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EFFECT OF POSITIVE COPING COUNSELLING ON QUALITY OF LIFE OF VICTIMS OF VIOLENCE WITH POSTTRAUMATIC STRESS DISORDER ATTENDING JOS UNIVERSITY TEACHING HOSPITAL GENERAL OUTPATIENT CLINIC
ABSTRACT
Objectives: To determine the effect of positive coping counseling on health related quality of life in victims of violence with post traumatic stress disorders attending JUTH outpatient clinic. Study Design/Setting: A randomized controlled trial involving patients aged 18 years and above presenting in GOPC with history of exposure to Plateau ethno-religious violence and meeting the criteria for diagnosis of PTSD.
Methods: Subjects were randomly allocated to a control and an intervention group. The intervention offered was structured counseling for positive coping using a structured format.
Data was collected about patients’ socio-demographic characteristics, number of exposure to violence history and interviewer administered questionnaire on coping and health related quality of life. Physical examination was done to assess pulse rate, blood pressure and body mass index. Subjects were followed up for twelve weeks after which change in coping behavior and health related quality of was assessed. Physical examination to assessed change in pulse rate, blood pressure and body mass index was also done at the end of the twelve weeks period.
Results: One hundred and forty subjects were recruited for the study but only 132 successfully completed the study. The data obtained were assessed as per protocol. The mean age of the study subjects was 40.59+_ 9 while 39% were males and 61% were females. There was no significant difference in pulse rate,(79.73 vs 78.35 p=0.342) blood pressure mean (124.22/76.95 vs 123.97/77.65 p=0.88 systolic, 0.643 diastolic ) and BMI (24.13 vs 24.38 p=0.675) between control and intervention groups at the end of twelve weeks. For coping behavior, in the control group, 89.1% had negative coping behavior at baseline line while at the end of the study only 28.1% had negative coping behavior. For the intervention group, 95.6% had negative coping behaviour at baseline, while at the end of the study only 14.7% had negative coping behavior.
There was no significant difference in the distribution of coping behavior across the study group.
(χ2 = 3.552, p = 0.059).
The study also showed that at baseline both subjects in the control and intervention group had poor quality of life (χ2 = 27.273, p = 0.0005). However, after intervension, there was a significant effect of positive coping counseling on HRQOL of subjects in the treatment group after treatment (F = 20.896, p = 0.0005).
Conclusions; Structured counseling for positive coping offered in the study was found to be effective in reducing the proportion of subjects with poor quality of life by 45.4%. Coping behavior was negative among the subjects but this however improved significantly over the 12 weeks of positive coping counseling with a more significant increase in the intervention group than the control group. Therefore, structured counseling for positive coping helps improve the quality of life in patients with PTSD.
CONTENT.
TABLE OF CONTENTS
DEDICATION .......................................................................................................................... ii
DECLARATION....................................................................................................................... iii
CERTIFICATION I ................................................................................................................... iv
CERTIFICATION II................................................................................................................... v
ACKNOELEDGEMENT........................................................................................................... vi
TABLE OF CONTENTS ........................................................................................................... vii
LIST OF FIGURES ..................................................................................................................... xi
LIST OF TABLES ...................................................................................................................... xi
LIST OF ABBREVIATIONS ................................................................................................... xiii
ABSTRACT .............................................................................................................................. xi
nbn bnb bnbnb bv
CHAPTER ONE ........................................................................................................................ 1
1.0 INTRODUCTION ................................................................................................................ 1
1.1 Background ........................................................................................................................... 1
