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Schizophrenia is a serious neurodevelopmental psychiatric disorder that places a considerable strain on the healthcare system on a national, regional, and global scale. This study's objective was to measure the level of self-care among individuals with schizophrenia. In addition, to develop, implement, and evaluate the impact of 3 month group therapy on self-care skills in this specific group of patients. The sample comprised 120 individuals diagnosed with schizophrenia, with 60 assigned to study group (receiving group therapy) and 60 to control group (without group therapy). The Positive and Negative Syndrome Scale (PANSS) and The Exercise of Self-Care Agency Scale (ESCAS) were administered to all subjects. The study group observed a substantial decrease in the mean score of positive symptoms, negative symptoms, and symptoms of general psychopathology from baseline assessment to follow-up assessment.
Results
During the follow-up assessment, the study group exhibited a reduction in the mean of PANNS subscales by more than half and increase more than double in total score of ESCAS compared to the baseline assessment. Consequently, only the study group achieved a 70% increase in self-care in follow-up assessment. Increased self-care was more likely in patients who participated in the program, as indicated by the regression model.
Conclusions
Individuals with schizophrenia who underwent group therapy exhibited a significant decrease in positive, negative symptoms, and symptoms of general psychopathology. In addition, the implementation of group therapy led to a noticeable improvement in self-care skills compared to those without group therapy.
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PANSS
The Positive and Negative Syndrome Scale
ESCAS
The Exercise of Self-Care Agency Scale
ADL
Activities of daily living
IADL
Instrumental activities of daily life
Background
Schizophrenia is a serious neurodevelopmental psychiatric illness characterised by behavioural symptoms that often appear in late adolescence or early adulthood. It has extensive clinical and biological heterogeneity [1‐3], with pleiotropic genetic and pathophysiological pathways at work [4‐6]. The average lifespan prevalence of schizophrenia is roughly 1%, and only a small percentage of people with schizophrenia, approximately 10–15% are working [7]. Impairments in basic and advanced functional abilities are common among individuals with schizophrenia, impacting their ability to perform self-care activities [8]. In addition, the recurrence of symptoms poses a challenge, progressively diminishing patients' ability to independently manage various aspects of their lives [9]. These patients often exhibit deficits in dominance and autonomy when it comes to activities of daily living (ADL) and instrumental activities of daily life (IADL) [10].
Schizophrenia continues to exert a significant economic impact, and its prevalence is increasing, placing added strain on global, regional, and national healthcare systems. These findings can offer valuable insights for resource allocation and healthcare planning to address the growing number of schizophrenia patients, particularly in aging populations [11]. Worldwide burden of Diseases (2016) ranks schizophrenia as the twelfth disability disorder [12].
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Moreover, the failure of individuals with schizophrenia to adhere to basic personal hygiene principles and maintain order can have adverse effects on their social interactions, diminish their societal success prospects, and reduce their independence, employment opportunities, and social engagement [13, 14]. Consequently, promoting the ability of such patients to perform daily tasks independently becomes a crucial standard of care that necessitates attention to improve their self-care practices [15].
Despite the challenges faced by chronic schizophrenia patients, they can benefit from self-care interventions, involving behavioral modifications to enhance their health and well-being [16, 17]. Achieving successful self-care in this population requires more practice compared to other chronic illnesses, owing to the cognitive aspects of rationality and awareness [18]. The self-care behavior in severe mental illness [19] is influenced by various factors, including individual personality traits and societal support [20]. Therefore, effective collaboration between the government and society is essential to help patients regain self-care abilities through tailored interventions [21].
Research indicates that providing support to individuals with chronic mental illnesses can positively impact their ability to learn self-care and adhere to their prescribed medication [22‐25]. Unfortunately, many families fail to recognize the importance of offering social and emotional support to their relatives due to a lack of awareness about the symptoms of psychiatric disorders [26].
Psychiatric care has been shown to be effective in improving personal hygiene among schizophrenia patients [27]. However, the impact of training on behavioral changes in patients with chronic conditions tends to be short-term. Therefore, educational interventions must consider patients' psychological needs and adopt supportive communication styles to encourage them to sustain these behavioral improvements [28]. Individuals with schizophrenia have ability to make decisions regarding self-care is often hindered by psychiatric symptoms and a lack of insight into their condition [29]. Consequently, self-care in this population remains a significant healthcare challenge [16].
