To assess the Effectiveness of Psychoeducation Intervention on Reducing the Burden of Caring of Alcoholic Dependence Syndrome Patients among Family Caregivers

Background: Alcohol dependence is considered as a “family disease.” In terms of occupational and social instability, physical and emotional distress, and financial burden, alcohol dependency affects the person as well as those around them, which has a major effect on the lives of significant others. Aim: Study aims to assess the effectiveness of psychoeducation intervention on reducing the burden of caring for alcoholic dependence syndrome patients among family caregivers. Objective: 1.To identify the existing burden of caring of alcoholic dependence syndrome patients among family care givers in experimental group and control group.2.To evaluate the effectiveness of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers in experimental group and control group at post-test. 3. To evaluate the effectiveness of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers between experimental group Study Protocol Uke et al.; JPRI, 33(54A): 287-296, 2021; Article no.JPRI.74861 288 and control group. 4. To compare the effectiveness of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers between experimental and control group.5.To associate post-test score of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers with their selected demographic variables in experimental and control group. Methodology: The research design is experimental one group pre-test post with control group, and participants are, the Family caregivers of alcohol dependence syndrome patients. The aging population will be selected according to the criteria of inclusion and exclusion, and the sampling technique will be selected as the technique of purposive sampling technique. Data will be obtained by participants’ demographic variables and the use of a modified standardized scale for burden assessment and all scales distributed for reducing the burden of caring of alcoholic dependence syndrome patients among family caregivers. The literature review was identified through Pub MED, Medline, Cochran, computerized, books, library. Result: There may be effectiveness of psychoeducation intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family caregivers and this effectiveness will be tested with demographic variables by regression analysis. Conclusion: findings will be drawn from the statistical analysis.


INTRODUCTION
According to Global Status Report on Alcohol, Alcohol Use Disorders (AUDs) account for 1.4% of the global disease. Alcohol dependence is considered a "family disease." Alcohol dependence changes the individuals as well as those around them in terms of occupational and social dysfunction, physical and emotional distress, and a financial burden that has a serious impact on the lives of the significant others [1].
Alcohol use disorder (which includes a level that is sometimes referred to as alcoholism) is a pattern of alcohol use that involves problems controlling your drinking, being concerned about alcohol, continuing to drink alcohol even when it causes problems, having to drink more to have the same effect, or having withdrawal symptoms when you rapidly decrease or stop drinking [2].
Alcohol dependence syndrome is a previous psychiatric diagnosis (DSM-IV and ICD-10) in which an individual is physically or psychologically dependent on alcohol (also chemically known as ethanol). [3].
A chronic illness in which a person wants to drink alcohol and is unable to control his or her drinking. A person with this disease also needs to drink higher amounts to have the same effect and to have withdrawal symptoms after alcohol is stopped. Alcoholism affects physical and mental health and may cause problems with family, friends, and work [4].
(i) In the family the body of persons who live in one house or under one head, including parents, children, and servants. (ii) The group involving parents and their children, whether or not they live together; in a broader sense, all those who are almost connected by blood or affinity. (iii) Children of a person reared collectively. (iv) Those descended, or claimed descent from a common ancestor." From a psychiatric point of view, family means a group of individuals who live together in important phases of their lives and are bound together by biological and/or social and psychological relationships [5].
Family is a key resource for the care of patients, including those with mental illness in India. This has been attributed to the Indian tradition of interdependence and the concern of close relatives in adversity, as well as to the lack of mental health professionals. Family caregivers are those who provide care to other family members who need supervision or assistance in the event of illness or disability or those who provide unpaid care to family members with special needs [6].
Every time the family plays a key role in the care of patients with mental illnesses. This is especially true in India because of various factors, such as the tradition of interdependence, concern for the family, and lack of sufficient mental health professionals. Alcohol dependence has been a major social and personal threat in most countries. According to the Global Status Report on Alcohol, Alcohol Use Disorders (AUDs) account for 1.4% of the global burden of disease [7].
The burden is defined as the presence of problems, difficulties, or adverse events affecting the life(s) of a psychiatric patient or significant others. The families of patients with mental illness face stigmatization, the long-term economic and emotional burden of taking care of the patient. Patient illness has an impact on the work, social relationships, and leisure activities of family members. This evokes different feelings among family members, which may have an impact on the course and prognosis of the illness [8].
The family caregivers are those who provide care to other family members who need supervision or assistance burden [4]. Burden is said to be largely determined by family environment in terms of coping styles of different family members and their tolerance of the patients' aberrant behaviour. The family caregivers are those who provide care to other family members who need supervision or assistance in Family caregivers are those who provide care to other family members who need supervision or assistance from others. This adverse effect has been described as a burden. The burden is said to be largely determined by the family environment in terms of coping with the different family members' styles and tolerance of the patient's aberrant behavior [9] others. This adverse impact has been described as burden [4]. Burden is said to be largely determined by family environment in terms of coping styles of different family members and their tolerance of the patients' aberrant behaviou Caregivers restrict the freedom of family members, their personal space, and their social activities. Encouraging de-institutionalization of mental health policies leads the family to be caught unprepared to take care of members with schizophrenia, which in turn increases their caring of burden [10].
Alcohol abuse and alcoholism within a family is major problem that can destroy a marriage or drive a wedge between family members. This means that people who drink can blow through the family budget, because they fight, ignore children, and otherwise impair the health and happiness of the people they love. For married couples who get into physical altercations, some 60-70 percent use alcohol. In time, family members may even develop symptoms of codependency, inadvertently keeping the addiction alive, even though it may harm them. Family therapy and rehabilitation can help [11].
"Psycho-Education is a specialized form of education aimed at helping people to learn about a broad range of emotional and behavioral difficulties, their effects, and the strategies to deal with them". Psychoeducation has been used in mental health education to help individuals and their families and caregivers understand what's going on with the patient and to help them and their loved ones (Psycho-Educational Counseling Services, Inc., 2003) [12]. The concept of "psycho-education" refers to the process of providing psychological information to patients and clients, or anyone on a particular subject, or to students whose behavior is expected to change over a certain period of time within that subject [13,12,14].