1.2 Statement of the problem ...................................................................................................... 2
1.3 .1 Aim and objectives ............................................................................................................ 6
1.3.2 Objectives………………………………………………………………………………......6
1.4 Justification………………………………………………………………………………......7
1.5 Relevance to family medicine…………………….………………………………………….9
CHAPTER TWO……………………………………………………………………………….12
2.1 Global Violence……………………………………………………………………………..12
2.1.0 Definition of violence…………………………………………………………………......12
2.1.1 Types of violence………………………………………………………………………….12
2.1.2 Violence in Nigeria………………………………………………………………….…….13
2.1.3 Ethno-Religious violence in Plateau State………………………………………………..14
2.2 Post traumatic stress disorder (PTSD)……………………………………………………15
2.2.1 History and nomenclature of PTSD………………………………………………….....15
2.2.2 Overview of PTSD……………………………………………………………………..16
2.2.3 Pathology……………………………………………………………………………….16
2.2.4 Risk factors for PTSD…………………………………………………………………..17
2.2.5 Clinical Features of PTSD……………………………………………………………...18
2.2.6 Acute Stress Reaction…………………………………………………………………...19
2.2.7 Acute stress disorder……………………………………………………………………19
2.2.8 PTSD symptomatology and diagnosis……… …………………………………………20
2.3.0 Course of PTSD…………………………………………………………………………23
2.3.1 Screening for PTSD……………………………………………………………………..23
2.3.2 Measuring change in PTSD…………………………………………………………….25
2.4 PTSD and cardiovascular disease…………………………………………………………25
2.5 PTSD and Family functioning…………………………………………………………….28
2.6 Management of PTSD…………………………………………………………………….29
2.6.1 Nonpharmacological management………………………………………………………29
2.6.2 Pharmacotherapy for PTSD……………………………………………………………..32
2.7 Coping Behaviour and PTSD……………………………………………………………..33
2.7.1 Coping counseling in PTSD……………………………………………………………37
2.7.2 Assessment of coping…………………………………………………………………...38
2.8 Health related quality of Life (HRQOL) in PTSD………………………………………39
2.8.1 Assessment of Health related quality of Life………………………………..….………41
2.8.2 Benefit of assessment of HRQOL…………………………………………..………….42
CHAPTER THREE
3.1 Study setting…………………………………………………………………………….44
3.2 Study population…………………………………………………………………………45
3.3 Inclusion criteria…………………………………………………………………………45
3.4 Exclusion criteria………………………………………………………………...………45
3.5 Sample size………………………………………………………………………………46
3.6 Recruitment and randomization…………………………………………………………47
3.7 Study tools/ Instruments…………………………………………………………………48
3.8 Data collection…………………………………………………………………………..48
3.9 Study duration…………………………………………………………….…………….53
3.9.0 Study flow chart………………………………………………………………………53
3.10 Data management……………………………………………………………………...55
3.11 Data analysis……………………………………………………………………………55 3.12 Ethical clearance……………………………………………………………………….55
CHAPTER FOUR…………………………………………………………………………56
4.0 Results…………………………………………………………………………………..56
4.1 Sociodemographic characteristics of study subjects…………………………………..…57
- 1Age………………………………………………………………………………… …..58
4.1.2 Gender………………………………………………………………………………….58
4.1.3 Religion…………………………………………………………………………………58
4.1.4 Marital Status……………………………………………………………………… …58
4.1.5 Nationality……………………………………………………………………… ..…….58
4.1.6 Educational status…………………………………………………………………… ...58
4.1.7 Occupation……………………………………………………………………. .…..…..58
4.1.8 cigarette smoking……………………………………………………………..…. .……59
4.1.9 Alcohol use………………………………………………………………………………59
- Frequency of exposure of study subjects to violence………………………………….......59
- Mean value of clinical parameters of study subjects……………………………………….60
- 1clinical characteristics at baseline……………………………………… ……..…..…….60
4.4.2 clinical characteristics after the study……………………………… ………. .……..….61
4.4.3 Systolic and diastolic blood pressure at baseline and after the study…… …….……....62
4.4.4 Difference of body mass index at baseline and after the study…………….…….……....63
4.5.0 Coping behavior at baseline…………………………………….………………...……...64
4.5.1 Coping behavior after the study………………………………………………..……...64-65
-
Health related quality of life of study subjects…………………….……….…….…….….65
- Health related quality of life at baseline………………………………………….……...65
- Health related quality of life after the study………………………………..….…….…66
- Effect of sociodemographic factors on HRQOL of control group…………………...…67
- Effect of sociodemographic factors on HRQOL of intervention group…….……..…68-69
- Impact of coping counseling on HRQOL of intervention group……………..…..………70
- Differences in HRQOL between study groups at baseline and after intervention.……....71 CHAPTER FIVE………………………………………………………………………….......72
5.1.0 Sociodemographic characteristics…………………………………………………….…72
- Clinical characteristics of the study subjects………………………………………..…….74
- Coping behaviour………………………………………………………………….…...….78
- HRQOL of study subjects with PTSD…………………………………………………….80 5.5 Relationship between sociodemographic factors and HRQOL……………………...……81
CHAPTER SIX………………………………………………………………………………83
- Conclusion and recommendation…………………………………………..……………..83.
