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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”
1
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
2
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
3
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
4
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.
5
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
8
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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7
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.
15
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