BACKGROUND OF THE STUDY
The family is a system made up of subsystems within its boundary. The subsystems are the marital dyad, the sibling subsystem, and the parent-child subsystem. Changes in one part of the system lead to changes in the other parts of the system. Substance abuse affects every member of the family system devastatingly. It adversely affects the emotional climate of the family, the identity of the family, the tasks of the family, and the relationships between the members of the family. Family interventions focus on bringing about a positive change in all subsystems to help the family recover from the trauma of widespread negative effects of substance use on the family [15,16].
Epidemiological survey of 2992 people to estimate the prevalence of alcohol and drug dependence in rural and slum populations of Chandigarh, 6.88 percent of individuals met the International Classification of Diseases Dependency Criteria 10th Revision (ICD-10). Alcohol was the primary substance of dependence in the majority of urban slums and rural areas. Alcohol and drugs have affected almost all areas of life, including health (85.71%), family (77.31%), marital status (70.59), and occupational status (64.28%) [17].
Drug-dependent families face many challenges, including violence, disruption of family rituals, separation, divorce, inappropriate role models, and economic difficulties. Addiction does not break into the family the way a heart attack would do; instead, it creeps in slowly and silently until it is finally detected, and perhaps only then is the family confronted. However, by that time it left its mark on each member of the family [18].
Caregivers are often at the forefront of these issues, after all, because of their duties. It is not unusual for a caregiver to be in charge of monitoring and administering multiple prescription and over-the-counter medications. So, they may be the first to come across tell-tale signs of addiction, such as multiple prescriptions for the same medicine from different doctors, or bottles that have been emptied long before their monthly refill is due . [19].
It is also not unusual for a caregiver to regularly assist with bathing and personal hygiene tasks, so caregivers may also be the first to notice bruises, bumps or cuts due to drug or alcoholrelated falls or injuries. A caregiver is more likely to be the first on the scene of a fall or injury, for that matter [20].
Caregiver burden may be defined as both the activities that must be completed during caring and the manner in which the caregiver evaluates the completion of these duties. While caregiver stress has been related to a number of negative physical and mental health outcomes, less emphasis has been devoted to how it affects drinking habits [21].

