ALCOHOL USE INTERVENTION MANUAL
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- ALCOHOL USE INTERVENTION MANUAL
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Alcohol Use Intervention
Manual
YOU ARE NOT ALONE
WE CAN HELP YOU
Department of Social and Behavioural Research
National Institute for Research in Tuberculosis
(Indian Council of Medical Research)
No.l, Sathyamoorthy road,
Chetpet, Chennai-600031
Tamil Nadu, India
Email: nirt@icmr.org.in
www.nirt.res.in
April 2014
Alcohol Use Intervention Manual, 2014
Alcohol Use Intervention Manual
Published by:
Department of Social and Behavioural Research
National Institute for Research in Tuberculosis
(Indian Council of Medical Research)
No.l, Sathyamoorthy Road,
Chetpet, Chennai-600031
Tamil Nadu, India
Email: nirt@icmr.org.in
www.nirt.res.in
April 2014
Alcohol Use Intervention Manual, 2014
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Preface
1 uberculosis (TB) remains a major global public health problem. India has
more new TB cases annually than any other country. In 2011, out of the estimated
global annual incidence of 9 million TB cases, 2.3 million were estimated to have
occurred in India. Under the Revised National TB Control Programme (RNTCP),
diagnosis and treatment facilities including a supply of anti TB drugs are provided
free of cost to all TB patients. Drugs are provided under direct observation and the
patients are monitored to facilitate complete treatment. Despite of all this, it has
long been evident that excessive alcohol intake is one of the major risk factors for
treatment non-compliance and mortality. Detecting alcohol use disorder,
specifically alcohol abuse and dependence, provides a critical opportunity for early
intervention efforts to reduce adverse impacts of alcohol consumption and promote
adherence for TB treatment. Strategies involving alcohol intervention needs to be
integrated into the TB control programme.
This intervention manual is intended to guide health professionals on alcohol
intervention strategies for tuberculosis patients on Directly Observed Treatment
Short course (DOTS) who consume alcohol excessively referred to as Alcohol Use
Disorder (AUD). It has been found that those who have AUD are non compliance
for TB treatment and require help to cope with this problem coupled with the need
?
for TB treatment regularly. This is an individual intervention manual and need to be
-
used on a one on one basis.
The content of the manual has been designed through community based
approach which took into account the inputs from TB patients with AUD, families
\
and health providers.
Dr. Beena E Thomas
Scientist’C’
Alcohol Use Intervention Manual, 2014
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Acknowledgements
The Department of Social and Behavioural Research, NIRT acknowledges the valuable
input and support provided by the various stake holders
1.
Central TB Division
2. State TB Officer
3.
City Health Officer, Chennai
4. District TB Officer
5.
T.T .Ranganathan Clinical Research Foundation, Chennai (TTK Hospital)
6.
Public health providers like Medical Officers, Senior Treatment Supervisor, Senior
Tuberculosis Laboratory Supervisor, Health Visitors, Lab technician and Health
Nurses
7.
TB patients and their family members
8.
Ms. Jamuna Senthilkumar, Ms. Sudha Ganapathy, (Retd) Dr. Mohana Suhadev, (Retd)
and Ms. Senthanro Ovung for their support in compiling and editing the content of the
manual
Alcohol Use Intervention Manual, 2014
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Abbreviations
TB
Tuberculosis
RNTCP
Revised National Tuberculosis Control Programme
DOTS
Directly Observed Treatment Short course
CAT
Category
IP
Intensive Phase
CP
Continuation Phase
MDR
Multi Drug Resistant
'
XDR
Extensively Drug Resistant
j
HIV
Human Immuno Deficiency virus
|
Alcohol Use Intervention Manual, 2014
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Contents
Page numbers
Session 1:
Introduction
6
TB and alcohol
Session 2:
13
Alcohol and its effects
Session 3:
20
Tuberculosis
Session 4:
22
Feedback
Alcohol Use Intervention Manual, 2014
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Session 1
Introduction, TB and alcohol
1.1
1.2
1.3
1.4
1.5
Rapport building
Intervention overview
Information on TB
Information on alcohol consumption
Wrap-up
Note: Text in italics is not read aloud
1.1 T^apport building
The reason we are here is to discuss about the ways for better treatment adherence.
7.2 Intervention overview
Each session must be conducted according to the schedule (as depicted below).
