Relationship between Self-Efficacy, Social Support and Treatment Motivation among Addict Patients

Introduction:

Particularly among young people who are of working age, drug abuse is one of the most severe public health issues, with detrimental effects on one's health, family, community, education, and career (Moustafaa et al., 2020). According to Lüscher & Janak, (2021) addiction is a chronic relapsing condition marked by obsessive drug seeking, prolonged use despite negative effects, and permanent brain alterations. Commonly described as "a complicated brain disorder and a mental illness.

The United Nations, (2019) estimated in the 2016 World Drug Report that 275 million persons were involved in illicit drugs, including cannabis, amphetamines, opioids,  and cocaine. When combined, these present an annual prevalence of illicit drug abuse of 5.6% (WHO, 2018). Approximately 11 million people who inject drugs, 1.3 million are living with HIV, 5.5 million with hepatitis C, and 1 million with both HIV and hepatitis C (WHO, 2018). According to the National Addiction Research Study from 2018, 33% of Cairo residents regularly use drugs, compared to 22.4% of Upper Egypt residents and 9.6% of Delta residents (Rabie et al., 2020).

Self-efficacy is the belief that one can carry out behaviors required to attain an intended result (Bayr & Aylaz, 2021).Self-efficacy in the context of substance use can be seen as a person’s confidence in their ability to refrain from using substances in the future. Self-efficacy is frequently a therapy objective since it is a key indicator of recovery from substance misuse, including cocaine dependency, alcohol, opioids, and tobacco (Hussain et al., 2021).

Additionally, Lim et al., (2022) noted that improve the self-efficacy of people with substance abuse disorders results in improved performance, less withdrawal symptoms, increased stress resistance, and avoidance of negative outcomes. In a similar line Tusianah et al., (2021) found that, low self-efficacy can ruin patients' motivation, obstruct their cognitive capacities, and have unfavorable effects on their physical health.

Nikmanesh et al., (2017) defined social support as "the most effective tool to deal with chronic disease and tensions that make it simple to face problems.  According to (Grussling,  2021)social support can be divided into verbal and nonverbal support, inferred by mere presence, guidance, emotional encouragement, empathic listening, shared problem-solving, compassion, information, concrete aid. In this respect (Rubio et al., 2020) added that social support can come from family, friends, professionals and can have strong influences on whether an individual exits or remains in the substance abuse culture.

According to Nikmanesh et al., (2017), addiction is disorder that requires much more support than physical illnesses. Patients who abuse substances should therefore receive special attention from social and psychological support systems, especially following medical treatment. It aids people in experiencing themselves as valuable, respected, and valued human beings. It is very stressful to go through withdrawal process and break ties with peers who use substances, and this process need for social support. Therefore, one of the things that play a specific role in sustaining drug addicts' withdrawal is social support.

Motivation is defined by (D'Agostini, 2020) as a person's desire to alter their behavior. It plays a crucial role in the treatment of addictive behaviors like alcoholism and drug abuse (Mokuolu & Adedotun, 2020). Additionally, it has been demonstrated that patient attitude toward therapy and treatment outcomes are both predicted by the level of motivation throughout treatment (Kizilkurt & Gıynaş, 2020). In this context, Meisler, (2020) reported that motivation plays a critical role in treatment of any illness especially for the patients with addiction. Moreover, motivation affects how likely patients are to seek out treatment options, adhere to treatment guidelines, and notably, make successful long-term improvements.

In the same context, (Gorgulu,  2019) reported that, social support affecting external motivation. Family and friends also play a role in reinforcing the patient’s treatment compliance and motivation. The author also added that substance user’s low self-efficacy may trigger negative beliefs, affecting treatment adherence and motivation negatively. Furthermore, ( Liu et al., 2020) stated that self-efficacy and social support have a direct relationship such that lower self-efficacy affects an individual’s motivation to seek out positive social supports, and less social support may result in decreased self-efficacy beliefs.