- Conclusion……………………………………………………………………..……….....83
- Recommendation and implication of the study findings………………………………….84 6.3 Strength and limitation of the study………………..…………………………………..…86
REFERENCES..................................................................................................................…...88
CHAPTER ONE
INTRODUCTION
• BACKGROUND
Global conflict and terrorism are prevalent in the present era,as a result,posttraumatic stress disorder (PTSD) has increasingly become a cause of substantial disability in both civilian and military populations.1 In the wake of increasing ethno religious conflicts plaguing Nigeria since the inception of democracy in 1999, Plateau State, the erstwhile home of peace and tourism has emerged as a flash point of conflict in Northern Nigeria2.Contest between the different groups in the State has resulted in sporadic violence in which many lives and properties estimated at billions of Naira have been lost.2 Violence and terrorism take a significant toll on mental health, and may be expressed in posttraumatic symptomatology, depression, low sense of safety,functional problems, low resiliency and distress that may require treatment.3 The disability and natural course of PTSD in psychiatric patients have been well characterized. However, even though the primary care setting has been described as the "defacto mental health care system,"surprisingly little is known about PTSD in primary care.4 Although investigations of Quality of life (QOL) in anxiety disorders remain less frequent than investigations of QOL in other disorders, there is evidence of diminished subjective well-being in patients with PTSD.5 Health-related quality of life (HRQoL) is an increasingly important outcome measure in healthcare, reflecting the transition of disease burden from infectious diseases to chronic conditions and the change from a paternalistic attitude to increased respect for autonomy and the subjective valuations of patients. Its measurement is important for rational public health policy, as it allows direct comparison between different conditions and intervention.6 In the trauma literature, there is evidence for the fact that the development of PTSD is associated with appraisals and coping styles.7 The success of targeting coping has been shown in studies on cognitive behavioural treatment in preventing or treating PTSD.7 Also, combinations of psychological (including counselling) and pharmacological interventions may help individuals to turn maladaptive (negative coping) responses into more adaptive one (positive coping).7
1.2 STATEMENT OF THE PROBLEM
The contemporary Nigeria has become a theatre of genocide, bloodshed and insecurity over the past years due to the deadly activities of terrorist groups.8 Terrorists of various groups and camps unleash havoc on the Nigerian populace.Though these groups are numerous, the most noticeable and deadly are the Boko Haram sect and Niger Delta Militants.8Conservative estimates put the number of people killed in communal violence across Nigeria since 1999 to 2012 at around 10,000; some government figures stand at more than 50,000 for Plateau state alone.9 Over the last decade, the political crisis in Jos, capital of Plateau State, has developed into a protracted communal conflict affecting most parts of the State. At least 4,000 and possibly as many as 7,000 people have been killed since late 2001, when the first major riot in more than three decades broke out in Jos. The number of internally displaced persons since 2001 peaked in 2004, with up to
220,000 people displaced .After the 2008 riot, more than 10,000 were displaced, while violence in 2010 alone resulted in about 18,000 people fleeing the clashes. Numerous houses in Jos have been burned and blackened remnants litter the streets in many parts of the city. Violence and displacement have reshaped Jos and many rural settlements. The presence of well-organized armed groups in rural areas, the proliferation of weapons, and the sharp rise in gun fatalities within Jos all point to the real risk of future large-scale violence.10
Worldwide, Violence is among the leading cause of death for people aged 15-44 years, accounting for about 14% of deaths among male and 7% of deaths among females.11 The World health report estimated that, in the situation of armed conflicts throughout the world, 10% of the people who experience traumatic event will have mental health problems and another 10% will develop behaviours that will hinder their functions effectively.11 Victims of violent trauma may suffer from a wide array of mental health problems, such as depression, somatization, hostility, generalized and phobic anxiety. 12, 13 The vast majority of studies in this area, however, has focused on posttraumatic stress disorder.14 The stress that results from traumatic events precipitates a spectrum of psycho-emotional and physio-pathological outcomes. Post-traumatic stress disorder (PTSD) is a psychiatric disorder that results from the experience or witnessing of traumatic or life-threatening events.15 It has profound psychobiological correlates, which can impair the person's daily life and be life threatening.15
