The Effect of Self-Efficacy on Treatment Outcomes of Clients Enrolled in a Methadone Treatment Program in Rural Maryland

Bonnie A. Franckowiak, DNP, FNP, CARN-AP

Self-Efficacy

“The belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations.”

- Albert Bandura, 1986

Self-Efficacy is belief in one’s ability to

succeed at tasks.

General Self-Efficacy is belief in one’s

general ability to succeed at tasks.

Specific Self-Efficacy refers to beliefs

about one’s ability to handle specific

tasks.

Why Study Self-Efficacy?

Addiction is a Medical Disease

Addiction is a “chronic, relapsing brain

disease”, which has implications not only as an

individual health problem, but also as a public

health problem. It impacts the drug abuser and

the community on a physical, mental,

psychological and social level.

(Qureshi, Al-Ghamdy, & Al-Habeeb, 2000)

Background: Opiate Addiction

▪ 24.6 million Americans used illicit drugs in

2013 (9.4%)

▪ National cost is approx. $700 billion annually

▪ >8,000 new users daily

(SAMHSA, 2014)

Background (cont.)

▪ Public health problem with global implications

▪ Contributes to global mortality and morbidity

(NIDA, 2011)

Global Burden of Disease

DALY = Disability Adjusted Life Years

The number of years of potential life lost due to premature mortality and the years of productive life lost due to disability.

Global Burden of Substance Abuse

▪ Drug dependence responsible for

20 million DALYs in 2010

▪ Opioid dependence was the largest

contributor, with 9.2 million

▪ Highest burden in higher income

countries

▪ Illustrates increased need for

treatment

(Degenhardt, et al. 2013)

Principles of Addiction Treatment: A Research-based Guide (NIDA, 1999)

▪ No single treatment is appropriate for all

individuals.

▪ Treatment must attend to multiple need

of the individual, not just drug use.

▪ Remaining in treatment for an adequate

period of time is critical for treatment effectiveness.

Medication assisted treatment (MAT) using Methadone

▪Gold standard of opiate treatment

▪ Strict state and federal regulations

▪ Individualized according to need

MAT (cont.)

▪ Pharmacology, counseling, and behavioral therapy

▪ Comprehensive approach; Individualized care

▪ Goal: return to a state of health and well-being,

and function well in family and community

▪ Low cost, safe, and effective; Accepted world-wide

LITERATURE REVIEW

Retention in treatment

Psychosocial support

Behavior change

Self-Efficacy

Health Belief Model

Literature Review

Retention in Treatment

▪ Client satisfaction leads to improved outcomes.

Kelly, O’Grady, Mitchell, Brown & Schwartz; 2011

▪ Chronic illness is best treated collaboratively by client and

provider.

VonKorff, Gruman, Curry & Wagner; 1997

▪ Adequate methadone dosing, psychiatric care, and

behavioral counseling are key to successful treatment.

Ciraulo, Piechniczek-Buczek & Iscan; 2003

▪ Individualized treatment plans are associated with better

retention and outcomes.

Hser, Evans, Huang & Anglin; 2004

Psychosocial Support

▪ Satisfaction and rapport with staff leads to a decrease in

illicit drug use, better compliance with treatment, and

improved outcomes.

Joe, Simpson, Dansereau Rowan-Szal; 2001

▪ Clients who felt that needs were met during treatment

stayed abstinent longer… at 1 year follow up.

Zhang, Gerstein & Freidmann; 2008

▪ Outcomes improve when psychosocial support is added to

medication treatment, compared to medication alone.

Amato, Minozzi, Davoli, Vecchi, Ferri & Mayet; 2009

Behavior Change

▪Motivation is an important factor in behavior change.

Kelly, Zyzanski & Alemagno;

1991

▪ Self-efficacy affects the decision whether or not to initiate

behavior change.

Stewart, Wolfe, Maeder & Hartz; 1996

▪Maintenance of new behaviors is related to self-efficacy.

Scherbaum; 2008

Self-Efficacy

▪ Positive health behavior is related to high self-efficacy.

Schwarzer & Fuchs; 1995

▪ Efforts to improve self-efficacy lead to improved treatment outcome and retention.