NEED FOR THE STUDY
A substance-dependent person in the family affects almost all aspects of family life. This leads to problems, difficulties, or adverse events that affect the lives of family members and place enormous burdens on family caregivers [6].
The psychological and behavioral impact on others is often far greater than that of a substance-dependent family member. Yet, due to the historical emphasis on substance dependence as an individual's problem, the study of family problems has been relatively neglected [22].
Members of the family are concerned about the substance abuse behavior of the individual, but they also have their problems. At times, complementary or mirroring problems may form the relationship into a codependent dimension, where the "non-ill" member becomes overly concerned with the difficulties of the other and renounces to his/her wants and needs. Of course, this concept may lead to the risk of pathologizing otherwise normal caring functions, particularly those related to empathy and selfsacrifice [23].
In a potentially highly unstable 'role play,' members often have to change their traditional family roles or add new, often inadequate functions to adapt to the unpredictable, unreliable, and sometimes demanding behavior of the substance abuser. The individual usually engages in the search or use of substances most of the time and is often incapacitated by the effects of alcohol or drugs, which prevents him or her from fulfilling any responsibility in the family [24].
According to a survey conducted by the Punjab Government, every 3rd male student in Punjab is committed to substance abuse. Consumption of opiates in Punjab is 3 times the national average reported. The problem of drug abuse has reached an epidemic state in the state of Punjab. Families of alcoholics, especially spouses, are at increased risk of stressful life events, medical and psychiatric disorders, and increased use of medical services [25].
Caregivers may also be in charge of giving care following a serious disease or of monitoring a dementia patient. A variety of external variables influence how an individual evaluates their caring obligations, including caregiver personality, social support network, family status, and other responsibilities.
As many of the families in India, as well as the rest of the world, were worrying and disturbed by the substance abuse, it is not the individual who is disturbed by the substance, it also affects the family members, who took care of the individual. Imparting knowledge through psychoeducation on reducing the burden of caring of alcoholic dependence syndrome patients among family caregivers will be helpful for them, which will further improve their physical as well as their mental health [26].

OBJECTIVES
 To identify the existing burden of caring of alcoholic dependence syndrome patients among family care givers in intervention group and control group.  To evaluate the effectiveness of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers in intervention group and control group at post-test.  To evaluate the effectiveness of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers between intervention group and control group.  To compare the effectiveness of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers between intervention and control group.  To associate post-test score of psycho education intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family care givers with their selected demographic variables in intervention and control group.

METHODOLOGY
The research design is an experimental research design and the sample will be selected as per inclusion criteria. A purposive sampling technique will be used for selecting the sample. Data will be collected by using the demographic variables and modified burden assessment scale for assessing the effectiveness of psychoeducation intervention on reducing the burden of caring of alcoholic dependence syndrome patients among family caregivers.

Inclusion Criteria
 Family care givers who were available during the period of data collection.
 Family care givers were willing to participate.  Family care givers include spouse, mother, father, son, daughter, and friend one who knew about the client for six weeks.

Exclusion criteria
 Family care givers who were already exposed to this type of study.

Data Management and Monitoring
Data collection will be conducted for a single month span. This research will be carried out after receiving authorization from the authorities concerned.

Tool for Data Collection
SECTION I-It consists of demographic variables of the family caregivers to participate in the study e.g., Age, gender, marital status, occupation, educational status, monthly income, religion, family type, residence, relationship with the patient, family history of substance abuse, years of substance dependence, Age of initiation of substance dependence.

SECTION II -A validated
Modified burden assessment scale will be used to assess the effectiveness of reducing the burden of caring of alcoholic dependence syndrome patients among family caregivers.

Modified Burden assessment scale
The investigator developed a modified burden assessment scale for the purpose of assessing the level of burden of caring of alcohol dependence syndrome patients among family care givers which was validated by 10 experts. The FBIS (family burden interview schedule) is a modified burden assessment scale for alcohol dependence of family care givers.

Data Analysis Method
Descriptive statistics or inferential statistics will be used. For analysis of demographic figures will be going used frequency and mean percentage, and standard deviation used for assessing the burden assessment amongst family caregivers.

RESULTS
This research study will plan to investigate to recover burden assessment between family caregivers with the help of a modified burden assessment scale. the researcher will investigate how to reduce the burden through intervention. This study will help to assess the effectiveness of psychoeducation intervention on reducing the burden of caring for alcohol dependence syndrome patients among family caregivers.
The Author conducted a pilot study for two-week 12 th October to 25 October 2020. Prior data collection permission was obtained from the primary health center Arvi Naka Wardha. Selected 10 samples to form Arvi Naka Wardha family caregivers, by non-probability convenient sampling technique. Investigator started data collection on knowledge of burden. The researcher used a validate modified burden assessment scale and the result was 10% of the moderate burden of family caregivers in pre-test score, 70% in pre-test had the severe burden, 20% of the extreme burden in pre-test score experimental group, 70% in pre-test had the severe burden, and 20% of the extreme burden in pre-test score control group, 10% in post-test had no burden and 90% in post-test had the mild burden of burden assessment score. In the pretest, the range of Level of burden Score in the experimental group pre-test was 84-133 and the range of Level of burden Score in the control group was 115-148. The mean Level of burden Score in the experimental group pre-test was 122.40 ± 14.362 and the mean percentage of the Level of burden Score in the control group was 125.80 ± 12.318. in the post-test, the range of Level of burden Score in the experimental group post-test was 10-51 and the range of Level of burden Score in the control group was 115-148. The mean Level of burden Score in the experimental group post-test was 38.60 ± 10.916 and the mean percentage of Level of burden Score in the control group was 125.80 ± 12.318.

