RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATIONS

1 Name of the candidate and

address (in block letters)

JOSEPHINE MARY C

1 YEAR MSc NURSING

FATHER MULLER COLLEGE OF NURSING

MANGALORE-575002

2 Name of the Institution

FATHER MULLER COLLEGE OF NURSING

KANKANADY

MANGALORE – 575002.

3 Course of study and

subject

M.Sc. NURSING

PSYCHIATRIC NURSING

4 Date of admission to

course

1 s t JUNE 2009

5 Title of the topic:

“A STUDY TO ASSESS THE EFFECTIVENESS OF MOTIVATIONAL

INTERVIEWING ON THE MOTIVATION FOR TREATMENT ADHERENCE

AMONG THE HOSPITALIZED ALCOHOLIC PATIENTS IN A SELECTED DE

ADDICTION CENTER AT MANGALORE”

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6 Brief Resume of the Intended Work

6.1 Need for the of Study

Alcoholism is a disorder characterized by a pathological pattern of

alcohol use that causes a serious impairment in social and occupational functioning.

1An alcoholic will continue to drink despite serious health, family or legal

problems. In the national co morbidity survey, the prevalence of alcoholism is 2.5

times more prevalent in men than in women. The lifetime prevalence was 20% in

men, and 8% in women. In India, a community survey was conducted at NIMHANS,

in 2000, employing a face to face interview of 1956 subjects, which found the

prevalence of alcohol dependence to be 3.79%. In NIMHANS, the registration for

alcohol related neuro psychiatric problems increased from 212 in 1985 to 995 in

1994 and presently constitute more than 10% of all registration in the psychiatric

department. 2

Alcoholism affects the person’s whole aspects of l ife

especially physical, social, occupational, marital, and family l ife psychological and

economical. Alcoholism also can contribute to juvenile delinquency, divorce and

anxiety. Some of the il l effects of alcoholism are given below:

Economic : Loss of health and job, and spending all his money for drinking purpose

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only.

Health: Cardio vascular disease, high blood pressure, heart attack, peripheral

vascular diseases, stroke, cirrhosis of liver, hepatocelluar carcinoma, gall stones,

pancreatit is, osteoporosis, Wernick’s encephalopathy, Korsakoff’s psychosis,

esophagitis, alcoholic hepatitis, hepatic encephalopathy, ascit ies, sexual

dysfunction etc. 3

Occupational problems : Poor performance, absenteeism, poor relationship with

colleagues, discipline problems, loss of job.

Social problems : Marital disharmony and domestic violence, neglect of children,

criminal behavior such as driving offences, disturbance of peace, petty crime,

accidents, rape, serious assaults, homicides, suicides etc. 4 , 5

Even if an alcoholic hasn’t been drinking for a long time,

he/ she can suffer relapse. An alcoholic should undergo treatment program which

will help him to become non alcoholic. Alcoholism treatment programs use both

counseling and medications to help a person stop drinking and rebuild their l ives.

Detoxification, long term pharmacological treatment, psycho social treatment

methods like: individual psychotherapy, cognitive and cognitive behavioral

therapies such as, operant behavior therapy, aversion therapy, group therapy,

family and marital therapy and relapse prevention are some of the treatments

available. 6 The most common reasons for discharge in between the treatment are

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psycho social problems, difficulties in the treatment program, and lack of interest

in the treatment. 7 The patients who are admitted in the de addiction center do not

adhere to the treatment and is not completing the course of treatment which they

have to undergo. Incompletion of treatment significantly increases the risk of

relapse.

Motivation is the driving or pulling force within the organism,

which results in persistent behavior directed towards a particular goal.

Motivational interviewing is a well known, scientifically tested method of

counseling clients, developed by Miller WR in 1983, and viewed as a useful

intervention strategy in the treatment of problem drinkers, lifestyle problems and

diseases. He defined motivational interviewing as a directive, client centered

counseling style for eliciting behavior change by helping clients to explore and

resolve ambivalence. 8 Motivational interviewing is found to be effective in

promoting treatment adherence among alcoholics and other patients in different

health care settings.

