A TEMPORAL PROFILE OF PRO-ABSTINENCE-ORIENTED CONSTRUCTS FROM THE MODIFIED THEORY OF PLANED BEHAVIOR IN A SLOVENIAN CLINICAL SAMPLE OF TREATED ALCOHOLICS – AN 18-YEAR FOLLOW-UP Mirjana RADOVANOVIĆ1*, Maja RUS-MAKOVEC1 1University Psychiatric Hospital Ljubljana, Alcoholism Treatment Unit, Poljanski nasip 58, 1000 Ljubljana, Slovenia Received: Sep 2, 2017 Accepted: Nov 7, 2017 Original scientific article Introduction: Using the modified Theory of Planned Behaviour (mTPB), different indicators of therapeutic success were studied to understand pro-abstinence behavioural orientation during an 18-year after-care period following a 3-month intensive alcoholism treatment. The indicators were: perceived needs satisfaction (NS), normative differential (ND), perceived alcohol utility (UT), beliefs about treatment programme benefits (BE) and behavioural intentions (BI). Methods: The sample of 167 patients who consecutively started an intensive alcoholism treatment programme has been followed-up for 18 years, using standardised ailed instruments at the end of the treatment, and in the years 4-5, 9 and 18 of follow-up. The last data collection was completed by 32 subjects in 2010. The analysis followed the standard explore-analyse-explore approach. After the initial descriptive exploration of data, multivariate analysis of variance (MANOVA) in SPSS statistical package was set to explore between-groups and within-groups differences over time. Results: At the between-group level, BI remained stable at the same level as at the end of the treatment programme, whereas BE and UT robustly changed over time and levelled off after 10 years of follow-up. NS and ND show a trend of pro-abstinent orientation and level off after 10 years of follow-up, although the trend is not significant. The same results were confirmed by the within-subject level. Conclusions: Studied constructs stabilised after ten years of follow-up, apart from BI. The latter suggests that BI level needed for completion of an intensive treatment programme suffices for the maintenance of abstinence when accompanied by the change in perception of alcohol usefulness. Uvod: Z uporabo konstruktov iz prilagojene Teorije načrtovanega vedenja smo raziskovali kazalnike terapevtskega uspeha po intenzivnem zdravljenju sindroma odvisnosti od alkohola in v obdobju 18-letnega sledenja, da bi bolje razumeli v abstinenco usmerjeno vedenje skozi čas. Uporabljeni kazalniki so: subjektivna zaznava zadovoljitve potreb (NS), normativnost (ND), subjektivna zaznava privlačnosti alkohola (UT), prepričanja o koristnosti programa zdravljenja (BE) in vedenjski nameni (BI). Metode: Vzorcu 167 pacientov (128 moških in 38 žensk), ki so zaporedno vstopili v program intenzivnega zdravljenja sindroma odvisnosti od alkohola, smo sledili 18 let. Podatke smo zbirali ob koncu programa zdravljenja ter pet, deset in osemnajst let po končanem programu. Standardne vprašalnike smo anketirancem poslali po pošti. Na zadnji vprašalnik je odgovorilo 32 oseb (26 moških in 6 žensk). Obdelava podatkov je upoštevala uveljavljen tristopenjski pristop deskripcija – analiza – raziskava. Razlike v kazalnikih skozi čas smo analizirali z metodo multivariatne analize variance (MANOVA). Uporabljeni statistični paket je bil SPSS. Rezultati: Analiza razlik skozi čas (raven med skupinami) je pokazala, da je BI na enaki ravni ves čas sledenja kot po končanem zdravljenju, medtem ko sta se BE in UT robustno spreminjala v obdobju sledenja in se stabilizirala deset let po končanem zdravljenju. Tudi NS in ND kažeta trend v smeri proabstinenčnega vedenja in stabilizacijo po desetih letih, vendar razlike niso statistično značilne. Analiza razlik na ravni subjektov je potrdila rezultate na ravni populacije. Zaključki: Proučevani konstrukti so se stabilizirali po desetih letih sledenja, z izjemo BI, ki je bil ves čas študije na enaki ravni kot po zaključenem programu zdravljenja. Iz slednjega je mogoče sklepati, da je raven vedenjskih intenc, ki je potrebna za uspešen zaključek intenzivnega programa zdravljenja SOA, zadostna za vzdrževanje abstinence skozi čas, če temu sledi sprememba v doživljanju privlačnosti alkohola. ABSTRACT Keywords: long-term abstinence, behavioral indicators, theory of planned behaviour, alcoholism treatment IZVLEČEK Ključne besede: dolgoročna abstinenca, kazalniki vedenja, teorija načrtovanega vedenja, program zdravljenja sindroma odvisnosti od alkohola *Corresponding author: Tel: + 386 1 300 34 50; E-mail: drmirjana@siol.net 10.2478/sjph-2018-0002 Zdr Varst. 