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Group-based psychological therapy has shown to be more effective for improving social functioning and self-care in schizophrenia patients [30, 31]. The beneficial aspects of intra-group therapy, such as constructive peer support to alleviate feelings of isolation and rejection, contribute to the preference for this treatment approach over cost-effective individual methods [32]. Psychiatric care has also demonstrated positive effects on aspects like nutrition, clothing, and hygiene in schizophrenia patients [33].
Despite the prevalence of schizophrenia and the potential benefits of group therapy on self-care abilities, there is currently no Egyptian study that explores this area. Therefore, this study could offer valuable insights to design services and enhance the self-care skills of schizophrenia patients in Egypt. This study's objective was to measure the level of self-care among individuals with schizophrenia. In addition, the study aimed to design, implement, and evaluate the impact of group therapy on self-care skills in this group of patients.
Methods
Participants and procedures
The research design employed in this study was quasi-experimental, involving a pretest–post-test controlled approach. Data collection took place at the inpatient psychiatric department of Assiut University Hospital. The study involved a total of 120 schizophrenic participants who were categorized into two groups, each comprising 60 patients. Group 1 received psychiatric medication alongside group therapy targeting self-care skills (study group), while Group 2 received only psychiatric medication without intervention (control group). Participants with other psychiatric disorders, intellectual disabilities, neurological or medical conditions were excluded. Eligible participants were diagnosed with schizophrenia according to DSM-5 criteria and fell within the age range of 18–60 years and accepted participation in this study.
Sample size
The EPI info statistical programme version 7 was used to calculate sample size. The sample size was established using the specifications of a 0.5 proportion, a 95% degree of confidence, and a 5% margin of error. It was calculated that each group needed 60 individuals based on these parameters [34].
Measures
All individuals were evaluated using a semi-structured interview designed by psychiatrists from Assiut University's psychiatry department. The Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) [35] was used to diagnose psychiatric disorders, and the Structured Clinical Interview for DSM-5 Disorders—Clinician Version (SCID-5-CV) during the psychiatric interview [36] was used to confirm the diagnosis and exclude comorbidities.
Socio demographic data included age, residence, educational level, occupation, and family medical history.
Positive and Negative Syndrome Scale (PANSS). The PANSS is a 30-item scale used to measure schizophrenia-specific positive, negative, and general psychopathology. Ratings range from 1 (symptom not present) to 7 (symptom extremely severe). The PANSS total score ranges from 30 to 210, while the positive score (items 1–7) and negative score (items 8–14) range from 7 to 49. The PANSS overall psychopathology score (items 15–30) ranges from 16 to 112. In addition, composite rating is calculated by subtraction the negative value from the positive value, yielding a bipolar index ranging from − 42 to + 42, showing the dominant syndrome [37].
The Exercise of Self-Care Agency Scale (ESCAS) was based on Orem's theory of self-care. This scale consists of 43 items assessing self-care skills related to motivation, knowledge, self-worth, and active versus passive responses to situations. It is Likert scale with five points and higher ratings indicate increased autonomy in self-care. Cronbach's alphas were ranged from 0.86 to 0.92 and 0.80 to 0.91, respectively [38, 39].
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Tools validity
The research tools underwent validation by a panel of five experts in the fields of Psychiatric and Mental Health, and necessary modifications were made accordingly.
Tool’s reliability
To evaluate the reliability of the instruments, Cronbach's Alpha was used, resulting in a value of 0.968 for the Positive and Negative Syndrome Scale (PANSS) and 0.870 for The Exercise of Self-Care Agency Scale (ESCAS).
Pilot study
A pilot study was conducted with 12 individuals diagnosed with schizophrenia, who were not included in the final study. The pilot study intended to investigate 10% of the sample to assure the accuracy and relevance of the research tools, but no modifications have been adopted based on the results of the pilot results.
Procedure
From October 2022 to July 2023, group therapy was designed, implemented, and evaluated the self-care skills in individuals with schizophrenia. To guarantee randomization, the selection procedure was divided into two phases. The sample was first randomly chosen using computer-generated random numbers. To ensure representation from all pertinent groups, a fixed number of patients from each group (n = 60 patients for each group) are chosen at random. The chosen sample was used to create the control group and study group. Patients were allocated to either group at random. For 8 weeks, the study group received psychiatric medication and group psychotherapy, while the control group received medication only.