Anxiety disorders not only contribute to biopsychosocial morbidity,but also may constitute a risk factor for sudden cardiac death.16 Cardiac arrhythmias, rather than induction or exacerbation of coronary atherosclerosis, seem to be the culprit in this setting.16
Chronic PTSD is often debilitating with work impairment or even unemployment, altered life trajectories, compromised social relations, marital discord and divorce and even violence. Among USmilitary veterans, chronic PTSD commonly leads to disability compensation.17 Exposure to a terrifyingevent such as violence may confront an individual with such horror and threat to a degree that usual psychological defences are incapable of coping with the impact.The consequences may be temporarily or permanently altered capacity to cope, changed concept of self and reduced quality of Life (QoL).18 Evidence is accumulating that anxiety and affective disorders are associated with substantial impairments in quality of life and functioning. Individuals with major depressive disorder,obsessive- compulsive disorder (OCD), panic disorder, and social anxiety disorder have substantially poorer quality of life than community comparison cohorts. In many cases,the quality of life impairments associated with these anxiety disorders are equal to or greater than those seen with other chronic medical disorders.19 PTSD is one of
the most common enduring mental health problems to occur and has probably received most attention in the research literature. Epidemiological research suggests that a third of individuals who develop acute PTSD remain symptomatic for six years or longer.The impact on social, interpersonal and occupational functioning for those who develop chronic PTSD can be very significant across the life span.20
Detection of PTSD in primary care is vital; primary care is most often the first point of contact for people experiencing mental and physical health problems.21 Failure to identify and treat PTSD has adverse effects on physical and mental health because traumatic stress is associated with increase health complaints, health services utilization, morbidity and mortality. Also, untreated PTSD can impair recovery from medical conditions.21 Prevention of PTSD can potentially reduce a significant burden of individual and societal suffering. PTSD symptoms seldom disappear completely, coping with PTSD symptoms and the problems they cause is usually a continuing challenge for survivors of trauma. It is through receiving treatment for PTSD that many learn to cope more effectively.
When a trauma survivor takes direct action to cope with problems, he or she often gains a greater sense of personal power and control. Active coping means recognizing and accepting the impact of traumatic experiences, and then taking concrete action to improve things. PTSD is a common mental disorder that is often associated with high levels of disability and co-morbid conditions. Numerous psychobiological alterations accompany PTSD. Primary healthcare providers are often the first and only source of advice and support for patients suffering from PTSD.
Appropriate intervention by primary healthcare providers may improve treatment outcomes.22 The goal of intervention is to enable the patient to re-establish psychological equilibrium and return to pre-accident functioning, if possible. This can often be accomplished by discussing the trauma experience, offering reassurance, educating the patient about PTSD, emphasizing coping strategies and prescribing medication when indicated. Rigorous research,including randomized controlled efficacy trials and effectiveness research, have shown that trauma focused therapy are quite effectivein similar degree and often yield outcomes that are enduring.23 Knowledge about people's experienceof reactions following exposure to violence, including the impact on their QoL,is needed to improve the understanding of these complex psychological processes. Its measurement is important for rational public health policy,as it allows comparison between different conditions and interventions using quality-adjusted life- years.