2018;57(1):10-16 ČASOVNI PROFIL KONSTRUKTOV PRILAGOJENE TEORIJE NAČRTOVANEGA VEDENJA V SLOVENSKEM VZORCU PACIENTOV PO ZDRAVLJENJU ODVISNOSTI OD ALKOHOLA – 18-LETNO SLEDENJE Radovanović M, Rus-Makovec M. A temporal profile of pro-abstinence-oriented constructs from the modified theory of planed behavior in a Slovenian clinical sample of treated alcoholics – an 18-year follow-up. Zdr Varst. 2018;57(1):10-16. doi: 10.2478/sjph-2018-0002. 10 © Nacionalni inštitut za javno zdravje, Slovenija. 1 INTRODUCTION Behavioural changes are one of the first recognized consequences of the addiction. The same is true for the syndrome of alcohol dependence. They are rather well understood by the patients themselves and people around them. Human beings are biologically equipped to observe, compare and interpret behaviours. Nevertheless, how well do we truly understand the mechanisms behind representations of a vast variety of behaviours? Do we have accepted or agreed upon theoretical concepts explaining the driving forces and many different facets of a behaviour? One of the theories that drew researchers’ attention from many scientific fields was developed by Icek Ajzen. His earlier work on the Theory of reasoned action (TRA) was extended in the 1980s to the Theory of planned behaviour (TPB). Briefly, TPB has its roots in the research of the attitudes by Allport and is based on Expectancy value models by Triandis (1). Ajzen, Fishbein and their colleagues set out to explain the discrepancy between the attitudes and observed behaviours, and they named this approach the Theory of reasoned action (1, 2). However, not all behaviour is fully intentional. By adding the concept of perceived behavioural control, their theoretical framework focused on predicting deliberate behaviours, hence the name TPB (3). The core assumptions are: a) a person’s behaviour is determined by her/his intention to perform a behaviour of choice; b)this intention is a function of one’s attitude(s) toward said behaviour and one’s subjective norms about the behaviour in question; c)another key factor is a perceived behavioural control (3). Addiction is a disease which mobilises all the abilities of a patient to sustain itself for as long as possible. Alcohol is the most widely used drug in the world. Epidemiological data from general population and student population studies show time and again that its use is among the highest in Europe (for recent data, see e.g. 4, 5). Addressing the negative or dysfunctional behavioural patterns and helping the patients develop new, health-oriented behaviours are among the more important goals of intensive addiction treatment programmes, alcoholism treatment included. The effectiveness of intensive alcoholism treatment programmes is evidence- based and comparable to treatment outcomes for other chronic non-communicable diseases (6-8). Alcoholism treatment programmes are also economically efficient if the patient remained sober up to 12 months (7, 8). On the other hand, to the best of our knowledge, few studies researched prognostic factors for stabile abstinence and long-term benefits (more than five years) of treatment due to complexity of factors influencing the outcomes (9- 11), or the studies used very specific populations (e.g. adolescents, young adults, specific co-morbid conditions) (e.g. 12), or were completed more than 30 years ago (13). Even fewer studies were based on behavioural theories, rather than diagnostic criteria, which change over time (14, 15). The modern understanding of treatment effect encompasses a broad concept of rehabilitation at a level of psychosocial functioning (16). The results of rehabilitation are incorporated into a pro-abstinence oriented lifestyle, i.e. relatively unburdened by the addiction-related problems. Such changes promote functional behaviours within the family, work and social environments of the patient, thus reflecting a paradigm shift from ‘having a chronic non-communicable disease’ to ‘being in a state of conditional health’, when pro-abstinence lifestyle is sustained over time. Recognition of long-term prognostic factors for abstinence and non-addiction-oriented lifestyle (together underlining ‘pro-abstinence behaviours’) informs both: for clinical populations, more personalised alcoholism treatment goals, based on individuals’ needs; and for alcoholism prevention programmes for general population, a theoretical background aimed at decreasing the burden of the disease. TPB explains a chosen behaviour (e.g. abstinence from alcohol) as a result of intentions to engage in a behaviour and relevant