This study conducted through four sequential phases
The preparatory phase
The program used in this study was developed by researchers following these steps:
1.
Examining the theoretical framework of group therapy.
2.
Examining the theoretical framework of the Positive and Negative Syndrome Scale (PANSS).
3.
Determining the techniques to be included in the program.
4.
Reviewing previous programs prepared by former researchers in the field of group therapy.
5.
Identifying the topics to be covered in the program.
6.
Preparing exercises and activities for each technique and session of the program.
7.
Preparing or selecting the illustrations to be used by the researchers for program implementation.
To acquire theoretical comprehension of the various aspects of the issue, 2 months were spent reviewing historical and contemporary literature related to the study topic. Following an extensive review of the literature, the study tools were designed.
The implementation phase
This phase included the following stages.
Stage 1: Pre-intervention stage (assessment)
After obtaining official permission to conduct the study, the researcher conducted individual interviews with each participant diagnosed with schizophrenia. Each participant provided written consent after being informed of the study's objective. Personal data was collected, and participants were asked to complete the Positive and Negative Syndrome Scale (PANSS) and the Exercise of Self-Care Agency Scale (ESCAS) to assess the impact of group therapy on self-care skills. This assessment process lasted approximately 15–20 min.
Stage 2: Intervention stage only for group 1
Group therapy was implemented in ten groups, with each group consisting of six patients. A total of eight sessions were conducted for each study group over a period of 4 weeks. Each session lasted approximately 1 h, with two sessions conducted per week. The group therapy included the following sessions:
First session: Providing information about the definition, types, causes, signs, and symptoms of schizophrenia.
Second session: Educating patients about different types of antipsychotic medications, their effectiveness, and potential side effects.
Third session: Focusing on the impact of mental illness on hygiene and nutrition.
Fourth session: Instructing patients on proper skin care, oral hygiene, appropriate clothing selection, and the importance of hygiene for overall well-being.
Fifth session: Addressing the definition and causes of insomnia. Sleep is a crucial component for physical and mental health, as it plays a vital role in self-care. Chronic sleep disturbances can significantly reduce an individual's quality of life, limit their ability to practice adequate self-care, and potentially increase mortality rates[40, 41].
Sixth session: Discussing the effects of insomnia and available treatments.
Seventh session: Emphasizing the importance of nutrition for individuals with schizophrenia.
Eighth session: Providing recommendations for food selection based on specific nutritional needs.
Stage 3: Evaluation of the program
The program's effectiveness was evaluated immediately after the implementation of the group therapy for both the control and study groups.
Statistical analysis
SPSS version 26 (Statistical Package for Social Science) was employed for data entry and analysis. The data was presented in the formats of number, percentage, mean, and standard deviation. Our data had normally distributed tested by Shapiro–Wilk test. To compare qualitative variables, the Chi-square test was utilized. Using independent samples t test, quantifiable variables between groups were compared. The paired t test was employed to compare similar groups. While risk factors were identified using multivariate linear regression, associated factors for self-care were evaluated using Pearson correlation. The P value is regarded as statistically significant when P 0.05.
Results
Sociodemographic and clinical characteristics
In this study, individuals with schizophrenia were recruited and categorized into two groups (60 patients per group), group 1: study group and group 2: control group. No significant statistical difference between studied groups regarding demographic and clinical variables (see Tables 1 and 2).