1.3 AIM AND OBJECTIVES
1.3.1 AIM OF STUDY
To determine the effectiveness of structured counselling for positive coping on the health related quality of life of adult victims of Plateau State ethno-religious violence with post traumatic stress disorder attending Jos university teaching hospital outpatient clinic (JUTH OPC).
1.3.2 OBJECTIVES
1.To determine the type of coping behaviours in victims of Plateau recurrent ethno-religious violence using a pretested- The Brief COPE tool.
- To determine the baseline health related quality of life of victims of Plateau ethno-religious violence with PTSD attending JUTH OPC using the COOP-WONCA charts.
- To compare the resting baseline pulse rate, blood pressure and body mass index of victims of Plateau ethno-religious violence with PTSD before and after treatment to ascertain if PTSD treatment and positive coping counseling improve cardiovascular outcome.
- To compare- at the end of the study period, the health related quality of life of victims of Plateau violence with PTSD receiving cognitive behavioural therapy and pharmacotherapy (if indicated)
with that of those who received the same treatment with additional structured counselling for positive coping .
1.4 JUSTIFICATION FOR THE STUDY.
With over four hundred (400) ethnic groups, belonging to several religious sects, Nigeria since independence has remained a multi-ethnic nation, which has been grappling and trying to cope with the problem of ethnicity on the one hand, and the problem of ethno-religious conflicts on the other.24 Religious bigotry, adoption of extreme position by ethnic, tribal and communal groups have instigated alarming degrees of conflicts on the country to the extent that secularity posture enshrined in the Nigerian 1999 constitution is fast retreating and all national integration efforts seem bleak as the dividing lines are constantly redrawn by identity conflicts.25 An intriguing phenomenon about conflicts and terror in the country is that they span the entire length and breadth of the country, dominating all strata of the polity and assuming both rural and urban dimensions.25
For some years now Plateau State has been a theatre of violent conflict. Over the past decade, at least 4,000 people have been killed in Jos and smaller cities and villages in Plateau State.26 Episode of mass killing and destruction of lives and properties seems to have started from 2001 and continued to 2010. But after 2010, there have been quite a number of episodic violence till date.26 In recent years, attacks have become more frequent and widespread.27
Violent conflicts pose a challenge to human civilisations, human health and health system.
Epidemiological studies indicate that war ranks among the top-ten causes of death worldwide.28
In addition to direct physical injury, victims of violence are at increased risk of a wide range of psychological and behavioural problems, including anxiety disorders ( PTSD).11
While most victims of Plateau recurrent ethno-religious violence usually have their physical injuries treated in hospitals, the future psychological complications are given less attention.The end result is the development of PTSD and other mental health symptoms. Posttraumatic stress disorder is a chronic and disabling psychiatric disorder associated with a significant degree of morbidity.19 The chronic form of PTSD is often debilitating. The disability associated with PTSD includes work impairment, change in life trajectories,impaired social relations,marital instability and perpetuation of violence. This not only represents a burden to the individual but to society as well. 29
A growing number of studies have shown that PTSD is associated with lower relationship satisfaction and higher levels of marital conflict and aggression in both military and civilian.30 Traumatic experiences that happen to one member of a family can affect every one else in the family. PTSD not only affects trauma survivors, but also has an indirect effect on those surrounding them particularly their family members. 31 Patients with PTSD and/or histories of trauma are likely to present to primary care. Previous research has found that individuals with mental disorders are more likely to seek help from a nonpsychiatric physician rather than from a mental health professional.32 One study estimated that as many as 47% of office visits to general medical physicians were due to anxiety symptoms.33
Appropriate treatment of PTSD is essential to reduce symptoms and increase both the functioning and quality of life of the patient. Once PTSD has been diagnosed, appropriate interventions should be made. Acute interventions should focus on promoting a sense of safety, calm, self- and community efficacy, connectedness and hope. 34
Efficient and adaptive coping skills could buffer PTSD reactions among those experiencing a traumatic loss, since training patients in the use of effective coping skills is part of treatment for PTSD.35 .Studies have found that emotion-focused coping (negative coping),especially an avoidant strategy, is related to worse overall mental health outcomes.35 Ethnoreligious violence has become recurrent in Plateau state.There is need for a study to evaluate the mental health impact of this violence on Plateau indigenes with a view to establishing a screening and treatment protocol for PTSD in patients visiting the general outpatient clinic who have been exposed to violence. Structuredcounselling for positive coping in the face of recurrent violence may prove a more effective treatment measure that may improve the health related quality of life of victims of ethno-religious violence in Plateau State.
