|Year : 2020 | Volume
| Issue : 2 | Page : 72-78
Effect of Nurse Led Brief Psycho-Education in Improving Self-Reported Medication Adherence Among Clients with Alcohol Dependence Syndrome Attending a Tertiary Care Hospital North India: Quasi-experimental Study
Manisha Deswal1, Jaison Joseph2, Vinay Kumar3
1 MSc Nursing, College of Nursing, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
2 Department of Psychiatric Nursing, College of Nursing, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
3 State Drug Dependence treatment Centre, PGIMS, Rohtak, Haryana, India
|Date of Submission||24-Jul-2020|
|Date of Decision||07-Sep-2020|
|Date of Acceptance||06-Oct-2020|
|Date of Web Publication||08-Feb-2021|
Mr. Jaison Joseph
Department of Psychiatric Nursing, College of Nursing, Pt. B.D. Sharma University of Health Sciences, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: Although fewer people in India consume alcohol, a larger proportion is affected by harmful use or dependence on alcohol. Medication compliance found to be the most important predictor in the outcomes of alcohol de-addiction treatment. Aim: This study aimed to evaluate the effectiveness of nurse-led brief psychoeducation in improving the self-reported medication adherence among treatment-seeking clients attending a de-deaddiction center of North India. Materials and Methods: This study is a quasi-experimental study in which a total of 70 subjects were consecutively recruited as per the sampling criteria. A trained nurse delivered a 30-min individual-based brief psychoeducation for those in the intervention group as per the standard module. The subjects in the control group received the usual hospital care. The outcome measures were changes in adherence to medication measured as per the Medication Adherence Rating Scale during a 1-week follow-up. Results: The mean age of the subject was 37.53 (standard deviation – 9.57). Disbelief toward treatment (84.28%), persisting comorbid illness (47.14%), and forgetfulness (35.7%) were the most common self-reported factors for medication nonadherence in this setting. The study observed a statistically significant improvement in the self-reported medication adherence in the intervention group as compared to the control group during the 1-week follow-up period (independent sample t-test; t = 7.14; P < 0.01). Conclusion: The present study identified that nurse-led brief psychoeducation might be an effective strategy in improving medication adherence among clients with alcohol dependence syndrome in this setting. However, further studies with the rigorous scientific approach are needed to generalize the findings.
Keywords: Alcohol dependence syndrome, medication adherence, nurse, psychoeducation
|How to cite this article:|
Deswal M, Joseph J, Kumar V. Effect of Nurse Led Brief Psycho-Education in Improving Self-Reported Medication Adherence Among Clients with Alcohol Dependence Syndrome Attending a Tertiary Care Hospital North India: Quasi-experimental Study. Indian J Psy Nsg 2020;17:72-8
|How to cite this URL:|
Deswal M, Joseph J, Kumar V. Effect of Nurse Led Brief Psycho-Education in Improving Self-Reported Medication Adherence Among Clients with Alcohol Dependence Syndrome Attending a Tertiary Care Hospital North India: Quasi-experimental Study. Indian J Psy Nsg [serial online] 2020 [cited 2021 Feb 28];17:72-8. Available from: https://www.ijpn.in/text.asp?2020/17/2/72/308828
| Introduction|| |
Alcohol is a social burden. Excessive alcohol consumption is a risk factor for a wide range of health and social problems and is a major cause of premature illness and death. Overall, 5.1% of the global burden of disease and injury is attributable to alcohol, as measured in disability-adjusted life years. Chronic excessive consumption can affect every part of the body and lead to long-term health problems. Alcohol misuse has been implicated in over 20% of traumatic brain injuries and 60% of all injuries reporting to emergency rooms. Alcohol use contributes to more than 60 different disorders, including fetal alcohol syndrome, liver disease, neurological disorders, cardiovascular and cerebrovascular diseases, anemia, and several cancers. It is clear that dependent use is associated with a significant burden of disease, but there is also evidence that the burden on health-care systems from nondependent, but harmful or hazardous use, may be greater than the burden due to dependent use. The recent national survey on the magnitude of substance use in India reported that alcohol is the most common psychoactive substance used by Indians and further suggest that fewer people in India consume alcohol, but a larger proportion is affected by harmful use or dependence on alcohol.
