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PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION “AN EXPLORATORY STUDY TO ASSESS THE KNOWLEDGE OF CAREGIVERS REGARDING THE DRUG COMPLIANCE AND FACTORS AFFECTING DRUG COMPLIANCE AMONG PSYCOTIC PATIENTS ATTENDING OUT PATIENT DEPARTMENT OF SELECTED HOSPITALS AT TUMKUR CITY.” SUBMITTED BY – MR. YUGAL SWARNKAR FIRST YEAR M.Sc. NURSING (MENTAL HEALTH NURSING) AKSHAYA INSTITUTE OF NURSING SCIENCES TUMKUR – 02 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE BANGALORE, KARNATAKA ANNEXURE – II SYNOPSIS PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION MR. YUGAL SWARNKAR 1 NAME OF THE CANDIDATE AND ADDRESS FIRST YEAR, M.Sc. NURSING AKSHAYA INSTITUTE OF NURSING SCIENCES, S.I.T. MAIN ROAD, TUMKUR – 572102 AKSHAYA INSTITUTE OF NURSING 2 3 4 NAME OF INSTITUTE SCIENCES, TUMKUR. COURSE OF STUDY AND FIRST YEAR, M.Sc. NURSING SUBJECT MENTAL HEALTH NURSING DATE OF ADMISSION TO COURSE 28/06/2008 “AN EXPLORATORY STUDY TO ASSESS 5 TITLE OF THE STUDY THE KNOWLEDGE OF CAREGIVERS REGARDINGTHE DRUG COMPLIANCEAND FACTORS AFFECTING DRUG COMPLIANCE AMONG PSYCOTIC PATIENTS ATTENDING THE OUT PATIENT DEPARTMENT OF SELECTED HOSPITALS AT TUMKUR CITY.” 2 6.BRIEF RESUME OF INTENDED WORK INTRODUCTION Mental illness is an age-old problem of mankind. It is recorded in the oldest literature of all cultures all over the world. Historically mental illness was recorded as demonic possession, the influence of ancestral spirits, and the result of violating a taboo or neglecting a cultural ritual leading to spiritual condemnation. A mention of mental illness has been made in Bible where king Soul during the 4th century B.C. was suffering from abnormal irritability, great suspiciousness and uncontrollable impulses following some disturbed behavior early in life. Apparently he was a case of manic-depressive psychosis. Bhagavat Gita first recorded the evidence of a situation similar to panic attack and interventions like psychotherapy, crisis intervention, and counseling and directive psychotherapy. The celebrated Greek philosopher Plato wrote that mentally disturbed people were in some “obvious” sense not responsible for their acts and should not receive punishment in the same way as a normal person. The Greek physician Hippocrates stated that brain was the central organ of intellectual activity and that mental disorders were due to brain pathology. He said people should be simply made to pay for the damage and let him be exempt from other punishments. Research studies from different part of the country have shown that mental illness is as common in India as it is elsewhere and is equally common in rural and urban areas. Mental illness is defined as any disturbance of emotional equilibrium as manifested in maladaptive behavior and impaired functioning caused by physical, chemical, biological, psychological, genetic, social or cultural factors. In India the reported rate of mental illness is 100 per 1000 population.1 It has been estimated that 20%-50% of any patient population is at least partially complaint and that in patients with schizophrenia and related psychotic disorders rates run as high as 70%-80%. 3 6.1 NEED FOR THE STUDY Providing care for a member of the family with mental illness is an exhausting task for caregivers. They are the people who are always with the patient and their role is very important. Many a time the immediate blood relatives or those who care for these patients are unaware of the importance of continuing medications. They are also ignorant about the side effects of these medications and importance of follow up. Failure to take prescribed medication is thought to be the biggest cause of subsequent relapse, and this fact must be made absolutely explicit. The patient’s family members may be helpful in promoting long-term medication compliance if they are fully informed.2 Lack of active Participation of family and the patient himself is a key problem in the fight against mental illness. In April 1976, the 1st International congress on patient counseling devoted a major session to patient’s compliance and drug regimen. Non-compliance to drug becomes a major problem in chronic illness because it is the dropout rather than the remainer who in the long run seem to be the typical patient in the treatment of chronic illness. Families may positively influence adherence to medication regimens, be the first line of assessment for adverse side effects and supervise administration of the medication and refill prescriptions. It has been reported that seven out of 10 people with severe mental illness had family members who could be involved in their care.3 Compliance to treatment has been poorly understood. Only a few reports have conceptualized the determinants of non-compliant behavior. On further reviewing of literature in this area it is found that not many Indian nursing researchers have done a systematic and scientific study to explore that factors affecting compliance. The investigator while working in the Psychiatric OPD noticed that majority of patients (about 90%) who come here had faltered some time or the other in taking medicines. Quite a number of them had relapse or aggravation of symptoms. While interacting with the caregivers it was also observed that they do not have sound knowledge about the illness and its treatment. 4 All these observations, experience, curiosity and interest in the field prompted the researcher to undertake this study. 