In addition, (Kizilkurt& Gıynaş,  2020) reported that, an individual’s motivation for change might be strongly affected by support provided from family, friends, emotions, and social interactions. Moreover, social support from the family was found to be significantly lower in the low motivation. Similarly, (Mokuolu & Adedotun, 2020) showed that, joint relationship between self-efficacy and social support. Also, (Nikmanesh et al., 2017) reported that, people with higher self-efficacy beliefs are more self-protective and more successful at quitting drug abuse.

The risk factors for addiction should be understood by nurses. They must accurately evaluate patients and disclose any indications of addiction. The most frequently reported signs of substance addiction include rapid changes in behavior, personality, social exclusion, poor job performance, preoccupation with the substances being abused, and sudden weight loss (Rayan, 2017). Through partnership with patients and their families, mental health nurses have a special responsibility to those patients with substance use disorders. They should support patients to enhance their self-efficacy by gaining the necessary knowledge and skills to avoid drug addiction (Gemeay et al., 2019).

The nurse has very important role in motivating individuals undergoing drug rehabilitation to help patient to make changes. Nurses evaluate patients' abilities through use of effective coping and problem-solving skills, initiate necessary lifestyle changes, engage in peer support, and demonstrate active participation in motivational programs. They also monitor their progress, assist patients in adjusting life without drugs, and teach them how to maintain their sobriety after leaving rehabilitation (Mohamed et al., 2021).

Significance of the Study:

The UNODC, )2019) most recent World Drug Report estimates that 35 million people worldwide suffer from drug use disorders and need treatment services. In the same context, a study of substance abuse among preparatory and secondary school students in Assiut Governorate found that the prevalence of substance use disorders was 22.9%, with 50% of those affected being between the ages of 12: 16 and 49.68% being between 16: 19, with a pronounced male preponderance (94.59% males, 5.41% females). The most often used substance was nicotine, which was used by 89.9% of users, followed by cannabis (5.3%), beer and alcohol (1.8%), and tramadol (1.5%) (Rabie et al., 2020). Moreover, between 1999 and 2018, the drug overdose crisis caused the deaths of approximately 500,000 people, the majority of whom were connected to the opioid drug class (Cisneros & Cunningham, 2021).

Furthermore, (Kizilkurt & Gıynaş, 2020) mentioned that a strong predictor of high motivation throughout the early phases of treatment was discovered to be good social support from the family .The same author added that, social support playing an important role in increasing the efficacy of patients to cope with stress and the negative effects of a stressful life, and an important role in adherence to treatment against alcohol and substance addiction, prevention of relapse, and long-term improvement. Therefore the current study emerged aiming to assess relationship between self-efficacy, social support, and treatment motivation among addict patients.

Aim of the Study:

The current study aims to assess relationship between self-efficacy, social support, and treatment motivation among addict patients.

Research Questions:

• What is the levels of self-efficacy, social support and treatment motivation among addict patients?
• Is there a relationship between self-efficacy, social support and treatment motivation among addict patients?

Subjects and Method

Research Design:

A descriptive correlational research design will be utilized in the present study.

Setting:

This study was conducted at Minia psychiatric health and addiction treatment hospital that is located in New Minia City and affiliated to ministry of health (general secretariat for mental health and addiction treatment). This hospital consists of two floors; the first floor includes female in-patients psychiatric department, nursing office, pharmacy and out-patient clinic for addiction and psychiatric treatment. The second floor includes hospital administration, male in-patients psychiatric unit and addiction treatment department. The capacity of this hospital is 53 beds for both sexes.The addiction treatment department consists of two sections: the first detoxification section is consists of 8 beds and the second is rehabilitation section is consists of 10 beds. The hospital serves the whole Minia governorate

Subjects:

A purposive sample will be utilized in this study. According to the registration office of Minia Psychiatric Health and Addiction treatment Hospital, the total numbers of patients attending the inpatient department and out-patient clinics during the last year 2020 were (400) addicted patients. Based on this, the sample size was calculated according to the following equation margin of error at 5 %, confidence level at 95%, population size 400, response distribution at 20% the sample size will be (153) patients.

                     t²     x    p (1-p)                                 

N =

                       m²                          

Inclusion criteria:

• The age of patients ranges from 18 - 60 years.
• All addicts with different types of drugs.
• Patient who addicted for 6 months and more.
• Both gender
• Free from other psychotic illness as drugs induces psychosis

Exclusion Criteria:

• Patients who are diagnosed as mentally retarded.
• Dual diagnosis.