Table 1
Sociodemographic characteristics among studied groups
Variables
Study group
n = 60
Control group
n = 60
Χ2
or t value
P value
No
%
No
%
Age: (years)
1.747
0.417
< 30
13
21.7
16
26.7
30– < 40
26
43.3
19
31.7
≥ 40
21
35.0
25
41.7
Mean ± SD
36.37 ± 7.92
37.62 ± 8.43
− 0.837
0.404
Sex:
3.348
0.067
Male
37
61.7
27
45.0
Female
23
38.3
33
55.0
Marital status
0.347
0.841
Single
32
53.3
30
50.0
Married
22
36.7
25
41.7
Divorced
6
10.0
5
8.3
Residence:
3.077
0.079
Rural
45
75.0
36
60.0
Urban
15
25.0
24
40.0
Education years
0.927
0.629
Less than 5 years
26
43.3
29
48.3
5–10 years
10
16.7
12
20.0
More than 10 years
24
40.0
19
31.7
Occupation
1.875
0.171
Not work
45
75.0
51
85.0
Work
15
25.0
9
15.0
Family history of psychiatric illness
21
35.0
23
38.3
0.144
0.705
Independent t test for mean, Chi-square test for numbers
Table 2
Clinical variables of the studied groups
Variables
Study group
n = 60
Control group
n = 60
Χ2
or t value
P value
No
%
No
%
Age of onset: (years)
1.325
0.516
< 25
24
40.0
18
30.0
25–35
26
43.3
30
50.0
> 35
10
16.7
12
20.0
Mean ± SD
27.30 ± 6.99
28.80 ± 7.13
− 1.164
0.247
Duration of illness in years
0.421
0.810
< 5
15
25.0
15
25.0
5–10
29
48.3
26
43.3
> 10
16
26.7
19
31.7
Number of previous ECT
49
81.7
51
85.0
0.240
0.624
Number of previous suicide
23
38.3
15
25.0
2.465
0.116
Number of previous hospitals admissions
46
76.7
45
75.0
0.045
0.831
Independent t test for mean, Chi-square test for numbers
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PANSS and ESCAS results
Significant reductions in PANNS subscales were observed in the study group between baseline and follow-up assessments. As, the study group exhibited a reduction of more than half in the mean of PANNS subscales from baseline to follow-up.
Furthermore, there was a noticeable difference in post-assessment PANSS scores between the study and control groups, with the study group having a significantly lower mean on the PANSS subscales compared to the control group. As one of the negative symptoms reported by individuals with schizophrenia is a lack of self-care, the lower mean on the PANSS subscales for the study group suggests an improvement in self-care, which can potentially alleviate negative symptoms.
The total mean of ESCAS significantly improved in the study group when comparing baseline and follow-up assessments. As the study group demonstrated more than double the improvement in the mean of ESCAS, with baseline scores at 45.98 ± 10.23 improving to 117.40 ± 12.96 at follow-up. In addition, there was a significant difference in follow-up assessment ESCAS scores between both groups, with the study group exhibiting a significant increase in the mean of follow-up assessment ESCAS scores (117.40 ± 12.96) compared to the control group (44.25 ± 12.34) (see Table 3).
Table 3
Positive and Negative Syndrome Scale (PANSS) and Exercise of Self-Care Agency Scale (ESCAS) score among studied groups
Groups
Baseline measure (T1)
Follow-up assessment (T2)
t value(&p value of 2 measures in the same group)
t value (#p value of pre-treatment of 2 groups)
t value (#p value of post-treatment of 2 groups)
Positive and Negative Syndrome Scale (PANSS) score
Table 4 shows correlation between difference of total Self-Care (pre–post assessment) and other variables. Total ESCAS had strong positive association with having program (r = 0.867, p≤ 0.001). In contrast, difference of total ESCAS had strong negative association with positive symptoms (r = − 0.738, p≤0.001), negative symptoms (r = − 0.766, p≤0.001), and general psychopathology symptoms (r = − 0.766, p≤0.001).
Table 4
Correlation between difference of total ESCAS (pre–post-treatment) and other variables
Variables
Total Self-Care
r
P value
Have program
0.867
< 0.001*
Age
0.089
0.333
Sex
0.160
0.081
Education years
– 0.083
0.366
Age of onset
0.113
0.219
Duration of illness
0.102
0.269
Positive and Negative Syndrome Scale
Positive symptoms
– 0.738
< 0.001*
Negative symptoms
– 0.766
< 0.001*
Symptoms of general psychopathology
– 0.766
< 0.001*
*Statistically significant difference (p < 0.05)
In multivariate regression model to identified possible risk factors of difference of total ESCAS (pre–post-assessment). Increase self-care was more likely in patients had program (p≤0.001) (see Table 5).