6.2 REVIEW OF LITERATURE “The more we search the more We find there is to know and As long as human life exists I believe, it will be so !!” Albert Einstein Literature review considered a systematic and critical review of the most important scholarly literature on a particular topic. The term refers to an extensive, exhaustive and systematic examination of publications relevant to the research study. The review helped the investigator in developing a deeper understanding and insight into the problem under study. It also helped in gaining information on the trends and developments in this area. The reviewed literature for the present study is:1. The study was conducted to assess the impact of non adherence and other factors associated with resource use and costs incurred by people with schizophrenia. A cross-sectional survey method was used and data was collected with the help of a structured interview schedule. 658 samples were studied and it was found that the rate of reported non-adherence was lower in the sub sample of patients resident in hospital (11.2%) compared with patients in other types of institution (21.2%).4 2. The study was conducted to evaluate the relationship between during compliance ad re-hospitalization in a group of schizophrenic patients. An exploratory survey was done with the help of a structured questionnaire. A total of 4325 patients were studied. Partially compliant patients with less then 70% compliance had significantly higher rates of hospitalization. There was an association between measures of partial compliance and risk of 5 hospitalization. The lower the level of compliance, the greater the risk of hospitalization. A gap of 1-10 days (Odds Ratio (OR)=1.98), a gap of 11-30 was associated with an OR of 2.81 and a gap of more than 30 days was associated with an OR of 3.96. Or in other words partial compliance was associated with increasing risk of relapse in the long-term treatment of schizophrenia.5 3. The study was Conducted an exploratory survey of 2507 subjects to find out their drug compliance. The data collected with the help of a structured questionnaire revealed that nearly two-thirds (64%) simply forgot to take there medication with 11% saying that this happened “often” or “very often”. Other main reasons cited were, to save money (35%) either thought they have no symptoms or symptoms went away (36%), did not believe that the drug was effective (33%), painful or frightening side effects (28%) and 25% felt that the drug did not allow them to do other things they wanted to do.6 4. The study was conducted to identify the factors associated with compliance or non-compliance to lithium therapy among the patients with bipolar affective disorder. The research approach adopted was that of a survey and data was collected with the help of structured knowledge questionnaire. The mean knowledge score of compliant patient (M=22.7) was significantly higher than that of their relatives (M=19.3). Males were found to be more compliant than females.(x2.21, P<0.04). Marital status was also significantly with drug compliance (x2.81, P<0.05). There was no significant between the compliance status and disease variables like duration of illness, number of episodes and number of hospitalizations. It was also found that 88.4% of non compliant patients stopped lithium for sometime after starting the treatment as they felt better. About 50% of patients forgot to take medicines and 42% patients felt taking lithium regularly as a stigma.7 5. The study was conducted to assess the attitudes, knowledge and practices of family members of clients with mental illness. A descriptive survey design 6 was used and data was collected with the help of a structured questionnaire with four modules. 78% were able to identify a cause or factor precipitating the onset of illness; about 97% stated that mental illness is curable with medication. Almost a third accepted that they used physical restraint to keep the ill client under control. More than 80% allowed the mentally ill client to attend the social gatherings or visit public places. 25% of participants objected to marrying a family member of a mentally ill person. The attitude scores were associated with education level of family members. The mean attitude score was statistically higher among those with secondary level of education (M=16.6, SD= 4.9) in comparison with those with primary level of education or illiterate (M=13.9, SD=4.5). Family members from urban area scored significantly higher (M=17.2, SD=4.5) than those from the rural area (M=14.3, SD=4.8).8 6. The study was conducted to assess how the psychiatric nurses assess & intervene in issue related to medication adherence. A total of 126 psychiatric nurses were included in the study. Open ended questionnaire which was to be self administered were send to the participants. Nurse approaches included providing medication education (70%) tracking adherences (62%) assessing medication effectiveness (45%) providing individualized, tailored adherence intervention(58%) & collaborating with other health care providers(50%) in medication planning.9 7 6.3 STATEMENT OF THE PROBLEM “An exploratory study to assess the knowledge of caregivers regarding drug compliance and factors affecting drug compliance among psychotic patients attending the out-patient department of selected hospitals at Tumkur” 6.4 OBJECTIVES OF THE STUDY 1. To identify the level of drug compliance among psychotic patients through care giver. 2. To assess the level of knowledge among care givers of psychotic patients. 