Compliance in the mental health-care setting can be related to certain factors such as patient-related factors, illness-related factors, and treatment-related factors. However, noncompliance to medication is a serious concern in the alcohol de-addiction setting. Various reasons have been cited in the literature for noncompliance to treatment among clients with alcohol dependence such as motivation, emotion, willingness to abstain, efficacy of medications, socioeconomic, marital and educational status, health-care system, medical condition or preexisting comorbidities, and the support from the caregivers. Lack of knowledge regarding various aspects of medication and adverse drug reactions were the major self-reported factors for noncompliance among treatment-seeking clients for alcohol dependence in the Indian setting., The major consequence of nonadherence can be disease progression caused by reduced functional abilities and quality of life. The substantial increases in access to care for substance use disorders (SUDs) have led to a greater emphasis on evaluating interventions to identify best practices for SUD treatment in health-care systems.
Various multifaceted interventions have been explored for managing nonadherence-related issues. Although the interventions were focused on the individual, group, and family level, the psychoeducational approach was the most commonly used modality in all the levels. Psychoeducational interventions focus primarily on enhancing the knowledge about the illness and management of side effects to achieve medication adherence. The available literature suggests the involvement of nurses as the therapist of alcohol brief interventions. As the biggest component of the health-care workforce, nurses can make a significant impact on the care of mental illness by engaging in nurse-led brief interventions. However, there is a dearth of evidence regarding nurse-led brief psychoeducation in improving medication adherence among treatment-seeking clients with alcohol dependence. This prompted the investigators to explore this area.
- To assess the effectiveness of a nurse-led brief psychoeducation in improving medication adherence among clients with alcohol dependence period at 1-week follow-up period
- To identify the factors influencing nonadherence among clients with alcohol dependence syndrome.
- H1: There may be a statistically significant difference in medication adherence scores before and after the nurse-led brief psychoeducation at 0.05 level of significance
- H0: There may not be any statistically significant difference in medication adherence scores before and after the nurse-led brief psychoeducation at 0.05 level of significance.
| Materials and Methods|| |
The study was a quasi-experimental study conducted at a tertiary care drug dependence treatment center of North India. Clients with alcohol dependence were the most common treatment-seeking population as per the study setting. Therefore, we included those clients who were undergoing treatment on an outpatient basis with a clinical diagnosis of F10 as per the International Classification of Diseases-10 criteria and taking medication for alcohol dependence prescribed by a psychiatrist. Further, those who are willing to participate in the study were included in the study. Clients in the acute stage of their illness, not able to read and write the Hindi language, and refused for a 1-week follow-up were excluded from the study. Ethical permission was obtained from the concerned authorities and confidentiality was maintained throughout the study. The outcome measure was the changes in medication adherence as per the Medication Adherence Rating Scale (MARS) as reported by the subjects.
Participants were treatment-seeking clients with alcohol dependence attending the outpatient department of a tertiary care drug dependence treatment center. Consecutive sampling was used and all the eligible subjects available during the period of data collection were enrolled as per the sampling criteria. A sequentially numbered sealed envelope technique was used for allocation concealment. The nature of the intervention was written on a paper and kept in the sealed envelope. The envelope was labeled with a serial number. The principal investigator opened the sealed envelope once the patient has consented to participate and then assigned the treatment group accordingly. A total of 76 participants were contacted through a referral from the treating team, of which six were excluded. The exclusion was based on the following aspects: refused for a 1-week follow-up due to patient-related factors (n = 04) and taking treatment for multiple drug dependence (n = 2). After the selection of participants, sociodemographic and clinical characteristics of the subjects were collected. Besides, the MARS questionnaires were administered to both the groups of participants before allocating them to either the intervention or control group. The control group received the routine care of review and advice from the psychiatric social worker. Apart from the routine care, the nurse-led brief psychoeducation was provided to those in the intervention group immediately after the MARS administration. All subjects were available during follow-up which was done after 7 days (±3 days) of intervention [Figure 1].
Apart from the sociodemographic data, a semi-structured checklist was developed to identify the factors of nonadherence to medication regimen under four headings: personal factors, socioeconomic factors, treatment-related factors, and health-care system-related factors. The current faith toward treatment, the preexisting comorbid illness, accessibility, and forgetfulness regarding medication were included in the personal-related factor domain. The availability of support system, economic barriers, and home care management were considered in the socioeconomic domain. The side effects to medication were the major items in the treatment-related factor and the noncooperation and unavailability of health-care personnel were included in the health-care system-related factor domain. Medication adherence was assessed using the MARS which consists of 10 questions with yes/no dichotomous responses. The total scores range from 0 (low likelihood of medication adherence) to 10 (high likelihood). Adherence is usually equivalent to scores >5.