Table 5
Multivariate regression between difference of total ESCAS (pre–post-assessment treatment) and other variables
Variables
B
Std. Error
Beta
t
P value
95.0% Confidence Interval
Lower Bound
Upper Bound
Have program
63.677
12.313
0.862
5.172
< 0.001*
39.276
88.079
Age
0.083
0.464
0.018
0.180
0.858
− 0.837
1.003
Sex
− 1.450
2.277
− 0.020
− 0.637
0.526
− 5.964
3.063
Education years
− 1.255
1.266
− 0.030
− 0.991
0.324
− 3.764
1.254
Age of onset
− 0.005
0.516
− 0.001
− 0.010
0.992
− 1.027
1.017
Duration of illness
0.040
0.504
0.005
0.079
0.937
− 0.958
1.038
Positive and Negative Syndrome Scale
Positive symptoms
− 0.121
0.396
− 0.044
− 0.306
0.760
− 0.907
0.664
Negative symptoms
0.352
0.403
0.128
0.871
0.385
− 0.448
1.151
Symptoms of general psychopathology
− 0.232
0.154
− 0.176
− 1.508
0.134
− 0.536
0.073
*Statistically significant difference (p < 0.05)
Discussion
Schizophrenia had wide range of symptoms with various risk factors [3, 42, 43]. In individuals with schizophrenia, self-care performance often shows a significant decline in functional abilities related to basic and advanced care needs [8, 44].This may lead to a lack of dominance and independence in daily living tasks, adversely affecting their overall quality of life [10, 45]. The aim of this study was to assess self-care in individuals with schizophrenia and evaluate the effectiveness of group therapy in enhancing their self-care abilities.
In this study, participants with schizophrenia who underwent the group therapy exhibited a reduction of more than half in positive, negative, and general psychopathology symptoms. In contrast, the control group showed only a slight decrease in symptoms. These findings align with a study by Abd El-Fatah and colleagues (2015), where significant improvement in PANSS scores was observed in schizophrenia patients who received both group therapy and standard treatment compared to the control group receiving only standard treatment [46]. This finding could be explained by the positive impact of self-care training in group therapy, which may have enhanced cognition and reduced negative symptoms of schizophrenia in the participants [47]. Enhanced cognition, resulting from the self-care training in group therapy, may have indirectly influenced positive symptoms by improving overall functioning and coping abilities in the participants with schizophrenia. Consequently, the improved cognition and coping skills could have contributed to the reduction in general psychopathology, which encompasses a broader range of symptoms beyond just positive and negative features.
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However, another study by Kashani Lotfabadi and colleagues (2022) reported minor improvements in schizophrenia patients with and without the program, without a significant difference between the groups [33]. This finding could be attributed to the patients' negative attitudes and lack of collaboration, which hindered their participation in the group activities designed to teach self-care practices. While patients with schizophrenia may experience minor improvements with or without the program, there may not be a significant difference between the two groups due to the challenges in engaging them fully in the self-care training activities. In the current study, individuals with schizophrenia showed more than double the increase in self-care compared to the control group, and this finding is consistent with previous research report, indicating that group therapy can indeed promote self-care behaviors in schizophrenia patients [33]. Furthermore, this finding aligns with Taş's (2017) study, which demonstrated that self-care training can effectively promote self-care habits in individuals with schizophrenia. This could be explained by the fact that group therapy introduces schizophrenia patients to self-care practices, potentially for the first time. Previous research suggests that educational interventions may improve the self-care knowledge and abilities of people with schizophrenia, enabling them to attend to their physical needs and properly care for their dental hygiene through brushing and toothpaste use [47]. Other studies have revealed that group therapy, rather than teaching alone, may help hemodialysis patients improve their self-care behaviors over time [48]. In addition, these studies have shown that group therapy helped enhance nulliparous outcomes [49] and self-care behaviors in women with diabetes by emphasizing self-care [50].
On the other hand, Kim Y-s and colleagues (2020) observed that psychiatric care may not effectively assist these patients in developing executive skills in the real world and sustaining their daily life responsibilities [51]. This might be explained by the possibility that participants with varying backgrounds, ages, and levels of education view issues and formulate ideas in ways that could help to explain the disparity.
The study further explored the factors associated with improved self-care in schizophrenia patients. Correlation analysis revealed that improved self-care was negatively correlated with positive, negative, and overall psychopathological symptoms in individuals with schizophrenia. This finding could be explained by the diverse range of cognitive, negative, and positive symptoms associated with schizophrenia. Negative symptoms and cognitive deficits are the primary factors influencing a patient's functional capacity while living with schizophrenia. While cognitive impairments typically indicate challenges in daily life and employment, negative symptoms often predict the severity of social deficiencies (interpersonal relationships). The basic activities of daily living involve managing one's physical needs and self-care. These activities are more resilient to cognitive decline compared to instrumental activities of daily living. However, cognitive ability does impact one's capacity to perform both instrumental and basic activities of daily living, as it involves reasoning and planning [47].The multivariate regression model confirmed that participation in the program was the only factor significantly associated with enhanced self-care.
