesion (69.6%), expressing skills (54.8%), and resol- Special issue Pathways of Change [page 4] [Healthcare in Low-resource Settings 2025;13(s1):13000] Table 3. Description of family's ability to care for schizophrenia patients (n=135). Indicator Category scale f (%) Fulfilling ADL needs Less 48 35.6 Enough 50 37.0 Good 37 27.4 Assisting with social interaction Less 72 53.3 Enough 47 34.8 Good 16 11.9 Aiding in productive skills Less 66 48.9 Enough 38 28.1 Good 31 23.0 Mean SD 91.78 26.064 Table 4. Relationship between Knowledge, Coping Skills, and Family Interaction in Outside-in Empowerment with the Family's Ability to Care for Schizophrenia (n=135). Variable Indicator Category scale f % Mean (Standard Deviation) p Knowledge Disease process Less 47 34.8 28.41 (12.802) 0.018 Enough 45 33.3 Good 43 31.9 Signs and symptoms Less 72 53.3 Enough 46 34.1 Good 17 12.6 Triggers and supports Less 77 57.0 Enough 40 29.0 Good 18 13.3 Care methods Less 71 52.6 Enough 28 20.7 Good 36 26.7 Preventing relapse Less 42 3.1 Enough 47 34.8 Good 46 34.1 Coping skills Information Maladaptive 58 43.0 46.59 (7.576) 0.004 Adaptive 77 57.0 Positive communication Maladaptive 57 42.2 Adaptive 78 57.8 Social interest Maladaptive 22 16.3 Adaptive 113 83.7 Coercion Maladaptive 34 25.2 Adaptive 101 74.8 Avoidance Maladaptive 21 15.6 Adaptive 114 84.4 Resignation Maladaptive 25 18.5 Adaptive 110 81.5 Patient's social involvement Maladaptive 47 34.8 Adaptive 88 65.2 Family interaction Cohesion Less 7 5.2 59.67 (9.564) 0.001 Enough 94 69.6 Good 34 25.2 Expressive Less 13 9.6 Enough 74 54.8 Good 48 35.6 Conflict Less 14 10.4 Enough 89 65.9 Good 32 23.7 ving conflicts (65.9%). Pearson correlation test results indicate that knowledge (p=0.018 <0.005), coping skills (p=0.004 <0.005), and family interaction are significantly related to the family’s ability to care for schizophrenia (p=0.001 <0.005). The multiple regression test results in Table 5, based on the variables of knowledge, coping skills, and family interaction in Outside-in Empowerment with the Family’s Ability to Care for Schizophrenia, indicate that family interaction (ß=0.392) is a signi- ficant predictor of the family’s ability to care for schizophrenia patients (p=0.042 <0.05). Discussion Age, occupation, and income are demographic characteristics of the family that correlate with the family’s ability to care for schi- zophrenia patients. Middle-aged families are likely more capable of assimilating information and knowledge regarding patient care. Furthermore, these families are psychologically mature, enabling them to effectively utilize coping skills, and they possess the necessary energy to care for schizophrenia patients. This is corro- borated which shows that the age of the caregiver or family influences the burden of care and duration of care. Employment status also defines the socio-economic resources that a family has at its disposal for patient care. This is corroborated showed that work influences the burden on families in caring for schizophrenic patients.16 This is supported which shows that income is a predictor of care burden, the family’s income serves as a financial resource, underpinning the care and treatment needs of schizophrenia patients.17 The majority of families exhibit a lack of knowledge about caring for schizophrenia patients, particularly in understanding the disease process, recognizing signs and symptoms, identifying trig- gering/supporting factors, and implementing patient care methods. Several studies suggest that families perceive the information on caring for schizophrenia as inadequate,3,4 and they lack sufficient formal training or support in patient care.18 Families require ongoing mental health education from mental health personnel that can reach peripheral communities. This mental health education should target not only families but also the surrounding community that forms the family’s support system. Employing suitable methods, aligned with education and involving local community leaders, is believed to enhance the family’s knowledge to care for and prevent relapse in schizophrenia patients. Family coping skills related to caregiving issues are somewhat maladaptive, especially concerning social involvement. This is substantiated by a study19 indicating that families primarily caring for schizophrenia patients tend to adopt maladaptive coping strate- gies, including avoidance, coercion, and withdrawal. These mala- daptive coping skills might result from insufficient utilization of social support from the community, limitations within the family in accessing patient care information, challenges in communicating with schizophrenia patients, and a continued reliance on forceful or authoritarian decision-making in patient care. Enhancing family coping resources can serve as a guide in implementing a family- centered care program aimed at reducing the burden of caring for schizophrenia patients through efficient family support.20 Mental health professionals should consider the family’s needs and chal- lenges in caring for schizophrenia patients, planning supportive resources for both families and patients across clinical and com- munity settings. Families are encouraged to adopt constructive coping strategies when caring for schizophrenia patients. Research findings suggest that family interaction remains in the moderate category regarding expression ability, cohesion, and conflict resolution. This could be attributed to the family’s hesitan- ce to discuss their struggles in caring for schizophrenia patients with other family members. Moreover, time constraints due to busy work schedules of each family member could also play a role. Inappropriate family involvement can render recovery-oriented services ineffective in facilitating the recovery of schizophrenia patients.21 The strength of cohesion