Nurse-led brief psychoeducation is a structured educational intervention containing one individual session of short duration (30 min) offered to help a person to achieve the goal of medication adherence. In the present study, the intervention was provided immediately after MARS administration. Initially, the subjects were encouraged to express their own physical and psychological problems associated with the current treatment. The psychoeducation included information about the knowledge regarding pathways of care in alcohol de-addiction, specific advice on improving identified factors of nonadherence, and general strategies to improve medication adherence such as alarm method, calendar method, and family supervision.
Data were analyzed using Statistical Package for the Social Sciences (IBM, Chicago, SPSS Inc. SPSS Statistics 16.0). The comparisons of baseline sociodemography and clinical variables were done by Pearson's Chi-square test (or Fisher's exact test where the expected number of frequency in a cell is <5) for categorical variables and independent sample t-test for the continuous variables.
| Results|| |
The mean age of the subject was 37.53 (standard deviation [SD] – 9.57). There was an equal number of clients in the age group of 31–45 years in both the study groups (n = 20, 57.14%). Around 14.2% (n = 5) of clients in the experimental group were at the age group of 15–30 years and 28.5% (n = 5) of clients in the control group were at the age period of above 40 years. There was an equal representation of subjects with an educational qualification up to senior secondary school in both the study groups (n = 3, 8.57%). However, most of the clients in the control group were illiterate (n = 6, 17.14). More than half of the participants were employed in the private sector. A major proportion of subjects in the intervention group reported the presence of a chronic medical history in the control group (51.4%). However, subjects with a family history of mental illness were more in the intervention group as compared to the control group (48.57% vs. 34.28%). Both the groups did not differ based on the sociodemographic and the clinical profile at the baseline [Table 1].
|Table 1: Comparison of the characteristics of the participants at the baseline|
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In the patient-related factor for nonadherence, most of the clients (84.28%) reported a lack of faith toward the treatment regimen. Around 35%–47% of the subjects reported forgetfulness and the presence of a comorbid illness as the cause of current medication nonadherence. In the socioeconomic factors for nonadherence, approximately 8% of the participants reported that an inadequate support system was attributed to medication nonadherence. Some of the participants discontinued their medication due to symptomatic relief (5.7%), side effects, and follow-up-related issues (10%). [Table 2] summarizes the various self-reported factors of nonadherence in this setting.
|Table 2: Factors of nonadherence to medication for alcohol de-addiction treatment|
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Independent sample t-test was used to compare the difference in medication adherence scores before and after the nurse-led psychoeducation. The mean medication adherence score was improved from 5.23 ± 1.16 to 7.11 ± 0.631 in the experimental group during postassessment. However, no such significant improvement was observed in the subjects in the control group (5.17/SD – 1.48–5.78/SD – 1.37). The findings revealed a statistically significant improvement in the medication adherence score in the experimental group as compared to the control group during the follow-up period. Therefore, nurse-led psychoeducational intervention resulted a statistically significant improvement in medication adherence in the study subjects [t = 7.12, df – 68, P < 0.001; [Table 3]]. Hence, the null hypothesis was rejected.
| Discussion|| |
The index study provides some evidence on the effectiveness of a nurse-led brief psychoeducation among treatment-seeking clients with alcohol dependence. All the study subjects completed follow-up which was done after 1 week of the baseline assessment. The major findings of the current study are that individual-based, nurse-conducted outpatient-based brief psychoeducation can result in the improvement of medication adherence in the short term.
