Indian Journal of Public Health

: 2019  |  Volume : 63  |  Issue : 3  |  Page : 233--238

Enabling factors for behavior change among people with alcohol dependency: An exploratory study in a mental health-care facility

Pavani Yamarthi1, Nanda Kishore Kannuri2,  
1 Research Fellow, Diabetic Retinopathy and Retinopathy Project, Indian Institute of Public Health Hyderabad, Public Health Foundation of India, Hyderabad, Telangana, India
2 Additional Professor, Department of Social and Behavioral Sciences, Indian Institute of Public Health Hyderabad, Public Health Foundation of India, Hyderabad, Telangana, India

Correspondence Address:
Nanda Kishore Kannuri
Indian Institute of Public Health, Plot No # 1, ANV Arcade, Amar Co-op Society, Madhapur, Kavuri Hills, Hyderabad - 500 033, Telangana


Background: Alcohol dependence has become a major public health problem with many implications on the lives of dependents and their families. Objectives: The objectives of this study is to ascertain the enabling factors to seek medical help and continue behavior change among alcohol dependents and to assess the perceptions of health-care providers regarding treatment-seeking behavior of alcohol dependents. Methods: The present study deployed the transtheoretical model (TTM) as a theoretical framework for analyzing the enabling factors to seek medical help and continue behavior change among alcohol dependents and to understand the perceptions of health-care providers dealing with alcohol dependents at a tertiary care psychiatry hospital in Guntur of Andhra Pradesh. In-depth interviews and desk review of hospital records were done. Respondents included treatment-seeking individuals for alcohol detoxification (action phase), patients attending follow-ups (maintenance phase), and mental health professionals at the study site. The study was conducted during August and September 2017. Qualitative analysis using thematic framework and MS EXCEL for quantitative data was used. Results: Themes and subthemes emerging out of analysis were fitted in stages of TTM of behavior change. In the process of behavior change, there were key supportive elements such as problem awareness (precontemplation), availability and accessibility of services (contemplation), appropriate treatment modality (action), and alcohol anonymous groups (maintenance), which sustained the progress of change and yielded effective outcomes. Conclusions: Alcoholism needs to be addressed holistically rather than focusing only on biological treatment.

How to cite this article:
Yamarthi P, Kannuri NK. Enabling factors for behavior change among people with alcohol dependency: An exploratory study in a mental health-care facility.Indian J Public Health 2019;63:233-238

How to cite this URL:
Yamarthi P, Kannuri NK. Enabling factors for behavior change among people with alcohol dependency: An exploratory study in a mental health-care facility. Indian J Public Health [serial online] 2019 [cited 2021 Jan 21 ];63:233-238
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Full Text


Alcohol dependence has become a major public health problem in India. It has many implications on the lives of the alcohol dependents and their families. Alcohol dependence also affects the productivity and growth of a nation. According to the National Household Survey (2004) of drug use in India, the prevalence for alcohol use is 62.5 million, among whom 16.8% have been identified as clinically dependent on alcohol. One of the significant findings from the survey was that a number of them were not in treatment.[1]

According to a survey of noncommunicable disease risk factor conducted in Andhra Pradesh in the year 2007, mean age of initiation of alcohol consumption on a regular basis was 20 years for the respondents in the age group of 15–34 years and 25 years for the respondents in the age group of 35–64 years. It was also reported that the percentage of alcohol consumption was high for respondents whose main occupation was agriculture or manual work.[2],[3],[4],[5]

Considering the multi-dimensional impact of alcohol dependency, there is a need for the identification of effective means to control alcohol consumption and health promotion.

Theoretical framework

To understand human behavior in the context of health, many theories such as health belief model, transtheoretical model (TTM)/stages of change, social cognitive theory, and social ecological model were widely used.

The present study deployed the TTM as a theoretical framework for analyzing the health-seeking behavior of alcohol dependents who approached a mental health facility for treatment. Based on >15 years of research, the TTM has found that individuals move through a series of five stages (pre contemplation, contemplation, preparation, action, and maintenance) in the adoption of healthy behaviors or cessation of unhealthy ones. According to Prochaska and Velicer, TTM theory explains intentional behavior change along a temporal dimension that utilizes both cognitive- and performance-based components.[6] The objectives of the present study were to ascertain the enabling factors to seek medical help and continue behavior change among alcohol dependents and to assess the perceptions of health-care providers regarding treatment-seeking behavior of alcohol dependents.