Data collection tools:

Considering the aim of the study data needed will be collected through the following tools:

Tool I : A structured interview questionnaire, it was designed by the researcher after extensive review of related recent literature. It composed of two parts:

Part (I) -: Socio-demographic data sheet includes personal data such as patient age, gender, educational level, marital status, occupation, residence, monthly income, and referral source.

Part (II) -: clinical data sheet such  as chronic disease, previous admission to hospital, previous surgery, addict patient in the family, type of drug or substance abused, method of substance abuse administration, age at onset of addiction, duration of addiction, cause of addiction, the addiction effect and number of substance abuse.

Tool II: General self-efficacy scale (GSE (:

This scale developed by Schwarzer & Jerusalem., (1995) is a self-report measure to assess their self-efficacy. A 4- Likert scale of 10 items relating to their dealing with their general feeling about themselves. The 4-Likert scale score are (4) exactly true, (3) moderate true, (2) hardly true, and (1) not at all true. It classified into 3 categories high self-efficacy if score ( ≥ 31),moderate self-efficacy if score  (21 ≤ 30),low self-efficacy if score  ( ≤ 20).

Tool III:Social support appraisal scale :

        This scale was developed by Vaux et al., (1988) is a self-report measure comprised of 23 items encompassing the perceived belief that the participant is loved, valued by, and interacts with family and friends. There are 5 reverse questions  (Q 3, Q10, Q13, Q21 and Q 22).  Responses were measured on 4 categories of scoring system are (1)strongly disagree, (2)disagree, (3)agree and (4)strongly agree. It classified into 2 categories satisfied with their social support if score(≥ 47) and dissatisfied if score  ( ≤ 46).

Tool IV: Treatment motivation questionnaire:

This questionnaire was developed by Ryan et al., (1995) to determine clients reasons for entering treatment and their feelings about treatment. A 3- Likert scale of 26 items under three dimensions as causes for treatment 5 items  (Q1- Q 5), probability of treatment 6 items (Q 6- Q11) and their feeling about treatment 15 items (Q12- Q26). The 3 - likert scale score is (1, 2, and 3) (1) if the response is not at all true, (2) somewhat true and (3) if very true scores. It classified into 3 categories very true treatment motivation if score  ( ≥ 52), somewhat treatment motivation if score  ( 26 ≤ 51) and not at all true treatment motivation if score  ( ≤ 25).

Validity of the tool:

The tools were translated into Arabic language and content validity was reviewed by five panels of jury experts in the faculty of nursing, Minia and Assiut university (psychiatric and mental health nursing department) to test the validity of tools. All jury members agree that the current study tools had a valid content and relevant to the aim of the study.

Reliability of the tool:

Reliability of the study tools have done by the researcher using the test re-test method of measuring internal consistency. Repetitive test responses have been contrusted using Cronbach's alpha coefficient test.The Cronbach's alpha coefficient test for general self-efficacy in the current study was 0.794. The Cronbach's alpha coefficient test for social support was 0.855 revealed a high internal consistency . Finally, the Cronbach's alpha coefficient test for treatment motivation showeded high internal consistency when measure in the present study; it equalized 0.842.

Pilot Study:

A pilot study was conducted at the beginning of the study. It includes (10%) of the total sample, to test clarity, completeness, feasibility, objectivity, applicability, adequacy of the study tools, determine possible problems in the methodological approach or tool and determine the time needed to complete the tools. No changes have done in the assessment, so the sample selected for the pilot study was included in the primary study sample.

Ethical consideration:

A written initial approval was obtained from the ethics committee of the scientific research at Faculty of Nursing, Minia University, there is no risk for the studied sample during performing the research. Oral informed consent was obtained from each participating patients after explaining the nature and benefits of the study. The patient has the right to accept or refuse the participation in the study without obligation.