A randomized controlled trial was conducted to assess the

effect of hazardous drinkers util izing community health care centers in rural

southeastern Idaho. Twenty-six hazardous drinkers attending five low-income

community health centers participated in the study. The experimental group

participated in one motivational interviewing session with the investigator, family

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nurse practit ioners. The comparison group received no treatment. Alcohol use was

tracked for 6 weeks after successful recruitment into the program. Participants in

the study significantly decreased their average number of drinks per day. At time 1

(pretreatment), the control group drank 4.37 drinks/day and the treatment group

drank 4.65 drinks per day. At time 2 (post test), the control group drank 3.77 drinks

per day and the treatment group drank 1.95 drinks per day. The effects of

motivational interviewing treatment on hazardous drinking also were measured by

serum gamma-glutamyltransferase (GGT), a l iver function test . There was also a

significant decrease in the GGT from pretest to post test in the treatment group.

The results of this investigation found that motivational interviewing shows

promise as an effective intervention for hazardous drinkers attending low-income

community. 9

The researcher has observed that there is lack of motivation to the

treatment adherence among some of the hospitalized alcoholic patients who quit the

treatment program in between and the relapse rate becomes very high. So

motivational interviewing has been taken as an intervention in order to help the

clients to adhere to the treatment when they are admitted in the de addiction center.

6.2 Review of literature

A placebo- controlled efficacy trial was conducted in University of

Pennsylvania, Philadelphia, to assess the alcoholism treatment adherence in 2002.

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All the subjects were participants in a randomized double bind placebo controlled

efficacy trial of naltrexone for the treatment of alcohol dependence. All subjects

received a medically based psycho social intervention focused on motivating

patients to change and on adherence to treatment. Compared with younger adults,

older adults had greater adherence at therapy sessions and greater adherence to

medication. 1 0

A randomized control trial was conducted at St. Barnabas Hospital,

New York, to assess the effect of motivational interviewing and treatment

adherence among psychiatric and dually diagnosed inpatients was investigated.

Subjects were 121 psychiatric inpatients , 93(77%) of whom had substance abuse/

dependence disorders, who were randomly assigned to Standard Treatment ( ST)

including pharmaco therapy, individual and group psychotherapy, activities

therapy, milieu therapy, and discharge planning or ST plus Motivational

Interviewing ( ST +MI), which involved 15 minutes feedback on the results of

motivational assessment early in the hospitalization and 1 hour motivational

interview just before discharge.Results indicated that the proportion of patients

who attended their first outpatient appointment was significantly higher for ST+ MI

group (47%) than for the ST group (21%; x 2 = 8.87, df=1, p <01) overall and for

dually diagnosed patients ( 42% for ST +MI vs 16% for ST only; x 2= 7.68; df= 1,

p<.01) Therefore brief motivational intervention show promise in improving

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outpatient treatment adherence among psychiatric and dually diagnosed patients. 1 1

Another prospective randomized trial on motivational

interviewing to promote physical activity for people with chronic heart failure in

Liverpool university, UK. Patients who are directed to engage physical activity

have a record of low compliance. 60 older aged heart failure patients were

randomly assigned to standard care, motivational interviewing or both. The primary

outcome was physical activity with 6 minutes walk test as a second outcome.

