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© 2021 Indian Journal of Community Medicine | Published by Wolters Kluwer – Medknow748
Abstract
Short Communication
IntroductIon
India is undergoing nutritional, demographic, and
socioeconomic transitions, which has created a double burden
of communicable and noncommunicable diseases (NCDs).
NCDs contribute to 71% of deaths globally. Every 2 s someone
aged 30–70 years dies prematurely from NCDs.[1] In India,
63% of deaths were due to NCDs, out of which 45% were
women.[1] Knowledge of the association of socioeconomic
factors and NCDs risk factors at the population level is essential
to understand the role of risk factors in the epidemiological
transition.[2] Women and men have different levels of exposure
to NCDs risk factors. Due to various social customs, women’s
opportunities for physical activities are reduced and thus more
vulnerable for NCDs.[3] Adult female mortality can lead to
higher mortality among small children, children withdrawn
from school, increased work burden on children. Women’s
health is, therefore, critically important to the health of future
generations.[4] Most of the studies in the field of NCDs included
wide range of age groups ranging from 15 to 60 years, but the
study on risk factors among young adult women of 15–24 years
of age has rarely been explored. Therefore, the present
study was done in a community setting with the objective of
identifying the association between risk factors of common
NCDs and sociodemographic factors among young adult
women of Palam Village, New Delhi.
Introduction: During the past 50 years, there is a substantial rise in noncommunicable diseases (NCDs) mortality in developing countries.
India is also undergoing demographic transitions. Lifestyle which increases the risk of NCDs in younger age group will lead to increase in
NCDs burden further in future generation. Objectives: The objective of this study is to determine the association between risk factors of
common NCDs and sociodemographic factors in young adult women of Palam Village, New Delhi. Settings and Design: A community-based
cross-sectional study was conducted in Palam Village, New Delhi. Materials and Methods: A total of 585 study participants were interviewed
using a predesigned, semi-structured questionnaire. Waist circumference, blood pressure (BP), and weight were measured using nonstretchable
measuring tape, digital BP apparatus, and digital weighing scale, respectively. Qualitative data are expressed in proportions and Chi-square
test is applied. Mean and standard deviation are used for quantitative data. Results: As the socioeconomic status improved, the frequency
of consuming adequate amount of fruits and vegetables in a day also increased. This association was statistically significant (P < 0.05).
Conclusion: The present study reported varied prevalence of different risk factors with various sociodemographic characteristics and there is
an urgent need to implement population, individual, and program wide prevention and control interventions.
Keywords: Noncommunicable diseases, risk factors, socio-demographic factors, young adult women
Address for correspondence: Dr. Tapas Kumar Ray,
Department of Community Medicine, LHMC, New Delhi ‑ 110 001, India.
E‑mail: tapaskray67@gmail.com
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How to cite this article: Singh A, Ray TK, Dhiman B. Association between
risk factors of common noncommunicable diseases (diabetes, hypertension,
and cardiovascular diseases) and sociodemographic factors in young adult
women. Indian J Community Med 2021;46:748-51.
Received: 09-02-21, Accepted: 09-08-21, Published: 08-12-21
Association between Risk Factors of Common
Noncommunicable Diseases (Diabetes, Hypertension, and
Cardiovascular Diseases) and SocioDemographic Factors in
Young Adult Women
Ankita Singh, Tapas Kumar Ray, Balraj Dhiman
Department of Community Medicine, LHMC, New Delhi, India
[Downloaded free from http://www.ijcm.org.in on Thursday, December 9, 2021, IP: 27.6.75.90]
Singh, et al.: Association risk factors of common noncommunicable diseases and socio-demographic factors in young adult women.
749Indian Journal of Community Medicine ¦ Volume 46 ¦ Issue 4 ¦ October-December 2021 749
materIals and methods
The present study was a community-based cross-sectional
study, conducted in Palam Village of New Delhi. It is one of the
field practice areas of the Department of Community Medicine,
Lady Hardinge Medical College, New Delhi. The study
protocol was approved by the Institutional Ethical Committee
of Lady Hardinge Medical College. Informed consent was
obtained from all the participants and confidentiality was
maintained. The study was carried out from November 2017
to March 2019. Data were collected from January 2018 to
December 2018. The study population comprised all the
women of 15–24 years of age who were permanent residents of
Palam Village (residing for more than 1 year). The sample size
was calculated by the formula N = 4pq/l2 where p represents
the prevalence of obesity (Body mass index >30) which is
14.6% obtained from the previous study done by Thakur
et al. on Profile of Risk Factors of NCDs in Punjab, Northern
India: Results of a State-Wide STEPS Survey. “One” was
allowable error, taken as 20% of p. Therefore, a sample size
of 585 individuals was taken. Palam village has a population
of 12000 and the total number of households is 2400. The
sampling unit was household and study unit were young adult
women of age 15–24 years. Systematic random sampling was
applied with a sampling interval of 4 (2400/585 = 4). An area
map was made, and the first household was selected randomly,
and then every 4th household was visited until the required
sample size was obtained. If an eligible participant was not
found in the 4th household, then adjacent one was visited. If
more than one eligible girl were residing in the same household,
then only one was included in the study by random selection.