Data collection procedure:

An official letter was granted from the dean of nursing college at Minia University, Ethical Committee, Nursing Faculty at Minia University. The scales were adopted, and translated into Arabic; then collect the jury approval for the scales to collect data of the study. Written consent were obtained from the director of Minia Hospital for psychiatric health and addiction treatment after explaining the purpose of the study and then, from Secretary General of Mental Health.

After obtaining the permission, the researcher began to introduce herself to the addict patient then, an oral informed consent was obtained from the patients after explaining the nature and purpose of the study through direct personal communication to gain their acceptance and cooperation as well as confidentiality was assured. A pilot study was done to assure scales clarity and applicability.  Then the reliability of the scales was done.

The investigator was collected data 3 days per week (Sunday and Tuesday from 2pm to 5pm outpatient clinics, and Saturday from 2pm to 8 pm at the inpatient unit).  Questions were asked and recorded by the investigator take from 20 to 30 minutes to complete the scale. The actual field work started from the beginning of June 2021 to the end of November 2021. Structured interviews conducted in one room of the in-patient department and outpatient waiting hall.

Statistical design:

The collected data was tabulated, computerized, analyzed and summarized by using descriptive statistical tests to test research questions by using SPSS version (26) e.g., frequency, percentage (%). Qualitative data were expressed as frequency and percentage. Probability (P-value) is the degree of significance, less than 0.05 was considered significant. The smaller the P-value obtained, the more significant is the result (*) and less than 0.001 was considered highly significant (**)

Results:

Table (1): Frequency and percentage distribution of the addict patients according to their socio-demographic characteristics (N=153).

Table (1) shows that, more than half of the addict patients (52.9%) are in age group ranged between <20years with mean age score (28.15+0.371). Regarding gender, most of them are males (96.7%). In addition (51%), (50.3%) and (68.6%) of the studied patients have secondary education, single, and technician respectively. Moreover, more than half (57.5%) of them are from urban areas.

Table (2): Frequency and percentage distribution of the addict patients according to their clinical data (N=153).        

Table (2) illustrates that, (70.6%) haven’t a chronic disease. Moreover, the same table explored that, (65.4%) of addict patients haven’t a previous admission to hospital. Also, (81.7 %) of them haven’t a previous surgery and above fifty percent (56.9%) of patients haven’t addict patient in the family.

Figure (1): Frequency distribution of the studied patients according to type of drug abused (N=153).

     Figure (1) illustrates that more than two thirds (66%) of the patient’s addict powder. While (11.1%) of them addict “hashish”.

Figure (2): Frequency distribution of the patients according to cause of addiction (N=153).

Figure (2) denotes causes of addiction, the high percentage (42.5%) of causes are to try and experiment while (30.1%) is pressure of friends and the low percent (1.3%) of causes are tension and anxiety.

Figure (3): Frequency distribution of the patients according to numbers of substance abuse (N=153).

Regarding to numbers of substance abuse, figure (3) shows that, highest percent of patients (92.1%) have daily substance abuse, while only (0.7%) has monthly substance abuse.

Table (3): Mean score comparison among addicted patient regards social support, self-efficacy and treatment motivation (N=153).

Table (3) reveals that, there are a statistically significant differences among total self-efficacy, social support and treatment motivation of inpatient department and outpatient clinics as (p=0.000**, p=0.000** & p=0.044*) respectively.

Table (4): Correlation between self- efficacy, social support and treatment motivation among addicted patients (N=153)

Table (4) explores that, there are a positive significant correlation between self-efficacy and social support as (r=.343**, P=.000). Moreover there are a positive significant correlation between self-efficacy and treatment motivation as (r=.141,* P=.053). In addition, there are a positive significant correlation between social support and treatment motivation as (r=.107*, P=.049)

Discussion:

Substance use is one of the important and serious problems at the international level that can distress many aspects of economic, social, physiological and emotional wellbeing, and considered one of the main problems in the present era (Ornell et al., 2020).The current study aims to assess relationship between self-efficacy, social support, and treatment motivation among addict patients.