Following treatment, patients who were directed to engage physical activity have a

record of low compliance. The motivational interviewing and both treatment groups

reported an increase in their level and type of activities, whereas standard group

did not. Thus motivational interviewing incorporates established behavior change

and a flexible approach to promotion of increased physical activity in older patients

with heart failure over a short period. 1 2

A randomized, controlled, clinical trial was conducted

in University of Arkansas, to assess the effect of motivational interviewing in

weight control program leading to weight loss and glycemic control for overweight

women with type 2 diabetes. A randomized, controlled, clinical trial was used in

which participants all received an 18 month, group based behavioral obesity

treatment and were randomized to individual sessions of motivational interviewing

or attention control ( total of five sessions) as an adjunct to the weight control

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program. Overweight women with type 2 diabetes treated by oral medications who

could not walk for exercise were eligible. Primary outcomes were weight and AIC,

assessed at 0, 6, 12, and 18 months. A total of 217 overweight women (38% African

American) were randomized (93% retention rate). Women in motivational

interviewing lost significantly more weight at 6 months (p= 0.01) and 18 months

(p=0.04). Increased weight losses with motivational interviewing were mediated by

enhanced adherence to the behavioral weight control program. Significantly greater

AIC reductions were observed in those undergoing motivational interviewing at 6

months ( p= 0.02) but not at 18 months. 1 3

6.3 Statement of the Problem

A STUDY TO ASSESS THE EFFECTIVENESS OF MOTIVATIONAL

INTERVIEWING ON THE MOTIVATION FOR TREATMENT ADHERENCE

AMONG ALCOHOLIC PATIENTS IN A SELECTED DE ADDICTION CENTER

AT MANGALORE.

6.4 Objectives of the Study

1. To assess the level of withdrawal symptoms among alcoholics by modified

Clinical Institute of Withdrawal Assessment Scale.

2. To assess the level of motivation for the treatment adherence before and after

motivational interviewing as measured by modified questionnaire on Readiness to

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Change.

3. To determine the association between motivation for treatment adherence and

selected baseline variables.

4. To assess the opinion of alcoholics regarding motivational interviewing by

opinionnaire.

6.5 Operational Definitions

Effectiveness: In this study, effectiveness refers to the extent to which the motiva-

tional interviewing produces an intended positive outcome by gain in scores of mo -

tivation to treatment adherence.

Motivational Interviewing: Motivational interviewing is a directive , client

centered counseling style for eliciting behavior change by helping clients to

explore and resolve ambivalence. It is a cyclic process in which the client will be

passing through five stages and they are: pre contemplation stage, contemplation

stage, preparation stage, action stage, and maintenance stage 8

In this study, motivational interviewing refers to the

client centered counseling, which is intended to enhance the client for motivation

to treatment adherence. Motivational interviewing will be given to the client who is

free from severe withdrawal symptoms, or with mild symptoms. The time duration

will be for 15 to 20 minutes / day for at least 5 to 7 days. Through this motivational

interviewing, the client is motivated for treatment adherence that is the completion

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of the course of treatment for 21days.

Motivation : Motivation is defined as, the conditions within the organism which

arouse, maintain and direct behavior towards a specific goal. It is a driving or

pulling force which results in persistent behavior directed towards a particular

goal. It is internal. In other words it is the process that energizes, maintains and

directs behavior towards the goal. 1 4

In this study, motivation is the driving force within the

alcoholic, that he changes himself after motivational interviewing, in order to

accept and adhere to the course of treatment that is to be completed for his

recovery.

Alcoholic: Alcoholic is a person who drinks too much or suffers from a disorder

caused by it. Alcoholism is a progressive disease of compulsive drinking that

interferes with one’s normal life. It affects a person mentally, physically and

affects everyone who has contact with him.

In this study, alcoholics are those individuals who

drink alcohol on a regular basis and are admitted to de addiction center and

diagnosed to have alcohol dependence syndrome by the treating physician, who

doesn't have severe withdrawal symptoms like, tremors, nausea, vomiting,

weakness, irritabili ty, insomnia, anxiety , alcoholic hallucinations, delirium, and

alcoholic seizures, when stopping the intake of alcohol which in turn affect the

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personal (physical and psychological), social , familial , and spiritual functioning.

DE ADDICTION CENTER : In this study, De addiction center refers to the De

addiction centre, where individuals with dependence on alcohol and other

substances are admitted for the medical treatment, holistic nursing care and for

alternative therapies to overcome their addictive behavior.