The positive and negative symptoms of schizophrenia are fundamental components of the disorder. Positive symptoms are easier to identify and can be described as "psychotic behaviors not observed in healthy individuals" (Delusions, hallucinations, abnormal motor behavior, etc.) [52]. On the other hand, negative symptoms are characterised by a reduction in normal functioning, either linked to interest and motivation (avolition, anhedonia, and a sociality) or expression capabilities (blunted affect and alogia), and are referred to as deficit syndrome [53]. The severity of symptoms in schizophrenia and delay of diagnosis and treatment in psychiatric illness [19] has consistently been associated with poorer functional outcomes in various areas, including impaired occupational and academic performance, difficulties in social functioning, decreased participation in activities, and reduced quality of life [54, 55]. To improve treatment outcomes for schizophrenia patients, a comprehensive management strategy should incorporate self-care. Therefore, medical and nursing teams responsible for treating schizophrenia patients should acquire knowledge about self-care, self-care activities, self-care agencies, and how to provide assistance when self-care is insufficient. This information empowers individuals to engage in self-care practices during educational sessions, post-education periods, and in-service training. Moreover, it is crucial as these intervention plans are non-invasive, non-pharmacological, affordable, and cost-effective that help in improving patients.
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Furthermore, institutionalized schizophrenia patients would benefit greatly from specialized group therapy. Data regarding these treatments can serve as valuable insights for shaping policy, guiding health planning efforts, evaluating outcomes, and informing health education initiatives.
This study had some limitations. First, cognitive function was not assessed [24]. Self-care and cognitive function should be linked. Second, long-term follow-up is needed to assess intervention program's impact on self-care. The last limitation is the lack of a single-blind method. Implementing such a method, where the rater is blinded to which patients received group therapy, would have enhanced the validity of our findings.
Conclusion
When applied to individuals with schizophrenia, this group therapy had a positive outcome. It is linked to a significant reduction in positive, negative, and general psychopathological symptoms. It was also associated with a significant improvement in self-care skills after the implementation of group therapy in the study group compared to the control group.
Acknowledgements
None.
Declarations
Ethics approval and consent to participate
This study was approved by the Institutional Review Board (IRB) of the nursing faculty with Nb (4310032). The Assiut University neuropsychiatric hospital manager gave permission. All participants signed a written informed consent form before participating in the study. Participants were informed of the study's purpose, which did not inflict injury or pain, and they gave their consent. They were informed that their data would be anonymized and protected. They were advised that the study is optional, and they might withdraw at any moment. This research was conducted in accordance with the most recent version of the Helsinki Declaration.
Consent for publication
The participant has consented to publishing their data result.
Competing interests
The authors have no conflicts of interest to declare that are relevant to the content of this article.
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Medizinischen Rat von Chatbots auf der Basis sogenannter künstlicher Intelligenz haben laut Umfragen bereits knapp die Hälfte aller Erwachsenen schon einmal eingeholt. Welche Chancen und Risiken birgt das?
Wer insgesamt zuversichtlicher aufs Leben blickt, trägt ein geringeres Risiko, später einmal an Demenz zu erkranken als pessimistischere Zeitgenossen. Dafür sprechen zumindest Ergebnisse einer Längsschnittdatenanalyse aus den USA. Ob mehr Optimismus allerdings tatsächlich einer Demenz vorbeugt, bleibt unklar.
Eine hochdosierte Influenza-Vakzine geht mit einer verzögerten Demenzdiagnose einher. Darauf deutet eine Auswertung von US-Gesundheitsdaten hin. Besonders auffällig sind die Effekte in den ersten Monaten nach der Impfung.
Intensive Senkung eines erhöhten Blutdrucks kann nach einer intrazerebralen Blutung die funktionelle Erholung verbessern – mutmaßlich über eine Reduktion der Hämatomausdehnung. Offenbar hängt das aber vom Ausgangsvolumen ab, wie eine Analyse ergeben hat.