Category 1
Session 1
Session 2
Session 3
Session 4
At the time of treatment
initiation
2nd month (End of
intensive phase)
4th month
6th month(End of
Continuation phase)
Alcohol Use Intervention Manual, 2014
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Session 1
Begin the intervention with an ice breaker activity in order to put the patient at ease
and build rapport. Make sure to remind them about confidentiality.
Category 2
Session 1
Session 2
Session 3
Session 4
At the time of
treatment initiation
2 */2 month
5th month
8th month(End of
Continuation phase)
Encourage the patient to give their views on each heading (in bold letters)
1.3 Information on TB
Tuberculosis
Tuberculosis (TB) is an infectious disease
caused by Bacterium, Mycobacterium
tuberculosis.
•
It is spread through the air by a person afflicted
with TB.
•
TB most commonly affects the lungs, but can
also affect almost any other organ in the body.
•
India is the highest TB burden country with 2.2
million TB cases
•
There are about 1,600 new cases of TB every
year
It is important to emphasize that TB can be cured, to lessen their worry
•
•
TB is completely curable if diagnosed early and treated.
If the disease becomes more severe and very difficult to cure & more drugs should
be taken for a longer duration.
Alcohol Use Intervention Manual, 2014
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Session 1
•
Spread of TB
When an infected person coughs or sneezes, TB
bacteria are released into the air in tiny droplets.
Other people may breathe in these droplets. Those
with low immunity may acquire the disease.
Diagnosis
Checking your sputum is the best way to find out if you have
TB. Samples of sputum (phlegm) coughed up from the lungs
can be tested for the bacteria that cause TB.
For this test, you have to provide
• Home sputum - collect sputum from a deep cough first
thing in the morning and bring it to the hospital
• Spot sputum - visit a hospital and they will collect a
sputum sample at the time of investigation
TB treatment method
•
•
Treatment for TB lasts 6-8 months
There are two stages or phases in the treatment of TB disease
Initial phase (first two months) - 3-4 combination of drugs should be taken
regularly as per instructions in the presence of healthcare providers to try to kill
as many TB germs as possible
Continuation phase- some of the medications are stopped and others are
continued to try and kill the remaining TB germs in your body
Alcohol Use Intervention Manual, 2014
Session 1
Sputum smear testing is repeated after two months (end of IP) to
check progress, and again at the end of treatment (end of CP)
•
•
•
-
Incomplete or irregular treatment results in drug resistant TB (MDR-TB, XDRTB). Drugs for TB should be taken regularly as per instructions. DOTS ensure
effective treatment
For this treatment plan, patients are given anti- TB medicines which you need to
swallow in the presence of healthcare providers/community DOT providers.
DOTS reduces risk to the community by ensuring that TB positive individuals are
cured and preventing the spread of TB
Preventing the spread of TB
• Medicines should be taken regularly and doses
should not be missed
• Avoid spitting anywhere and everywhere
• Patients should be taught to dispose sputum
hygienically
• Patients should cover their mouths while coughing
• To take care of themselves, to eat well and
get a lot of sleep.
•
To abstain from alcohol and refrain from
smoking
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Session 1
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Patients should complete the course of treatment. Patients who stop taking the
medicines without completing the course are at the risk of developing
complications
If you have already taken treatment for TB, please inform your healthcare
provider immediately as your treatment is based on this information
Ways to protect your family members
•
°
®
°
Regularly take TB treatment
Cover your mouth while coughing
Avoid indiscriminate spitting
Bring family members to screen for TB,
including children aged 6 years or below
1.4 Information on alcohol consumption
Brainstorm about the causes of smoking and
Alcohol consumption
°
•
It is better to quit smoking as smoking affects the lungs and
reduces the immunity level
Researchers found out that alcohol is one of the reasons for default in treatment.
Hence, there is a need to understand the causes of alcohol
consumption and its effect on TB treatment
hopbcqvj
The alcohol in your drink is absorbed into
your body through the stomach and distributed
via the bloodstream throughout the body and
reaches the brain and alters its function
Need to stop drinking alcohol
Most of the alcohol a person drinks is metabolised
(broken down) by the liver. It can break down about
30 ml of brandy an hour. Because the liver is the main
organ breaking down alcohol, it's also one of the first pails
of the body to be harmed by heavy drinking.