TREATMENT ADHERENCE: The word adherence originated from a Latin word

“Adhaereo” which means to stick to. Stedman's medical dictionary defines

adherence as, the act or quality of st icking to something. It is the extent to which a

patient continues an agreed- upon mode of treatment without close supervision. 1 5

In this study, treatment adherence refers to the

extent to which the alcoholic patients, who are admitted in the De addiction centre,

are willing to complete the course of treatment for 21 days which include a

structured schedule consist of detoxification program for 5to 7 days, psychotherapy

session including lectures, individual psychotherapy, group therapy, yoga,

meditation, games, sharing encounters with Alcoholic Anonymous Personnel for

2weeks of duration.

6.6 Assumptions

1. The chances of dropout during de addiction treatment are high among

hospitalized alcoholics.

2. The non adherence to the de addiction treatment is influenced by personality of

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the alcoholics, craving for alcohol, financial constraints, lack of interest to the

treatment and lack of motivation.

3. Motivational interviewing is found to be effective in promoting treatment adher -

ence among patients in different healthcare settings.

6.7 Delimitation

1. Only to the alcoholics who are admitted in the De addiction centre of Fr.Muller

Medical College Hospital .

6.8 Hypotheses( Projected outcome)

All hypotheses will be tested at0.05 level of significance.

H1: The final day post interventional motivational scores for treatment adherence

will be significantly higher than the 1 s t day pre interventional scores among the

alcoholics.

H2 :

There will be significant association between the selected baseline variables of

alcoholics and pre interventional motivation for treatment adherence.

Material and Methods

7.1 Source of Data

Hospitalized alcoholics who are admitted in De addiction centre of Father Muller

Medical College Hospital for the treatment of alcoholism.

7.1.1 Research Design

One group pre test post test time series design.

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7.1.2 Setting

Study will be conducted in the De addiction centre of Father Muller

Medical College Hospital Mangalore, is a multi specialty hospital with 1248 bed

strength and psychiatric unit has 150 beds, where alcoholic patients are treated with

structured schedule consist of detoxification program for 5to 7 days, psychotherapy

session including lectures, individual psychotherapy, group therapy, yoga,

meditation, games, sharing encounters with Alcoholic Anonymous Personnel for

2weeks of duration. On the final day of intervention opinionnaire will be

administered to the participants.

7.1.3 Population

The alcoholic patients who are admitted in the De addiction centre of Father

Muller Medical College Hospital Mangalore throughout the year 2009—2010.

7.2 Methods of data collection

7.2.1 Sampling Procedure

Purposive sampling

7.2.2 Sample Size

40

7.2.3 Inclusion Criteria

1. The patients between the age group of 18 and above.

2. The patients who are free from severe withdrawal symptoms.

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3. The patient who can speak English, Kannada, Malayalam and Tamil.

7.2.4 Exclusion criteria

Alcoholic patients who are not willing to participate in the study.

7.2.5 Instruments intended to be used

1. Baseline Proforma

2. Modified questionnaire on Readiness to Change.

3. Modified Clinical Insti tute of Withdrawal Assessment Scale.

4. Opinionnaire.

7.2.6 Data collection method

The investigator will obtain permission from concerned authority to conduct the

study. Informed consent will be obtained from the subjects, and they will be

screened for alcohol withdrawal symptoms with modified CIWA Scale. Those who

are free from severe withdrawal symptoms will be assessed for the level of

motivation to modified questionnaire on Readiness to Change. The motivational

interviewing will be given to the subjects, with low or no motivation and post tests

will be conducted on the 3 r d , 5 t h and 7 t h day of intervention. On the final day of

intervention opinionnaire will be administered to the participants

7.2.7 Data analysis plan

Descriptive statistics

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Collected data will be analyzed by descriptive statistics such as mean, standard

deviation, frequencies and percentages.