DISCUSSION
Aims of this study investigate reducing the burden of caring of alcoholic dependence syndrome patients among family caregivers through intervention. The results of the study were drawn on the statistical analysis.
One of the researchers has done A crosssectional assessment, the study demonstrates that caregivers of alcohol-dependent patients reported significant objective burden and subjective burden. Furthermore, the severity of alcohol dependence and the domains of burden such as financial burden, disruption of family interaction, and disruption of family routine activities were positively correlated with a high level of significance. The current study has illustrated that all the caregivers experienced a significant amount of burden which has to be addressed for better treatment outcomes of the patients. [27].
Researchers have done A cross-sectional study, compared to opioid and alcohol opioid dependence groups, more often the alcohol dependence group was older, married, currently working, having a higher income, and with the wife as a caregiver. Parameters like age, gender, relationship with a patient, marital status. F value is calculated using One-way ANOVA and T value is calculated using students unpaired tests were used to associate reducing the burden of caring of family caregivers scores with selected demographic variables significance at 5% level which is a statistically acceptable level of significance [28].
A cross-sectional descriptive study revealed that the study demonstrates that caregivers of alcohol-dependent patients reported significant objective burdens and subjective burdens. Furthermore, the severity of alcohol dependence and the domains of burden such as financial burden, disruption of family interaction, and disruption of family routine activities were positively correlated with a high level of significance. The current study has illustrated that all the caregivers experienced a significant amount of burden which has to be addressed for better treatment outcomes of the patients [29].
One of the researchers revealed that personal and socio-demographic factors of sex, age, marital status, education, and household income were all predictive of increased vulnerability to mental health problems over the last 12months. Both elements of the health status of one's relatives and family burden represent an increased vulnerability to personal mental health difficulties. the family burden would represent an elevated vulnerability to clinical personal mental health difficulties. Personal and sociodemographic factors were taken into consideration [30].
One of the researchers has done the quasiexperimental study; the majority of caregivers were female, married and homemakers, hailing from lower socio-economic status. There is a drastic reduction in caregiver's burden after SGWI in the experimental than in the control group. Improvement in quality of life in the experimental group after SGWI was maintained till the last follow-up [31].
One of the articles reveals that the Rating of burden is done on a three-point scale for each item and a standard question to assess the 'subjective' burden is also included in the schedule. Elements of family health examined included whether or not any illnesses are present within their parents, their spouse, their children, or their siblings, whether or not any physical illnesses are present within their family and whether or not any mental illnesses are evident within their family [32].
One of the researchers reported that it signifies a moderate-to-high burden of caregiving on the wives of these patients affecting adversely all aspects of their lives covered by the study instrument significantly. On comparing mean factor scores of burden assessment schedule and overall burden between AD and HD group, there was more burden (in all factors as well as in overall burden) on wives of HD patients than on wives of AD patients. Statistically, a significant difference was found in the factors of "impact on the marital relationship," "appreciation of caregiving," and "impact on the relation with others" but no statistically significant difference was found in the factors of "impact on well-being" and "perceived severity of disease" [25].
One of the researchers has revealed that there was a positive correlation between caregiver burden and the quantity of alcohol consumed, monthly alcohol expenditure, and years of marriage. The association between caregiver burden and various sociodemographic variables was not found to be statistically significant. There is a prevalence of moderate-to-severe caregiver burden among primary caregivers of patients of alcohol use disorder [33].

CONCLUSION
A conclusion will be drawn from the statistical analysis.

CONSENT AND ETHICAL APPROVAL
The research is endorsed by the Committee on Institutional Ethics of (DMIMS(DU)/IEC/Dec-2019/8678) Datta Meghe Institute of Medical Sciences. All participants must be requested to read and sign informed consent. 8.