What are some of the problems you have experienced (or you have seen anyone experienced)
due to alcohol intake
In short term-drinking too much can lead to a range of issues like weight gain, skin problems,
memory loss and depression
Over the long term- it can also cause more severe health problems such as increased risk of
high blood pressure, chronic liver disease and breast cancer
Alcohol Use Intervention Manual, 2014
Session 1
What happens in your body when you drink?
Brain
Nervous System
(
Headaches, Blackouts, Delusions,
Paranoia, Forgetfulness. Impaired
Judgement. Decline In IQ.
Dementia, Eplletic fits, Wernickes
disease (due to vitamin deficiency),
Haemorrhage, Peripheral neuritis,
Korsakoff's psychosis & Death
\________ .____________ /
Throat
"x
Peripheral neuritis-degeneration of
Pressure on portal circulation- risk of
the nervous system supplying limbs
haemorrage. Increased incidence of
cancer - 40x if smoker
\____ ___________ /
Gullet
Corrosive effect • risk of cancer
Lungs
A small amount of alcohol escapes
unused via breath 2-4%
X___________ _________ /
Liver
Muscles
X
Degeneration, weakness, pain
__________ _________ /
Heart
Fatty cells, tissue scarring, jaundice,
hepatitis, irreversible cirrhosis • the liver
breaks down 90% of alcohol consumed
X______________ __________/
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Weak & ‘fatty’ heart, weakening of
heart muscles, high blood pressure.
Anaemias due to decreased
^absorption of vitamins.
A small amount of alcohol escapes
unused via urine 2-4%
X________
_________
Session 1
Kidneys
(----------------------------------
Stomach
Gastritis, peptic ulcer
(direct corrosive effect)
Pancreas
Bad digestion, malnutrition, early diabetes
Fingers
Pins & needles
Sweat Glands
A small amount of alcohol escapes
unused via sweat glands 2-6%
Intestines
Inflammation (corrosion from alcohol)
J
Sex Organs
Male
_______
Nervous System
Depressed testicular production,
inpotenco, breast growth due to female
Malfunctions, skakiness. tremors
hormones not broken down by liver
Female
^Failure to ovulate, spontaneous abortion
Bones
Degeneration - risk of fracture
Alcohol Use Intervention Manual, 2014
Health related problems
Long-term excessive drinking can also lead to cirrhosis and liver cancer.
Drinking very large amount affects the functioning of brain which impairs mental
skills and alcohol related psychosis
Ulcer and cancer in stomach, mouth and throat, weakness of immune system, suffering
from cough and cold, illusion, aged appearance
Inflammation and dysfunction of liver, indigestion due to loss of appetite, jaundice
Tremor, numbness, irritation in hands and feet
Impotence, less interest in sexual intercourse
Knee pain, fracture and accident due to imbalance in gait pattern
Decreased muscle strength, anaemia, thrombosis (blood clotting)
Deterioration of meta cognitive skills, loss of memory, addiction towards alcohol,
insomnia, nightmares
Inflammation of heart, weakness of muscles, decreased blood flow, gastritis, stomach
ulcer, indigestion
Pancreatic inflammation associated with pain, dysfunction of pancreas and diabetes
Did you feel the session was useful? Discuss in detail
Feedback from patient: Write down the responses
What have you decided? What will be your choice?
Want to get out of the habit
Or
Become a victim to the habit and spoil your health
Scheduling and next steps
Inform that the next session will be on
We will discuss about TB treatment in next session. (Complete scheduling form)
Alcohol Use Intervention Manual, 2014
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Session 1
1.5 Wrap-up
Session 2
Facts about Alcohol and its effects on TB treatment
2.1
2.2
2.3
2.4
Recap of previous session
Facts about alcohol
Alcohol effects on TB treatment
Wrap up
Note: Text in italics is not read aloud
2.1
Recap of previous session
Encourage the respondent to give their views on each theme (in bold letters
What happens in our body after consuming alcohol ?
What happens when you drink more?
-Health problems
The more heavily you drink, the greater the potential for problems at home, at work, with
friends, and even with strangers. These problems may include:
Impact on community
Quarrels, theft, murder, cultural
degradation, disintegrated families,
psychosocial issues, suicide and death in
younger age, barrier for the overall
development of the society, committing
or being the victim of violence.