Inferential statistics

1. t’ will be used to find the motivation to treatment adherence of alcoholic

patients.

2. Chi-square test will be used to find the association between the selected

demographic variables and the mean readiness to change score of alcoholic

patients.

The results will be presented by frequency table, diagrams and graphs.

7.3 Does the study require any investigation/interventions to be conducted on

patients or the human or animals? If so please describe briefly.

Yes, the investigator will administer clinical institute of withdrawal assessment

scale and modified questionnaire on readiness to change to the hospitalized

alcoholic patients who are admitted for treatment in De addiction centre.

Motivational interviewing will be given to the alcoholics as intervention.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes. Ethical clearance has been obtained from the ethical committee.

List of references

1. Dorland’s Illustrated Medical Dictionary, 30th ed. Canada: WB Saunders Company; 1999.

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2. Benegal V, Velayudhan A, Jain S. Social cost of Alcoholism: A Karnataka

Perspective. NIMHANS Journal 2000 Oct; 67(1&2).

3. Townsend MC. Psychiatric Mental Health Nursing in Evidence Based Practice.

5 t h ed. New Delhi: Jaypee Brothers Medical Publishers; 2007.

4. BuddyT. Binge Drinking can lead to Risky Behaviors. [online] cited on 22 n d Nov

2009.available form:

http://alcoholism.about.com/health/Health _Effects of _Alcohol.htm

5. Addiction: What to know and how to get help? NIMHANS:2009.

6. Vyas JN, Ahuja N. Text book of post graduate psychiatry. 2 n ded. New Delhi:

Jaypee brother’s medical publishers; 2000.

7. Loveland C, Booth F,McAleenan K, Bunn J. Risk factors of AMC discharge

from VA in patient alcoholism treatment programs. J Subst Abuse Treat2004;

11(3).

8. MillerWR, Sovereign RG, Krege B. Motivational Interviewing with problem

drinkers. Behav psychoth 1988; 16(10).

9. Beckham, Nancy. Motivational interviewing hazardous drinkers. JAANP 2007

Feb; 19 (2).

10. Oslin WD, Pettinatt i H, Volpicelti JR. Alcoholism Treatment Adherence:

Older age predicts better adherence and drinking outcomes. Am J Geriat

Psychiat 2002 Nov-Dec ; 10(6):740-47

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11. Arthur JS, Panyalon MV, Kenneth RC. Motivational interviewing and treatment

adherence among psychiatric and dually diagnosed patients. J Nerv Ment Dis

1999 Oct; 187 (10): 630-35.

12. Broide DA, Inoue A. Motivational interviewing to promote physical activity for

people with chronic heart failure. J Adv Nurs 2005 May;50 (5): 518-26.

13. Smith D, DiLillo V, Green PG. Motivational interviewing improves weight loss

in women with Type 2 Diabetes. Diabetes Care 2007 May; 30(5).

14. Balachandran M.Psychology for nursing students.1 s t ed. Kerala: Thiruvanantha-

puram, Maanas publishers; 2003.

15 Stedman’s medical dictionary. 27 t h ed.USA: Lippincott Williams&Wilkins;2000.

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9 Signature of the

candidate

10 Remarks of the guide

11 Name & Designation of

(in block letters)

11.1 Guide

MRS. AGNES E JOSE. M.SC. (N)

ASSOCIATE PROFESSOR

PSYCHIATRIC NURSING

FATHER MULLER COLLEGE OF NURSING

MANGALORE

11.2 Signature

11.3 Co-guide (if any)

11.4 Signature

12 12.1 Head of the

Department

MRS.CHANU BHATTACHARYA M.SC. (N)

HEAD OF THE DEPARTMENT

PSYCHIATRIC NURSING

FATHER MULLER COLLEGE OF NURSING

MANGALORE

12.2 Signature

13 13.1 Remarks of the Chairman and Principal

13.2 Signature

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