Bourbeau; 2008 : Senbanjo, Wolff, Marshall & Strang; 2009

▪ Alcoholics with high self-efficacy resisted temptation to drink for longer time periods.

Vielva & Iraurgi; 2001: Allsop,Saunders&Phillips;2000

Self-efficacy is a fluid, dynamic concept.

Why is Self-Efficacy important?

Self-Efficacy

·Feelings

·Thoughts

·Motivation

·Actions

·Past

Performance

·Verbal

Persuasion

·Vicarious

Experience

·Psychological

/ Emotional

States

Health Belief Model (HBM)

▪ One of the most widely accepted and frequently used

models for study and implementation of behavior change.

Harrison, Mullen & Green; 1992

▪ Proven useful in improving patient compliance in many

studies related to various chronic illnesses.

HEALTH B Orel et al.; 2010: Ghaddar et al.; 2009: Koch; 2002

HBM (cont.)

Four conditions for behavior change:

The belief that one is at risk of developing a specific condition.

The belief that the risk is serious and the consequences are

undesirable.

The belief that the risk will be reduced by behavior change.

The belief that barriers to behavior change can be overcome and

managed.

(Janz & Becker, 1984)

Perceived Susceptability

to Disease “X”

Perceived Seriousness

(Severity) of Disease “X”

Demographic variables

(age, sex, race,

ethnicity, etc.)

Sociopsychological variables

Perceived Threat of

Disease “X”

Cues to Action

Mass media campaigns

Advice from others

Reminder postcard from physician/dentist

Illness of family member or friend

Newspaper or magazine article

Perceived benefits of

preventive action

minus

Perceived barriers to

preventive action

Likelihood of Taking

Recommended

Preventive Health Action

Health Belief Model

Janz & Becker, 1984

METHODOLOGY

Purpose:To determine if measurement of self-efficacy can be a useful tool in treatment of the opiate addicted client.

Research Questions

1. Are MAT and self-efficacy

related?

2. Are self-efficacy and

treatment outcomes

related?

1. I can always manage to solve difficult problems if I try hard enough.

2. If someone opposes me, I can find the means to get what I want.

3. It is easy for me to stick to my aims and accomplish my goals.

4. I am confident that I could deal efficiently with unexpected events.

5. Thanks to my resourcefulness, I can handle unforeseen circumstances.

6. I can solve most problems if I invest the necessary effort.

7. I can remain calm when facing difficulties because I can rely on my coping abilities.

8. When I am confronted with a problem, I can usually find several solutions.

9. If I am in trouble, I can usually think of a solution.

10. I can usually handle whatever comes my way.

The General Self-efficacy Scale (GSE)

Responses: 1= Not at all true. 2 = Hardly true. 3 = Moderately true. 4 = Exactly true.

English version by Schwarzer & Jerusalem, 1995

Specific Self-efficacy

11. If I ran into old friends who offered me pills or heroin, I could resist.

12. I can stay away from people I used to use with, and I feel strong.

13. If I was in a situation where people were using drugs, I would have

the strength to leave.

14. I feel that I am able to cope with stress in ways other than

using drugs.

Responses: 1= Not at all true. 2 = Hardly true. 3 = Moderately true. 4 = Exactly true.

Franckowiak, 2011

Additional questions relating specifically to opiate dependence

added by researcher.

Variables

▪ change in self-efficacy scores

▪ number of opiate-free urines

▪monthly group attendance

▪monthly individual counseling sessions

STUDY DESIGN

The Study

Admission

process

including

GSE

Initiate

Standard

MAT

After 6

months +/- 4

days

Obtain

informed

consent

Repeat GSE

Retrospective

record

review

of outcome

measures

Study Site:

Serenity Health, LLC Elkton, MD

Site Demographics:

96% Caucasian, 3% African American

54% female, 70% unemployed, 4% disabled

80% Medicaid, 20% self-pay

Average age 34 years

QUESTION #1: Are MAT and self-efficacy related?

Comparison of (Post- minus Pre-treatment) scores using Paired t-test

QUESTION #2: Are self-efficacy and treatment outcomes related?