Regarding distribution of the studied sample according to their age the findings of the present study revealed that, more than half of the addict patients are in  the age group <20years. The most likely reasons that could be advanced here are the pervasive effect of peer pressure on young adults and the effects of curiosity and experimentation. This result was congruent with (Poudel & Gautam, 2017) reported that, most of studied sample in the age group less were than 20 years. In contrast (Sharma et al., 2018) reported that, most of the drug addict’s between 25-34 year old.

Concerning gender the result of the present study revealed that, most of the studied sample was male. The reason for the male predominance in this study could be attributed to stigma in society toward person who addicted drugs; especially if those persons are female, Egyptian culture does not accept addicted women. So, the female patients are treated in secret and refuse to admit hospitals.  This result was congruent with (Rabie et al., 2020) reported that, in most studies, the majority of the substance users were males.

Regarding educational level the findings of the present study showed that, above fifty percent of patients were had secondary education degree. This may be due to individuals with the secondary level of education are usually work technicians, or commercial jobs with the relatively high income which is directed to the use of substance instead of other useful activities. This result was supported by (Ibrahim et al., 2018) reported that, most of the sample had a secondary school level of education.

Similarly, (Azim, 2019) mentioned that, (55.6%) respondents have completed their education to secondary level. In contrast, this result is not consistent with (El-Genady&Wahab, 2020), (Abdelkawy et al., 2022) reported that, majority of studied sample was primary education degree. Also, this result was disagreed with (Hassan & Atta, 2018) reported that, most of the studied sample was diplom after prep school (38.3%).

As regards marital status the findings of the present study revealed that, above fifty percent of the studied sample was single. This may be due to most of substance use patients ignore the marriage plan to keep privacy in practicing the addictive behaviors, avoid responsibilities and criticism from other spouse or reduce behavioral limitations. This finding was agreed with (Bayır & Aylaz, 2021) reported that, (67.9%) were single.

Also, this finding was agreed with (Gorgulu, 2019) reported that, (60.2%) were unmarried. In addition to, this result was congruent with (Abdelkawy et al., 2022) found that three fifths of the studied patients were single. Similarity, (El-Genady&Wahab, 2020) reported that, most of the studied sample was not married (46%, 12%, and 1%) single, divorced, and widow respectively. While this result was not consistent with (Jalali et al., 2018) reported that, (84%) were married and (16%) were single.

The current study results revealed that, more than half of the studied subjects were from urban areas. It may be explained by the fact that the urban regions are accessible for drug cultivation and drug deals, due to issues related to security and surveillance. On the other hand in rural areas, the stronger family bonds, social relations and fear of stigma make people to keep away from addiction. In addition to alcohol and drugs are forbidden as unacceptable behavior and are not encouraged by families and the society by cultures, beliefs, religion and law. This result was consistent with (Ebrahem et al., 2020) reported that, about two thirds of total studied patients were from urban areas. This result was disagreed with (Abdelkawy et al., 2022) reported that, majority of the studied patients were from rural residence.

Regarding the reason of previous admission the present study declared that all studied sample have previous admission to hospital for addictive reason. It might be related to the side effects of drugs which deteriorate the physical and psychological health, feeling of burden on family, stigma that attached to addict patient, withdrawal symptoms of drugs made family members of addicts afraid and rejected patients, all of these factors gave patients desire to change and motivates patient to seek treatment. This was in agreement with a study done by (El-Genady& Wahab, 2020) stated that the majority of the study samples were re hospitalized due to addict reason.

The current study explained that above two thirds of the patients addict powder, tramadol and hashish respectively. It might be related to opioids that muffle the perception of pain and boost feelings of pleasure, creating a temporary but powerful sense of well-being. Therefore, most patients prefer to use opioids. When an opioid dose wears off, the patient wanted those good feelings back, as soon as possible. The finding of the present study was supported by a study by (Andersson et al., 2021) reported that, among patients with primary drug use disorders, opioids represented the most prevalent drug. In contrast, this result was not consistent with (Gemeay et al., 2019) who mentioned that, the first line of used substances was tramadol (70%).