and relationships among fami- ly members is crucial for ensuring effective care for schizophrenia patients. Collective activities within the family can enable them to share caregiving responsibilities, seek solutions, and distribute caregiving tasks for schizophrenia patients. There exists a significant correlation between knowledge, coping skills, and family interaction in outside-in empowerment and the family’s ability to care for schizophrenia patients. This is substantiated by the fact that psychoeducation groups receiving outside-in empowerment exhibit a considerable enhancement in family relationships, caregiving burden, and coping skills.10 The result of outside-in empowerment is the amplification of caregi- ving knowledge, coping skills, and the bolstering of family interac- tion via psychoeducation. Families are trained on patient care, ran- ging from meeting Activities of Daily Living (ADL), aiding with social interaction, to building productive skills. Addressing the caregiving burden through adaptive coping mechanisms and enhancing family interaction, considered as a critical resource for caring for schizophrenia patients,22 can have a positive impact on the family’s ability to care for schizophrenia patients at home. Family interaction is the most influential factor affecting the family’s ability to care for schizophrenia. The strength of cohesion and interaction among family members is crucial in supporting the care for schizophrenia patients. Research findings23 indicate that strengthening family bonds, cultivating life insights, and promo- ting social mobility will positively influence the experience of caring for schizophrenia patients. The existence of shared activities within the family allows them to distribute the caregiving burden, seek solutions, and allocate caregiving tasks for schizophrenia patients. It can be concluded that the overall competence in outsi- de-in empowerment, particularly family interaction, can enhance the ability to care for schizophrenia patients. Special issue Pathways of Change Table 5. Factors influencing the family's ability to care for schizophrenia. Factor B Standard Error Beta t Sig. (Constant) 41.333 14.700 2.812 0.006 Knowledge 0.148 0.177 0.079 0.836 0.405 Coping skills 0.374 0.315 0.118 1.188 0.237 Family interaction 0.483 0.246 0.392 2.019 0.042 [Healthcare in Low-resource Settings 2025;13(s1):13000] [page 5] Implications This study highlights the critical role of outside-in empower- ment, specifically family knowledge, coping skills, and interaction in enhancing the caregiving capacity of families for individuals with schizophrenia. The findings underscore the need for struc- tured mental health education programs targeted at families, enabling them to acquire essential knowledge about schizophrenia care and adaptive coping strategies. Community-based mental health initiatives, led by trained mental health professionals, could play a significant role in disseminating relevant information and providing support. Additionally, interventions aimed at strengthen- ing family interactions, such as psychoeducation and family-cen- tered therapies, could foster a collaborative environment where caregiving responsibilities are more evenly distributed, reducing the burden on individual family members. These insights can inform policymakers and healthcare providers in designing holis- tic, family-centered mental health programs to improve long-term outcomes for schizophrenia patients. Limitations This study has several limitations. First, the cross-sectional design limits the ability to draw causal conclusions regarding the relationship between outside-in empowerment variables and care- giving capacity. Longitudinal studies would be beneficial to observe changes in family caregiving ability over time. Additionally, the study was conducted in a single public psychi- atric hospital in Central Java, which may limit the generalizability of the findings to other regions or settings. Finally, reliance on self- reported data could introduce response bias, as participants may have given socially desirable answers. Future studies should con- sider incorporating objective assessments and expanding the sam- ple to include multiple centers or community settings to enhance generalizability. Conclusions This study reveals that demographic factors, such as age, employment, and income, play a significant role in influencing a family’s ability to care for individuals with schizophrenia. Moreover, outside-in empowerment, encompassing knowledge, coping skills, and family interaction, is strongly associated with caregiving capacity. Among these factors, family interaction emer- ged as the most critical determinant, highlighting the importance of cohesive family relationships in effective schizophrenia care. These findings suggest that targeted interventions, such as psy- choeducation and family-centered support programs, can stren- gthen family resources and adaptive coping mechanisms, ultimate- ly enhancing the quality of care for schizophrenia patients. By addressing the caregiving burden through education, empower- ment, and community support, healthcare providers can facilitate more effective family-centered care, promoting improved outco- mes for both patients and their families. References 1. Suhardiningsih AVS, Sustrami D, Mundakir M. Parenting style, family support, and relapse among schizophrenia patients: a literature review. Healthc Low-Resource Settings 2024;12:11820. 2. Kusumawardani W, Yusuf A, Fitryasari R, et al. Family burden effect on the ability in taking care of schizophrenia patient. Indian J Public Heal Res Dev 2019;10:2654–9. 3. Mohr P, Galderisi S, Boyer P, et al. Value of schizophrenia treatment I: The patient journey. Eur Psychiatry 2018;53:107– 15. 4. 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