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Session 2
The consequences of drinking
Economical problems
Drop in income due to irregular to work, borrowing money for high interest rates
and falling into debt trap
Effect on Family
Arguments with or estrangement from your
spouse and other family members, suspicion,
Inability to take care of children and provide
education , failure to be a good role models,
inability to command and get respect from
others(loss of social esteem), anxiety and
depression
Issues related to work
Conflicts with colleagues due to illness,
Loss of job due to absence from or being late to work, and decreased productivity
Ridicule and disrespect by colleagues
2.2 Facts about alcohol
People who should completely abstain from drinking:
•
•
•
•
Youngsters below 21 years (legal age limit)
Those on medications or with other medical problems
like liver problems should not drink even small
quantities of alcohol
Pregnant women
Prior history or current serious psychiatric problems
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Session 2
It doesn’t give solution to your problems on the contrary it results to more problems
Alcohol has no nutritional value and gives a false sense of energy on the contrary it
affects your appetite and lowers the level of vitamins in your body
It does not increase your intelligence and work performance
You lose respect in the society
What will happen even if you drink less?
Before we get started, let’s talk about the need to stop drinking alcohol.
Even if less intake of alcohol creates/causes the following
•
•
•
Impairs the function of brain
Increased risk of accidents while driving, swimming and operating machines
Risk of getting HIV due to unprotected sex
Brands / Types of Alcohol
Units of alcohol are a measure of the volume of pure alcohol in an alcoholic beverage
Alcoholic content will be less or more in some of the drinks
30 ml - 1 unit
60 ml — 2 units
% bottle- 6 units
Calculation of units
Brandy, whisky, rum and gin- high alcohol content
Session 2
60 ml - 2 units
% bottle- 6 units
Beer - low alcohol content
I bottle- 650 ml- 2 units
Calculate the number of units of alcohol consumed per week
The number of units is calculated by the type, quantity and frequency of alcohol consumption
(How much, How long and Type of alcohol)
Assess drinking pattern in last week
Per week
Type
How much
In units
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Depending on the unit level consumed per week, inform them accordingly
Units per week
Strategies
Not at all drinking:
•
Appreciate and encourage them
for not drinking
1- 7 units
•
•
Right now not much effect
Still motivate them to cut down
the alcohol intake
Better not to drink more than 3
units per day and more than 7
units per week
•
More than 7 units
°
•
Please minimize your drinking
Heavy drinking leads to
physical or psychological harm
Session 2
What can you do to minimize drinking?
Every drink adds up and over time it can have a severe/serious impact on your health and
wellbeing than you realize. By making small changes to the way you drink you can make a big
difference. Not just the way you feel now, but to your long-term health.
That's why it's important to stick to the sensible drinking guidelines.
Alcohol Use Intervention Manual, 2014
By following these steps/strategies you can minimize your drinking.
Identify the triggers:
•
Is there any benefit?
•
Situation, place
Assess drinking pattern
-Perweek
Where your dinking pattern comes in
•
Brainstorm the ways to minimize drinking
•
Eat food before drinking
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Session 2
• Calculate the units (alcohol content)
-Per day
Following table can be shown once they complete the above exercise
Tackling the problem of heavy drinking
Once they know the facts, many people can quite easily revert back to sensible drinking if
they are drinking above the safe limits. If you are trying to cut down, some tips which may
help include:
Eat before you start drinking
•
Consider drinking low-alcohol beers, or at least do not drink strong beers or
lagers.
•
•
Try pacing the rate of drinking. Perhaps alternate soft drinks with alcoholic drinks.
It may be worth reviewing your entire social routine. For example, consider:
-Cutting back on types of social activity which involve drinking.
-Trying different social activities where drinking is not involved.
-Reducing the number of days in the week where you go out to drink.
-Going out to the pub or club later in the evening.
Try to resist any pressure from people who may encourage you to drink more than
you really want to.
•
From this it’s very important to know
“You can live happily and peacefully with out drinking”
Alcohol Use Intervention Manual, 2014
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Session 2
•
Here are some of the questions that can be asked to realize to cut down their drinking
■
■
■
■
■
You are not going to achieve anything
Is it necessary to drink?
Monitor the level of drinking
Calculate the units of alcohol consumed per week
Do contact if you need help
2.3 Alcohol effects on TB treatment
The reason why we ask you not to drink alcohol while you are taking TB medication is
to avoid increasing drug side effects and toxicity, because both can affect the liver and
is likely to cause rifampicin to be less effective.
