Exploring Factors Contributing to Treatment Relapse Among Schizophrenia Clients at Zomba Mental Hospital, Malawi: A Phenomenological Study Guided by Andersen's Behavioural Model of Health Services Use

Schizophrenia is a long-term condition that affects how a person thinks, feels, and behaves. While modern medicine offers treatments that help many people manage their symptoms, the illness often returns. This return, known as relapse, forces patients back into hospitals and disrupts their lives. In many parts of the world, doctors have long assumed that relapse happens simply because patients forget to take their pills or stop taking them on their own. However, in places where resources are scarce and cultural beliefs differ from Western medicine, the story is often more complicated. To understand why people stop getting better, researchers look at three broad categories of influence: what a person believes before they get sick, the practical tools and money they have to get help, and how they feel about their own need for treatment at any given moment.

At Zomba Mental Hospital in Malawi, a team of researchers set out to understand why clients with schizophrenia were returning to the hospital after being discharged. They did not just ask patients if they took their medicine; they sat down with ten people who had experienced a return of their illness to hear the full story of their lives. The researchers listened to how these individuals described their journey, from their first diagnosis to their most recent hospitalization. They found that relapse was not caused by a single mistake or a single barrier. Instead, it was the result of a chain reaction where personal beliefs, difficult living conditions, and feelings of wellness or distress all pushed and pulled against each other until treatment was abandoned.

The study began by talking to ten patients, five men and five women, who were recovering in the hospital's rehabilitation wards. All of them had been diagnosed with schizophrenia and had experienced at least one return of their symptoms. Some had relapsed once, while others had been readmitted three or four times. The researchers used a method called phenomenology, which focuses on understanding the deep, personal experience of the people involved. They conducted long, face-to-face interviews, asking open questions about what happened leading up to their return to the hospital. They recorded these conversations, wrote them down word for word, and then looked for patterns in what the patients said. To ensure their findings were trustworthy, they checked their interpretations with the patients and kept a clear record of how they reached their conclusions.

The patients' stories revealed that their decision to stop treatment often started with what they believed about the illness itself. Many did not see schizophrenia as a lifelong condition that required constant care. Instead, they viewed the medication as something to take only when they felt acute symptoms, like a fever. Once the fever broke, they felt the medicine was no longer needed. For some, cultural and spiritual beliefs played a larger role. Several patients described their symptoms as being caused by witchcraft or spiritual possession. They believed that prayer or traditional rituals could heal them completely, making medical tablets unnecessary. One patient explained that they stopped taking their drugs because they felt God had healed them, while another noted that their family believed they were bewitched and offered no support. These deep-seated beliefs meant that even when patients were physically stable, they did not feel a need to continue their treatment.

Even when a patient wanted to stay on their medication, the world around them often made it impossible. The researchers heard repeatedly about the sheer difficulty of getting to the hospital. Zomba Mental Hospital is the main referral center for the country, meaning many patients live far away. One participant described walking for three hours just to reach the facility. The cost of transport was a heavy burden, and for those who were unemployed, it was often insurmountable. Once they arrived, they faced another hurdle: the hospital sometimes ran out of the very drugs they needed. Patients spoke of waiting for long periods only to be told that essential medicines were not in stock. This lack of availability forced them to go without treatment. Furthermore, once they were discharged, the support system often vanished. Patients reported that no one visited them at home to check on their progress, and the stigma in their communities made it hard to ask for help. Without a steady supply of medicine or a supportive network, staying on track became nearly impossible.

The final piece of the puzzle was how patients judged their own recovery. A common theme was the feeling of being cured. When symptoms faded, patients often felt a sense of relief and believed they were fully well. This feeling of wellness, combined with the side effects of the medication which some found intolerable, led them to stop taking their drugs on their own. One patient recounted stopping after a period of deep sadness following the death of a husband, feeling that the grief was too heavy to manage with pills. These personal assessments of need often clashed with the medical reality that the illness required maintenance treatment even when symptoms were quiet. When these internal feelings of being "cured" met the external reality of no money for transport or no medicine on the shelf, the result was predictable. Patients stopped taking their medication, sometimes turned to alcohol or cannabis to cope with their distress, and eventually relapsed.

The researchers concluded that treating relapse requires looking at the whole picture rather than blaming the patient. It is not enough to simply tell someone to take their pills. The solution must address the beliefs that make them doubt the need for medicine, the practical barriers that stop them from getting it, and the emotional triggers that make them feel they no longer need it. The study suggests that nurses and health workers need to provide education that respects cultural beliefs while explaining the chronic nature of the illness. They also need to work with the health system to ensure medicines are always available and to create follow-up programs that reach patients in their homes. By tackling these three areas together, the cycle of repeated hospitalization might finally be broken. The findings offer a clear path forward, showing that in Malawi, as in many places, healing requires more than just a prescription; it requires a system that understands the human experience behind the illness.