3. To find out the association between knowledge of caregivers and drug compliance among patients receiving anti psychotic drugs. 4. To find out the association between drug compliance and selected demographic variables of psychotic patient. 5. To find out the various reasons contributing to drug non-compliance. 6. To prepare information booklet on improving drug compliance among psychotic patients. 6.5 OPERATIONAL DEFINITIONS Compliance The word compliance means following the prescribed treatment or co-operating with the treatment plan. In this study it refers to the extent to which the patient’s behavior coincides with the recommendations of the health care providers. It includes following the prescribed drug regimen, or keeping up the follow-up dates. Caregivers In this study the word caregivers refers to a close relative, friend or a paid person who attend to the immediate needs of the patient. 8 Psychotic patients In this study the word refers to a person, who is being diagnosed as a case of schizophrenia, bipolar affective disorder or major depression according to ICD-10 classification and who is receiving antipsychotic drugs 6.6 ASSUMPTIONS 1. The caregivers of psychotic patients will co-operate during the study. 2. Psychotic patients have different levels of drug compliance. 3. The care givers of psychotic patients have some knowledge regarding mental illness and its treatment. 6.7 HYPOTHESIS There will be significant association between knowledge of caregivers and level of drug compliance of psychotic patients. 7 MATERIALS AND METHOS OF THE STUDY A] SOURCE OF DATA: Before proceeding with the main study the written permission will be obtained from the authorities of the selected hospitals. Information will be obtained from the respondents who are willing to participate in this study. The data collection procedure will be carried out for a period of 6 weeks through interview method. B] RESEARCH DESIGN: Exploratory survey design study. C] STUDY SETTING: Sneha manovikas Kendra & O.P.D of District govt. hospital at Tumkur. 9 D] POPULATION: The target population of the study will be caregiver of psychotic patient. E] SAMPLE TECHNIQUE Purposive sampling technique. F] SAMPLE SIZE A sample size of this study is 80 caregivers in Tumkur. G] CRITERIA FOR SAMPLE SELECTION INCLUSION CRITERIA 1. Care givers of psychotic patient receiving Antipsychotic drug & who will follow up in the O.P.D. of selected hospitals at Tumkur. 2. Care givers who are willing to participate in the study. 3. Care givers who can communicate in English/Hindi/kannada. EXCLUSION CRITERIA 1. Care givers of the patients with , psychiatric as well as medical problems. 2. Care givers of the patients who are not attending the out-patient department of selected hospitals at tumkur. 7.2 METHODS OF DATA COLLECTION Before proceeding with the main study the written permission will be obtained from the authorities of the selected hospitals. Information will be obtained from the respondents who are willing to participate in this study. The data collection procedure will be carried out for a period of 6 weeks through interview method. 10 Description of the tool 1. Socio demographic Performa to collecting demographic data. 2. Structured questionnaire to assess the knowledge of caregivers of psychotic patients receiving antipsychotic drugs. 7.3Methods of Data analysis and interpretation Data will be analyzed according to the objectives of the study using descriptive and inferential statistics and will be presented in the form of tables, graphs and diagrams. 7.4Duration of the study : 6 weeks. 7.5Does the study require any investigation or intervention to be conducted on the patients or other human being or animals? If so please describe briefly. No 7.6Has Ethical Clearance been obtained from your institution in case of the above? . 11 8. LIST OF REFERENCES: 1.Gopinathan.P.S., Patients who discontinue day hospitalization.29(3) ed. Indian journal of Psychiatry. 1999, P.No 197-201. 2.Brooking J .I et al. A Text Book of Psychiatry & mental Health Nursing 1St ed., Edinburgchurchill Livingston 1992, P.No 409-410. 3. Johnson. B.S. Psychiatric Mental Health Nursing Adaptation & Growth 4th ed. Philadelphia: Lippincott 1997,P.No 54-56 4. Knapp M, et al., Non Adherence to Antipsychotic medication regimens Association With recourses use & costs. British Journal of Psychiatry,2004 , P.No 184 5. Widen P, et al. Partial Compliance and risk of rehospitalization among California Medicaid Patient with Schizophrenia.55(8)ed.Psychiatric Services 2004, P.No 886-891 6. Break well et al. Expressed emotion affective style lithium compliance and relapse in resent onset mania. Psychopharmacology Bulletin 2004 P.No 44,628638 7. Bhaduri et al. A study of factor associated with compliance or non compliance to litihium therapy among the patients with bipolar affective disorder ,The nursing journal of India .2003 ,vol LXXXXIV(1),P.No 9-11 8. Vimala D Rajan A.K.et al. A study to assess the knowledge, attitude and practice of family members of client with mental illness. The Nursing Journals of India.vol LXXXXIV(10),P.No 223-224 9. Kemppaien. j et al. Psychiatric Nursing & Medication Aadherence.41 (2)ed,Journal of Psychosocial Nursing. 2003. P.No 39-49 12 9 Signature of Candidate 10 Remarks of Guide 11 Name and Designation of (in block letters) 11.1 Name of Guide 11.2 Signature 11.3 Name of Co-Guide (If Any) 11.4 Signature 11.5 Head of the Department 11.6 Signature 12 12.1 Remarks of the Principal 13 12.2 Signature 14