• Patients may feel better after a few doses of treatment, but treatment should be
continued as advised by the doctor
• TB is curable if you take all the TB medicine which are given to you and do not miss
any doses, because if you do not take all the TB medicine, or if you stop taking it too
early, there is a chance for not getting cured completely or chances of getting TB again;
it would be more difficult to treat for a second time.
• High alcohol intake may adversely affect the regularity with which you take your
medication. However, it is important to remember that there is a need to minimise/avoid
drinking during treatment.
• If you have trouble taking medicine, you should always tell your TB doctor or nurse.
They should be able to suggest ways to help, or directly assist you to take your TB
drugs
• It’s better to show the list of medicine you take (vitamins, herbs, prescriptions, and
medicines you can buy without a prescription) when you visit your healthcare provider.
•
Did you feel the session was useful? Discuss in detail
Feedback from patient: Write down the responses
Scheduling and next steps
Inform that the next session will be on
TB treatment in next session. (Complete schedulingform)
We will discuss about
Alcohol Use Intervention Manual, 2014
Session 2
2.4 Wrap-up
Encourage the respondent to give their views on each heading (in bold letters)
3.1
Recap of previous sessions (1 and 2)
We would like to inform you that there is a need to investigate your contacts for TB.
It is better to screen them for TB in your PHC if they have TB symptoms
3.2 Treatment adherence
Following details will provide ideas on patient's treatment adherence
Have you been regular with your TB medication?
How many doses did the patient miss?
Has compensatory dose been taken?
Reason for late attendance
Alcohol Use Intervention Manual, 2014
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Session 3
Information on TB
Spread of TB
Diagnosis
Treatment period and method
Need for sputum test, whether it’s given for testing
Preventive measures for spread of TB to you and family members
Effects of alcohol
Calculation of units
Assessing drinking pattern
Ways to minimise drinking
Alcohol effects on TB treatment
Encourage the patient to realise the need to continue the treatment by providingfollowing
details
What happens when you are irregular with treatment?
•
If the patient is defaulted to take drugs, it results in severe complications like MDR and
XDR TB
•
It worsens the health and leads to death
•
As TB is an airborne disease, it may spread to your lovable child and wife.
•
Even if you are not able to continue with your treatment from DOTS provider
please inform us, so that we can suggest ways to help you to continue treatment.
So by continuing the TB treatment for required period, you will be cured from TB
completely
Side effects of drug
Write down the experiences and explain them the following
- Side effects like Nausea, Abdominal pain is common. There is nothing to worry
as all these will disappear within few days
- There is no damage to health due to consumption of too many drugs
- If there are more side effects please inform us, we will help you
3.3 Wrap-up
Did you feel the session was useful? Discuss in detail
Feedback from patient: Write down the responses
Scheduling and next sessions
Inform that the next session will be on(Specify the date).
Alcohol Use Intervention Manual, 2014
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Session 3
We would like to know the side effects you have experienced once the treatment started
(Complete schedulingform)
Session 4
Feedback
4.1 Review of Patient’s progress
4.2 Wrap-up
Note: Text in italics is not read aloud
We would like to get a feedback on your health progress as well as the intervention sessions
Session 4
4.1
Review of Patient’s progress
1. What do you think about the intervention?
2. What topics should have been covered more in-depth?
3. What topics were covered that you felt did not work for you?
Alcohol Use Intervention Manual, 2014
Session 4
23
Future implementation
1. What other program components would be helpful for TB patients who consume alcohol
2. What would you suggest about changing/modifying
the assessment visits?
,YES I CAW
3. Any other suggestions
Session 4
4.2 Wrap-up
Encourage them to complete the treatment and remind them to minimise their drinking habit
as alcohol consumption not only interferes the TB treatment but also it has its own effects.
Thank them for the feedback as well as for the time spent during the interventions.
Alcohol Use Intervention Manual, 2014
Drawing competition for school students on commemoration of World TB day 2014 held at National Institute for Research
in Tuberculosis - ICMR, Chennai
I
Department of Social and Behavioural Research
National Institute for Research in Tuberculosis
Indian Council of Medical Research
No 1, Sathyamoorthy road, Chetpet, Chennai-600031
Tamil Nadu, India
www.nirt.res.in
Alcohol Use Intervention Manual, 2014
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