Many approaches are advocated for improving medication adherence in the alcohol de-addiction setting. Compliance enhancement therapy (CET) is identified as one of the promising and cost-effective psychological interventions for improving compliance to alcohol treatment. In a study, the investigators explored the effectiveness of integrative treatment blending motivational interviewing and CET for improving medication adherence among clients undergoing pharmacotherapy for alcohol dependence. The researchers observed a high rate of medication adherence (79%) 121 treatment-seeking, alcohol-dependent adults during 2-week follow-up. Similar findings of increased medication compliance (80%) following CET were also reported a multisite study on a random sample of 320 subjects. Anton et al. investigated the effectiveness of naltrexone combined with cognitive behavioral therapy and motivational enhancement therapy for improving alcohol treatment outcomes. The findings of the study revealed a high retention and adherence to treatment over a 12 week period. Most of the psychoeducational intervention was conducted among clients with schizophrenia and other mental illness. A community-based intervention from South India reported that besides antipsychotic medications, structured psychoeducation can favorably influence the course and reduce disability in a cohort of patients with schizophrenia. A study by Lin et al. tested the effectiveness of a nurse-led psychoeducational program called “balancing my swing program” with 10 weekly sessions among Taiwanese Han-Chinese with bipolar II disorder. This study concluded an improved medication adherence in the intervention group as per the MARS during the follow-up. A multicenter, cluster-randomized trial tested the effect of five sessions of the psychoeducation program and identified an improved medication adherence among clients with bipolar affective disorders subjects. However, the content of psychoeducation for improving medication adherence is of paramount importance. The interventions that utilize combined approaches seem more effective than unidimensional approaches. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. The index study adopted a psychoeducational approach for improving adherence to alcohol treatment and the results of the current study corroborate the findings earlier researches.
The investigators of the current study would like to make a special note on the acceptability of a nurse conducted brief psychoeducation in this setting. Most of the psychoeducational interventional studies were conducted by various health-care professionals and among caregivers of clients with various mental illnesses. Shin assessed the effects of family psychoeducational intervention for Korean Americans who had a family member with mental illness and found significantly decreased stigma and increased coping skills in the psychoeducational group members as compared with the control group. A recent study by Innamuri et al. oncluded that a nurse-conducted group psychoeducation in the Indian setting is an effective and feasible option to improve the knowledge of schizophrenia among caregivers, especially about management, course, and prognosis. The available literature suggests pharmacist-related interventions for improving medication adherence in patients with alcohol dependence. There is scanty evidence on the nurse-conducted brief psychoeducation in alcohol de-addiction setting. The findings of the index study are preliminary research data on the psychoeducation among clients with alcohol dependence syndrome in the Indian setting.
The current study observed that knowledge and belief regarding treatment is an important factor for medication adherence. A major proportion of our study subjects reported a lack of faith in their treatment (84.28%). An earlier study among bipolar disorder subjects also supports these findings. In another study, Sultan et al., reported that lack of knowledge about the nature of the illness was the major reason for noncompliance among patient with schizophrenia. A meta-analysis regarding medication nonadherence in mental illness reported that attitudes and beliefs are the important factors in predicting adherence. The inadequate support system was the most identified reason for caregiver related nonadherence to medication in our study (8.57%). Similar findings are also reported among patients undergoing pharmacotherapy for alcohol and opioid dependence. A study by Lucca et al. reported that side effects, cost of medicines, and nonavailability of medicines were the major reasons for nonadherence in patients with mental illness. However, in our study, only 10% of the study subjects reported nonadherence due to side effects associated with their current medication and further provides a favorable attitudes toward medication treatment for alcohol dependence in this setting.
The findings of the study have important policy implications for the preparation nurses as brief psychoeducation therapists in the alcohol de-addiction setting. The adoption of this intervention into routine nursing practice should be considered to promote an evidence base for the independent functioning of nurses within the realms of the nursing profession.
The present study has the following limitations. The results of the outcome measure are based on the self-reported measure. We assessed the short-term outcome of a single session and long-term effect was not assessed due to logistic reasons. The sample size was small, and therefore, the study may have lacked the power to test the effectiveness of the intervention. Despite these limitations, to the best of our knowledge, the present study is a pioneer one from India to evaluate the effectiveness of a nurse-conducted brief psychoeducation for medication adherence in the alcohol de-addiction setting.
| Conclusion|| |
The present study identified that nurse-led brief psychoeducation might be an effective strategy in improving medication adherence among clients with alcohol dependence syndrome in this setting. However, further studies with the rigorous scientific approach are needed to generalize the findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Global Status Report on Alcohol and Health 2018. World Health Organization; 2019.
Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373:2223-33.
Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health 2011;34:135-43.
Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, et al
. Epidemiology of DSM-5 alcohol use disorder: Results from the national epidemiologic survey on alcohol and related conditions III. JAMA Psychiatry 2015;72:757-66.
Fleischhacker WW, Oehl MA, Hummer M. Factors influencing compliance in schizophrenia patients. J Clin Psychiatry 2003;64 Suppl 16:10-3.