Correlation of group and individual sessions, and number of opiate-negative urine screens using Pearson

Correlation

Analysis of Data

RESULTS

Gender Mean N Std. Dev.

Pre GSE

(General)

Females 25.86 14 4.276

Males 26.36 14 5.652

Combined 26.11 28 4.924

Pre GSE

(Specific)

Females 7.07 14 3.245

Males 8.50 14 3.391

Combined 7.79 28 3.337

Pre GSE

(Total)

Females 32.93 14 4.358

Males 34.86 14 8.047

Combined 33.89 28 6.425

MEAN PRE-TREATMENT GSE SCORES BY GENDER

Post GSE

(General)

Females 30.43 14 2.243

Males 31.07 14 5.166

Combined 30.75 28 3.922

Post GSE

(Specific)

Females 12.71 14 2.758

Males 13.79 14 3.118

Combined 13.25 28 2.939

Post GSE

(Total)

Females 43.14 14 3.780

Males 44.86 14 7.695

Combined 44.00 28 6.012

MEAN POST-TREATMENT GSE SCORES BY GENDER

t p value RangeAverageIncrease

Post-Pre

GSE score

(general)

5.730 .000 3.28 – 6.94 5.2

Post-Pre

GSE score

(specific)

7.163 .000 3.77 – 6.805.1

Post-Pre

GSE score

(total)

7.928 .000 7.49 – 12.72 10.1

COMPARISON OF PRE- & POST- TREATMENT

GSE SCORES

Research Question #1

Is MAT related to self-efficacy?

In this study, MAT does appear to

be related to self-efficacy.

Pre GSE

(General)

Pre GSE

(Specific)

Pre GSE

(Total)

Negative

Urine

Pearson

Correlation-.152 .047 -.092

Sig. (2-tailed) .441 .810 .643

N 28 28 28

CORRELATION OF GSE SCORES

AND NUMBER OF OPIATE NEGATIVE

URINE SCREENS

Pre GSE

(General)

Pre GSE

(Specific)

Pre GSE

(Total)

Individual Sessions Pearson

Correlation.010 .168 .095

Sig. (2-

tailed).962 .392 .632

Group Sessions Pearson

Correlation-.283 -.234 -.338

Sig. (2-

tailed).145 .232 .078

N 28 28 28

CORRELATION OF GSE SCORES

AND INDIVIDUAL AND GROUP SESSIONS

Research Question #2

Are self-efficacy and

treatment outcomes related?

No correlation was found

between self-efficacy scores and

any of the treatment outcomes

measured.

Descriptive Data

High GSE scores yielded more opiate negative urine

screens.

Subjects with high GSE scores preferred groups.

Subjects with low GSE scores preferred individual sessions.

Five subjects had unchanged or lowered GSE scores.

28 of 50 subjects identified completed the study.

Transferred to other treatment

facility 3

Moved out of area

2

Medical issues / Hospitalization

4

Incarceration

6

Administrative discharge

1

Referred to pain management

1

Left AMA

2

Unknown

3

Participants

who did not

complete the

study

(n = 22)

DISCUSSION & RECOMMENDATIONS

Strengths of the Study

Homogeneity of sample

All subjects received same MAT protocol

Inter-rater reliability

Met 6 month minimum for MAT

Limitations of the Study

Small sample size

High attrition rate

Did not control for additional group attendance

Did not control for type of group attended

Recommendations for Research Replicate with larger sample size and longer

duration.

Add measure of stress level.

Assess motivation for treatment.

Control for other variables (onset of drug use,

treatment history, and concurrent substance use).

Add control group who receives an intervention to

increase self-efficacy.

Recommendations for Practice

Repeat GSE at intervals throughout treatment, and

incorporate into Relapse Prevention programs.

Continue use of GSE testing as an aid in treatment

planning and counselor assignment.

Use GSE testing to strengthen patient assessment,

and view of “whole person”.

Follow Up at One Year…

Of the 28 subjects who completed the original study, 22 remained in treatment.

“Self-belief does not necessarily ensure success, but self-disbelief assuredly spawns failure.”

- Albert Bandura

From Self-Efficacy: The exercise of Control, 1997

Final thought...

Questions & Discussion

Thank you.