Concerning to the cause of addiction, the findings of current study showed that, less than half of the studied sample were abuse drugs for try and experiment. It might be related to that teenagers turn to drugs because they are just curious and want to experiment these substances with their peers who give him the feeling that he becomes mature enough. This result was congruent with (Dumbili et al., 2021) reported that, the most common cause of drug abuse is for experiment. On the other hands this finding was disagreement with (Azim, 2019) indicated that, (38.9%) respondents were using drugs in order to enhance their self-confidence.

Regarding to numbers of substance abuse, the findings of present study showed that, most of the studied sample was abusing drugs daily. This might be attributed to that addict patients take drugs daily to feel more euphoric and to increase their sexual ability as well as ability to work, beside tolerance to addicted substance and craving that push the patient to abuse the drug daily or even more. This finding was congruent with (El Ibrahimi et al., 2022) found that the greatest percent was abusing drugs daily. However, these findings were disagreement with (Hugo et al., 2021) reported that, about 50% used their main drug 2-3 days a week or more.

Regarding mean score comparison among addict patient the result of the present study revealed that, total self-efficacy, social support and treatment motivation were high among out-patient than in-patient. This might be related to different factors such as, during detoxification phase is distinguish by experience of negative emotions such as anxiety and depression, incomplete receive educational program due to effect of withdrawal symptoms, lack of support from staff, in-effective coping patterns. Additionally patients are newly involved in treatment and rehabilitation plan.

On other hand, the present study revealed that studied outpatients acquired more confidence and motivation due to obtained support from family and after attending psycho-educational program confidence increases gradually and acquire knowledge about substance related disorders than before. This finding was agreed with (Abdelkawy et al., 2022) reported that, self-efficacy; social support and treatment motivation are high among out-patient than in-patient.

The current study findings explored that; there were a positive significant correlation between self-efficacy, social support and treatment motivation. It might be related to when there is support from friends and relatives; the patient will feel more confident and rises his efficacy and motivation to complete the addiction treatment program. This finding was consistent with (Gorgulu, 2019) reported that, social support affecting external motivation. Family and friends; also play a role in reinforcing the patient’s treatment compliance and motivation. Also, the author added that substance user’s low self-efficacy may trigger negative beliefs, affecting treatment adherence and motivation negatively.

In addition, this finding agreed with results (Badie et al., 2021) reported that, a significant positive correlation between social support and quit addiction self-efficacy (r= 0.309; P < 0.01). Also, (Devlin, 2019) reported that, significant associations were found amongst social support and general self-efficacy. Social support was highly positively related to general self-efficacy (r =.476, p <.05). Moreover, social support from the family was found to be significantly lower in the low-motivation group compared with that reported in the high-motivation group (p = .004).

furthermore, this result was congruent with (Kizilkurt& Gıynaş, 2020) evidenced that high level of social support provided by the family was found to be a significant predictive factor of high motivation at the initial stages of treatment and the findings also demonstrated the existence of a joint relationship between self-efficacy and social support, this was in line with findings which stated that self-efficacy and social support help patients progress through the stages of rehabilitation. Similarly, (Mokuolu & Adedotun, 2020) showed that, joint relationship between self-efficacy and social support. Also, (Nikmanesh et al., 2017) reported that, people with higher self-efficacy beliefs are more self-protective and more successful at quitting drug abuse.

Conclusion

The current study concluded that:

The results of the current study revealed that total mean scores of self-efficacy, social support, and treatment motivation are higher among outpatients than inpatients. In addition, the studied participants showed that there was a positive significant correlation between self-efficacy and social support. Moreover shows that, there were a positive significance correlation between self-efficacy and treatment motivation & between social support and treatment motivation.

Recommendation

• Designing and implementing psych-educational programs are essential for addict patients to increase self-efficacy and improve their motivation for treatment to prevent the problem of drug addiction.
• Further cognitive and behavioral studies should be undertaken to strengthen social support mechanisms, increase the supportive participation of family members and to develop motivational techniques in order to increase the individual’s compliance and motivation.
• Designing and implementing educational programs at schools and communities about risk factors & hazards of addiction to prevent the problem of drug addiction and its negative consequences on the individual, families and communities.
• The preventive services should be mainly directed towards young and middle aged males, less educated persons, working in technical or commercial jobs and living in urban areas.