 Materials and Methods

A cross-sectional, descriptive study was conducted in a mental health facility established and maintained by an NGO in Guntur district of Andhra Pradesh, between August and September 2017. Purposive sampling strategy was used to recruit participants who were attending alcohol anonymous groups and follow-up treatment from the outpatient services of the facility. Individuals who were abstinent from alcohol for more than a period of 2 months (action and maintenance phase according to TTM) were selected as study respondents. Mental health professionals providing services in the facility were the other set of respondents. Ethical approval was taken from the Institutional Ethical Committees of Indian Institute of Public Health-Hyderabad and Guntur General Hospital, respectively.

In-depth interviews were conducted with the study participants and mental health professionals. After obtaining written informed consent from participants, in-depth interviews were conducted in a separate space in the OPD setting maintaining their privacy and confidentiality. Two different interview guides were developed for patients and health-care providers. The major themes explored among the patients were on history of alcohol intake which included alcohol initiation, problem awareness, treatment-seeking behavior, motivation from social factors, individual factors, and institutional factors, whereas the major themes explored for health-care providers were challenges faced during the treatment, effective interventions for deaddiction, opinion on reasons for drop outs, retaining abstinence of alcohol, support needed from government and public. Desk review of hospital records was conducted to collect secondary data.

Data collected through the interviews were analyzed using thematic analysis approach.[7] Data analysis began after the first interview and “emergent themes” were also added to the interview guide. Adequate flexibility was given in structuring interview guide.


The analysis of 14 in-depth interviews with the study participants and mental health professionals are presented in this section. The findings are organized into three sections. Demographic details of participants [Table 1], thematic framework for treatment-seeking participants [Table 2], and treatment providing professionals [Table 3].{Table 1}{Table 2}{Table 3}

Demographic details of treatment-seeking participants

According to the data from the hospital records, it was evident that the prevalence of alcohol dependency was more among men in Guntur region. Among the respondents who participated in the study, the age distribution was in the range of 25–55 years which signifies early onset of dependency in younger age group. All of the respondents were married with most of them having at least one child. Except one of the respondents, all of them were working which indicates their job security. Most of the respondents belong to rural and semi-urban localitiesAs per the medical records of facility and the information provided by the participants most of them were admitted as inpatients for detoxification, and later followed up as outpatients. Some were admitted twice or more than twice on IP basis indicating the very high chances of relapse in alcoholism which requires a lot of patience and support from the family of the dependentsYears of dependency among the study participant's ranges from 10 to 30 years. Most of them had 10–15 years dependency history and it signifies the damage caused to the alcohol dependents in terms of their time, money, physical and mental health, and the duration of abstinence ranges from more than 2 months to up to 7 years. Eight out of 11 participants were abstinent for more than 1 year (maintenance phase) and some were more than 4 years which reflects their good levels of motivation.

Treatment-seeking behavior of participants

Theme 1: Reasons for alcohol initiation

The reasons mentioned for alcohol intake according to most of the participants were peer's influence, enjoyment, to mask physical pain after hard work, desire to taste alcohol after seeing elders in the family taking alcohol, force of relatives to take in some occasions, which are similar in other studies conducted previously.

Theme 2: Realization (reasons for seeking treatment)

All of the respondents expressed that they started to realize problem only when some or more form of damage occurred in the form of disturbances in the family, loss of job/business, loss of family's respect among relatives and neighbors and there was lot of impact on their work life which was in the form of loss in business and agriculture, suspended from services, discontinued studies, career growth declined.

Theme 3: Reasons for treatment adherence

The most cited reasons for treatment adherence were categorized into social factors, individual factors, and institutional factors.

Social factors

According to the respondents, the social factors that helped them to adhere to the treatment were support from the family members and other well-wishers. They received support in the form of suggestions and reminding them of their responsibilities; accompanying them to hospital for treatment, follow-ups and alcohol anonymous groups; financial support; searching for services which provide treatment.