1.5 RELEVANCE TO FAMILY MEDICINE.
Family medicine is the medical specialty that provides continuing and comprehensive health care forthe individual and the family. A Family physician possesses unique attitude,skill,and knowledge thatqualify him to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of a family regardless of sex,age,or type of problem (i.e.biologicbehavioural, or social).36 Family physicians have a key role to play in the management of victims ofviolence as caregivers, researchers, communicators and advocates. As caregiver, the study seeks to add to the family physician vast knowledge of providing care to patient with chronic illness like PTSD. Post-traumatic stress disorder is an anxiety disorder that can cause significant distress and increased use of health resources. However in primary care settings, psychiatric diagnoses such as PTSD may be overlooked due to several factors, including lack of clinician awareness of PTSD symptoms, failure to ask patients about traumatic experiences, and, most importantly, a limited amount of time to obtain a complex medical and trauma history. Because traumatic experiences that happen to one member of a family can affect everyone else in the family, family physicians have a key role in managing victims of trauma. The study hopes to provide counselling for positive coping in addition to the usual treatment for PTSD to victims of violence with PTSD that will not only improve their quality of life but will assist them cope with similar future challenges and maintain good family functioning. Treating PTSD and providing additional structured counselling for positivecoping popularized in JUTH primary care setting, will also reduce the cycle of violence being experienced in Plateau State since positive coping reduce the development of PTSD which has been found to be associated with revenge.
This study will also provide more information on the role of structured counselling in the treatment of chronic diseases such as PTSD. The family physicians role as a communicator and health educatoris stressed in this study and will confirm the vantage position a family physician has in providing wholistic care for diseases that not only affect the victim but also the entire family. The study also emphasizes the family physicians role as a researcher.A family physician practising in an area where ethno-religious violence is recurrent has a duty to research into the health impact of such violence on its citizens.Findings from such study will provide information to primary care physicians that willassist in identifying traumatized victims of violence and help them get treatment.This can be achieved through conducting brief screening for PTSD symptoms, provision of on-site trauma- related patient and family education materials,educating other health care providers in identification and referral of crisis victims with trauma related problems, contributing to the development of genuinely multidisciplinary teams that ensure integration and continuity of patient care. Developing organized psychological or mental health assistance for victims of ethno-religious violence and a professional social support for victims of traumatic events in developing countries such a Nigeria.
Primary care physicians in low-income countries need to be trained to recognize PTSD and to provide early intervention to reduce its associated morbidity. Information on PTSD in a primary care setting is needed to provide clinicians and researchers with knowledge to assist clinicians in identifying and assessing trauma victims, particularly since general medical facilities are typically the first place where patients with PTSD present with symptoms .This study will examine PTSD and trauma exposure in patients visiting general medical facilities, including the types of traumatic events experienced,coping strategies in face of recurrent violence and effect of counselling for positive coping on HRQoL.
EFFECT OF POSITIVE COPING COUNSELLING ON QUALITY OF LIFE OF VICTIMS OF VIOLENCE WITH POSTTRAUMATIC STRESS DISORDER ATTENDING JOS UNIVERSITY TEACHING HOSPITAL GENERAL OUTPATIENT CLINIC