attitudes towards behaviour, subjective norms and behavioural control (17), similar to Bandura’s concept of self-efficacy (18). Clinical experiences based on following-up patients who had completed the intensive treatment programme and abstained from alcohol and other drugs for two or more years yielded an observation that this group of the clinical population accomplished abstinence-oriented behavioural changes, but many of them lacked the ability to feel good or find pleasure in life. Our project used modified TPB model (mTPB) to include perceived needs satisfaction (NS). This concept is based on Maslow’s classification of needs and includes acceptance, safety and creativity (19, 20). The aim of this study is to understand the relationship between long-term abstinence (5 years after the treatment and onwards) and mTPB constructs over 18-years of follow-up after the intensive hospital-based and abstinence-oriented high threshold alcoholism treatment programme. 2 SUBJECTS AND METHODS The study used a convenience sample of 167 (128 male, 38 female) consecutive patients admittedinto an intensive hospital-based alcoholism treatment programme in 1992. This intensive treatment programme could not admit patients with severe impairment in neuropsychological functioning, acutely suicidal or acutely psychotic patients without long-term stable remission. The programme duration was on average 10-12 weeks. It followed a biopsychosocial paradigm, and was comprised of group psychotherapy and additional treatment modalities (e.g. occupational therapy, art therapy, social skills training, etc.). It had two phases: during the first, patients 10.2478/sjph-2018-0002 Zdr Varst. 2018;57(1):10-16 11 10.2478/sjph-2018-0002 Zdr Varst. 2018;57(1):10-16 12 were full-time inpatients and, during the second, they continue the same programme, but spend two-thirds of the day outside of the institution (patients were in a day hospital). An active participation of important others was stressed as an essential part of the programme and the aftercare recovery in a group setting once a week was strongly recommended. Treatment orientation has been based on the synthesis of different therapeutic approaches, including principles of psychodynamic group psychotherapy, behavioural-cognitive interventions, elements of motivational enhancement therapy and (behavioural) marital and family therapy. The sample gender distribution was the same as in the clinical population. Subjects’ average age in 1992 was 38 years. The research was approved by Republicof Slovenia National Medical Ethics Committee and it conforms to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh in 2000). All the study subjects were informed about the details of the study and that the return of the fulfilled questionnaires will have been treated as the acceptance of the informed consent.The refusal to accept the informed consent was the only exclusion criterion. Mailed standardised self-fulfilled structured instruments were used. The original TPB by Ajzen was appealing to the research team because it did not require a specific questionnaire and it allowed modifications of the constructs. Our modification includes three constructs from the original TPB: normative differential, behavioural intentions and beliefs, and two constructs to include our research subject of interest: alcohol utility and perception of needs satisfaction. The instruments were constructed and standardised via use in different populations. Several kinds of validity were considered. Contrast or opponent groups validity was tested in representative samples of employed and unemployed inhabitants of the biggest city in the country, pharmacists, prisoners and a sample of highly successful individuals, students of psychology and students of other major subjects. Validity was tested also as internal consistency, using Cronbach alpha coefficients, which are mostly very satisfactory. Reliability was verified with the following techniques: correlation between forms, Spearman-Brown (un)equal lengths, Split half (Guttmann), Alpha coefficient. Most coefficients were between 0.80 and 0.90. Sensibility was identified as the relation between the certain measure of central tendency and measure of dispersion: in our case, as the relation between mean and amplitude of responses. Almost all instruments, applied in the presented research, were previously applied in other studies in non-clinical populations, and their distributions tested with Kolmogorov Smirnov test did not differ (p>0.05) or differed only slightly (0.04