Patient flow and feasibility
During the study period, 60 consecutive inpatients were screened, of which 40 (70%) met substance use criteria for participation, and were recruited to the intervention study (figure 2). 39/40 (97%) of the eligible patients received at least one counselling session; 32/40 (80%) completed all four counselling sessions, and 26/40 (65%) completed the three-month follow-up (overall study retention rate). In total, 14/40 recruited patients (33%) were excluded from the final analysis: 5 (13%) because they were discharged before the inpatient counselling intervention was completed, 3 (8%) because they were ultimately found not to have MDR-TB (one false-positive genotypic for rifampicin resistance, and two cases of extended drug resistance), 3 (8%) because they were lost to follow-up, and 3 (8%) because they withdrew consent. One patient withdrew consent after the ASSIST score was administered but before any counselling sessions were administered, and two withdrew consent during the inpatient intervention.
The last column in Table 1 shows the demographic characteristics of the group of patients that completed the MI-RP intervention. There were no differences between the demographics of the overall sample, and the groups of patients that were excluded or who completed the intervention (table 1). The majority of patients were male (n=14; 54%), with a mean (SD) age of 36.3 (10.6), and of mixed race or “coloured” (n=20; 77%). [The term “coloured” refers to an ethnic group of people who possess some degree of sub-Saharan ancestry, but not enough to have been considered Black African during apartheid. It is a commonly used marker of race identity in South Africa]. Almost all patients had some school education (n=25; 95%), with mean (SD) school grades completed of 7.8 (3); the majority were unemployed (n=16; 62%) and lived in formal housing (n=20, 77%). The mean (SD) ASSIST score was 19 (6.1), indicating moderate risk; only 2 (8%) patients were high risk (ASSIST score ≥27). Alcohol was the most commonly used substance, with 25 patients (96%) reporting alcohol use in the three months before enrolment; 5 patients (42%) reporting cannabis use, 1 (4%) reporting cocaine use, 3 (12%) reporting amphetamine use and 2 (8%) reporting inhalant use. Regular (either daily or several times per week) alcohol, cannabis, and amphetamine use was reported in 16 (62%), 4 (16%) and 1 (4%) of patients, respectively. Four (15%) patients regularly used more than one substance.
The ASSIST score decreased following the intervention (pre-intervention median (IQR) 17.5 (15-24) versus 6 (6-8)). Depressive symptomatology improved, with the median (IQR) CES-D score significantly lower post-intervention [23.5 (18-34) vs. 17 (13-22)]. Several other secondary measures also improved post-intervention (Table 2).There were also significant improvements in nicotine dependence, health status, functional impairment, psychological distress, readiness for change and perceived social support (table 2). Only two patients (8%) had positive urine screening for a drug of abuse at follow-up. All patients that completed follow-up were adherent to treatment, culture-converted, and were ultimately cured.
Patients’ experience and acceptability
Three themes emerged from qualitative data that reflect patients perceptions of the acceptability of the counselling programme. The first theme highlights patients’ levels of motivation for addressing their substance use. The second theme describes the acceptability of the proposed counselling programme. The third theme describes recommendations for modifying the counselling programme.
Motivation for behaviour change
High levels of motivation for addressing substance use were reported by all patients. Reasons put forward to why they agreed to receive counselling included “to want to resist it, to bury alcohol away forever” and “I wanted to quit alcohol, but I didn’t know how to do that”. This motivation for changing alcohol use seemed to go hand in hand with their health-related concerns and the desire to live a healthier life. This is illustrated by two patients who had the following to say about why they agreed to access counselling:
“I decided to participate in the study because I realised it was the right way to live your life, to let go of things that are wrong; like drugs, alcohol, and using syringes [Patient 58]”.
“I decided to take part because I didn't want to be like I was anymore. And the programme really helped me to stop doing the things I was doing before. [Patient 45]”.
Acceptability of counselling programme
Patients reported positive experiences with the counselling programme, noting that “it was just so nice” and “I was happy all those times when I went for my sessions”. A few expressed that their stay in the hospital provided the space and time to reflect on their life and their health. The counselling sessions facilitated this reflection and ultimately their change in behaviour. As some patients reflected:
“I learned a lot from the sessions. I was always someone who liked to make trouble, do things like drinking and smoking, but now I choose to do things like taking a walk, gardening or playing football” [Patient 58]”.
“They helped me a lot. Number one, I no longer do alcohol. Even if a person is drinking, I don’t have that thing to say let me also take a sip [Patient 47]”.
There was consensus that the content, structure and delivery of the programme was acceptable. Patients could not identify any aspect that was redundant or not applicable to their needs. The counsellor delivering the programme content was acknowledged for her kindness, understanding, and ability to listen and explain the programme content clearly. These characteristics were conveyed by the following patients:
“I was a bit nervous at the beginning, but she made me feel very comfortable, she explained things to me so well. [Patient 34]”.
“I felt good because I could talk to her and she always understood what I was talking about. [Patient 33]”.
The written information booklet that accompanied the counselling sessions was considered highly valuable to patients, not only while they were receiving the counselling sessions in the hospital but following discharge as well. A few described using the booklet as a resource to refer to when they are facing challenges in their life. Several patients described how they were still referring to the booklet:
“I liked the part about experience, and what you are going to do when you leave the hospital, and writing every day about my experiences, what I did that day. [Patient 58]
The things in the booklet still have value for me, I recently took out the booklet again, and just yesterday I was thinking about the booklet again, and I went through it and looked at the old work assignments I did. [Patient 37]”.
Recommendations for modifying the counselling programme.
Although many patients thought that the duration of the intervention was appropriate, approximately half expressed that additional sessions would have been valuable. Unfortunately, whether these sessions should be conducted in hospital or after they were discharged into the community was not explored in the present study. The preference for additional sessions is expressed by the following patient:
“I think there should be more sessions. I enjoyed the counselling very much, I liked it and looked forward to it [Patient 37]”.
One of the challenges that some of the patients expressed during the counselling sessions was completing the homework tasks due to low levels of literacy. Four patients reported that they identified someone in the hospital, either another patient or a healthcare worker to assist them to complete the tasks.