Individual factors

From the participants perspective the individual factors which helped them in seeking treatment as their intention to change their behavior (self-motivation). Initially, they faced many problems such as withdrawal symptoms, pressure from peers, craving to drinking alcohol. They could overcome these by engaging in their job, taking up hobbies such as book reading, religious customs, taking tea/coffee, spending time with family, attending alcohol anonymous groups, staying connected with hospital and seeking advice from professionals whenever required.

Treatment pathway

The treatment pathway followed at the study site according to the participants was initial admission in to the hospital on inpatient basis until remission of withdrawal symptoms. First providing information to family and then counseling sessions which includes psychosocial education. After discharge partial support from institute was given through regular medication intake from hospital, seeking suggestions from professionals for the difficulties they faced when they were back to their environment for example writing practice to address trembling of hands, control of irritability-breathing exercises, low self-esteem-encouraging reading books, emotionally disturbed patients-counseling to improve their coping skills. Once they were stabilized they were given medication to be taken at home and follow-ups were done once in 15 or 30 days and attending Alcohol Anonymous groups weekly once.

Thematic framework: Perspectives of treatment providers

Theme 1: Perspectives on initiation of alcohol

Increased availability, exposure at the family level at very young age like in villages they encourage toddy intake as a healthy behavior, mandatory intake of alcohol on some occasions by elders, influence of technology development despite government regulations, and urbanization and imitation of western culture were the reasons for alcohol initiation as perceived by health-care providers.

Theme 2: Perspectives on role of family

Family plays a major role in both dropouts and abstainers. They should be educated about the problem, symptoms and particularly chances of relapse. Once patients get discharged and families tend to relax there is a chance of patients to go back to old behavior. Hence, the family is included in the process of treatment since the inception and their support plays a major role in maintaining patients staying sober.

Theme 3: Retaining factors for abstinence

The retaining factors observed in this study from the providers view were family support, appropriate treatment pathway, attending alcohol anonymous groups along with participants' intention to change.

Theme 4: Effective interventions

The facility chosen as a study site follows a unique multimodality treatment-bio psycho social intervention by detoxification and treating other comorbid conditions such as depression, motivation enhancement therapy and cognitive behavior therapy, vocational rehabilitation to address various issues in alcohol dependence. In their opinion the effective interventions for dealing with alcohol dependents were detoxification and relapse prevention by psychosocial interventions such as coping skills development, lifestyle modification, family counseling, encouraging them forming alcohol anonymous groups.


The overall objective of the study was to analyze the enabling factors for behavior change among alcohol dependents. The findings are in consonance with various studies conducted on the motivational factors for alcohol dependents to seek care in India.[8],[9],[10],[11],[12],[13]

Using TTM framework the study made an effort to analyze supportive elements at each stage of behavior change along with motivational factors which not only enhances progression of change but also yields effective outcomes as relapse is very common in alcoholism.[14],[15],[16]

It was evident from the respondents that during the precontemplation phase the participants had experienced major problems due to their dependence such as financial loss, health problems, and family disturbances. It was also apparent that the respondents were unaware about the dependency nature of alcohol and its ill effects. Here the participant's motivation to change triggered by problem awareness is the key factor to move in to the stage of contemplation.

During the contemplation phase, again due to lack of awareness regarding treatment, the respondents have tried different methods such as deaddiction powders, traditional healers, and religious practices to address alcohol dependency. Lack of services and accessibility, the respondents reported a delay in seeking treatment leading to loss of money and hope. At this stage along with social support, availability and accessibility of appropriate services are the key factors for speedy progress in to action phase.

Most of the respondents have approached the health facility signifying an action phase - as a last resort due pressure from family and friends. All the respondents mentioned that due to their past experiences, they were uncertain regarding the outcome of treatment in the health facility. To support the patients in the action phase, according to the health-care providers in the facility, they follow a unique multimodal treatment-bio psycho social intervention which contributes for the patients to be confident regarding the treatment outcome and progress to maintenance phase.

During the maintenance stage, self-management was a key prerequisite. Among the various strategies deployed by the respondents, attending alcohol anonymous groups was found to be most effective supportive factor for self-management.


Alcoholism has emerged as an important public health challenge. Theoretical frameworks such as TTM play a major role in understanding complex issues such as behavioral change and underlying motivational factors that facilitate progressive change. The current study findings indicate that alcoholism needs to be addressed holistically at individual, community, institutional, and health systems levels for effective outcomes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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