O'Malley SS, O'Connor PG. Medications for unhealthy alcohol use: Across the spectrum. Alcohol Res Health 2011;33:300-12.
Lohit K, Kulkarni C, Galgali RB. Factors influencing adherence to anti-craving medications and drinking outcomes in patients with alcohol dependence: A hospital-based study. J Pharmacol Pharmacother 2016;7:72-9.
] [Full text]
Joseph J, Basu D. Adverse drug reactions to disulfiram treatment with or without alcohol challenge in the Indian setting: Systematic review. J Postgrad Med Edu Res 2019;53:21-30.
Cargiulo T. Understanding the health impact of alcohol dependence. Am J Health Syst Pharm 2007;64:S5-11.
National Institute on Drug Abuse. Addiction Science: From Molecules to Managed Care. Bethesda, MD: National Institute on Drug Abuse; 2008.
Klimas J, Tobin H, Field CA, O'Gorman CS, Glynn LG, Keenan E, et al
. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database Syst Rev 2014;(12):CD009269.
Joseph J, Basu D, Dandapani M, Krishnan N. Are nurse-conducted brief interventions (NCBIs) efficacious for hazardous or harmful alcohol use? A systematic review. Int Nurs Rev 2014;61:203-10.
Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res 2000;42:241-7.
Heffner JL, Tran GQ, Johnson CS, Barrett SW, Blom TJ, Thompson RD, et al
. Combining motivational interviewing with compliance enhancement therapy (MI-CET): Development and preliminary evaluation of a new, manual-guided psychosocial adjunct to alcohol-dependence pharmacotherapy. J Stud Alcohol Drugs 2010;71:61-70.
Kranzler HR, Mueller T, Cornelius J, Pettinati HM, Moak D, Martin PR, et al
. Sertraline treatment of co-occurring alcohol dependence and major depression. J Clin Psychopharmacol 2006;26:13-20.
Anton RF, Moak DH, Latham P, Waid LR, Myrick H, Voronin K, et al
. Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence. J Clin Psychopharmacol 2005;25:349-57.
Kumar CN, Thirthalli J, Suresha KK, Venkatesh BK, Arunachala U, Gangadhar BN. Antipsychotic treatment, psychoeducation regular follow up as a public health strategy for schizophrenia: Results from a prospective study. Indian J Med Res 2017;146:34-41.
] [Full text]
Lin EC, Berk M, Hsu PC. A nurse-led psychoeducational program Balancingmyswing improves medication adherence among Taiwanese Han-Chinese with bipolar II disorder. Neuropsychiatry 2017;7:302-9.
Pakpour AH, Modabbernia A, Lin CY, Saffari M, Ahmadzad Asl M, Webb TL. Promoting medication adherence among patients with bipolar disorder: A multicenter randomized controlled trial of a multifaceted intervention. Psychol Med 2017;47:2528-39.
Haddad PM, Brain C, Scott J. Nonadherence with antipsychotic medication in schizophrenia: Challenges and management strategies. Patient Relat Outcome Meas 2014;5:43-62.
Shin SK. Effects of culturally relevant psychoeducation for Korean American families of persons with chronic mental illness. Res Soc Work Practice 2004;14:231-9.
Innamuri R, Palani K, Silas M, Samuel R, George DE, Peravali V, et al
. Effects of group psychoeducation on knowledge of caregivers of people with schizophrenia. Indian J Psych Nurs 2019;16:105.
Peterson AM. Improving adherence in patients with alcohol dependence: A new role for pharmacists. Am J Health Syst Pharm 2007;64:S23-9.
Savaş HA, Unal A, Vırıt O. Treatment adherence in bipolar disorder. J Mood Dis 2011;1:95-102.
Sultan S, Chary SS, Vemula SR. A study of non-compliance with pharmacotherapy in psychiatric patients. AP J Psychol Med 2014;15:81-5.
Lingam R, Scott J. Treatment non-adherence in affective disorders. ActaPsychiatrScand 2002;105:164-72.
Weiss RD. Adherence to pharmacotherapy in patients with alcohol and opioid dependence. Addiction 2004;99:1382-92.
Lucca JM, Ramesh M, Parthasarathi G, Ram D. Incidence and factors associated with medication nonadherence in patients with mental illness: A cross-sectional study. J Postgrad Med 2015;61:251-6.
] [Full text]
[Table 1], [Table 2], [Table 3]