Information regarding risk factors (Physical inactivity, dietary
risk factors, stress, and behavioral risk factors [tobacco and
alcohol use]) for NCDs was collected by semi-structured
interviews schedule consisting of sociodemographic
characteristics, global physical activity questionnaire (GPAQ)
by the WHO to assess physical activity level, dietary assessment
by predesigned questionnaire, stress assessment using general
health questionnaire 12 (GHQ 12), and behavioral risk factors
by predesigned questionnaire. Nonstretchable measuring tape,
digital weighing scale, portable stadiometer, and digital blood
pressure (BP) apparatus were used to measure waist and hip
circumference, weight, height, and BP, respectively. Data were
coded and entered in Statistical Package for the Social Sciences
(SPSS) IBM SPSS version 23.0 (Armonk, NY: IBM Corp.
Released 2015). Qualitative data were expressed in proportions
and Chi-square test was applied. Mean and standard deviation
were used for quantitative data. Suitable tests of significance
were applied wherever necessary.
results
A total of 604 households were visited, and 596 study
participants were enrolled. Eleven study participants were
excluded from the study (six refused to give consent, and
five were pregnant). Hence, the data of 585 participants
were analyzed. The results have been tabulated below.
Proportion of women belonging to upper socioeconomic
status in the study participants consuming adequate amount
of fruits and vegetables was 1.7%, whereas proportion of
women belonging to lower socioeconomic status in study
participants consuming adequate amount of fruits and
vegetables was 2.2%. As the socioeconomic status improved,
the frequency of consuming adequate amount of fruits
and vegetables in a day also increased. This association
was statistically significant (P < 0.05) [Table 1]. Of 243
study participants with Waist-Hip circumference Ratio
(WHR) ≥0.85, 46.5% participants were from lower-middle
socioeconomic status and 40.7% were from upper lower
socioeconomic status whereas 0.8% of participants were
from upper socioeconomic status. This association was not
statistically significant (P > 0.05) [Table 1]. Out of 158 study
participants who had sedentary lifestyle, 45.5% participants
were from lower middle and 44.3% participants were from
upper lower socioeconomic status. This relationship between
socioeconomic status and level of physical activity was not
statistically significant (P > 0.05). Of 411 study participants who
were consuming inadequate amount of fruits and vegetables
in a day, 60.3% belonged to nuclear family and this difference
was statistically significant (P < 0.05) [Table 2]. About 57.8%
of married participants were eating salty food and snacks
more than once in a week and this association was statistically
significant (P < 0.05) [Table 3]. Out of 158 research participants
who had sedentary lifestyle, 30.3% were housewives, 29.7%
were employed, and 39.8% were students and this difference
was statistically significant (P > 0.05) [Table 4].
dIscussIon
Understanding the underlying mechanisms and pathways
linking women’s social determinants with avoidable NCD
mortality is central to challenge the root causes of health
inequities and inequalities.[5-7] This is mandatory for achieving
one of the United Nations Sustainable Development
Goals (SDG 3, target 3.4) by the year 2030, as well as the
WHO “25 by 25” target by 2025.[8] The present study identified
significant differences in distribution of risk factors of NCDs
in young adult women by socioeconomic status, employment
status, type of family, and marital status. Proportion of women
consuming inadequate fruits and vegetables in a day is higher in
joint families (39.6%) as compared to nuclear families (24.7%)
and this was found to be statistically significant (P < 0.05).
Family is a basic unit of society and proximal food environment
which has an impact on food choices and dietary behaviors
through the mechanisms such as parent role modeling and
social norms.[9] Due to rapid sociocultural changes, especially
industrialization, the concept of family has also undergone
extreme changes. Moreover, strained relationships between
adult and adolescent family members may result in fragmented
family eating practices where children avoid family meals and
instead choose to eat outside the home or with friends.[10] One
reason of lower fruits and vegetables consumption is lack of
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Singh, et al.: Association risk factors of common noncommunicable diseases and socio-demographic factors in young adult women.
Indian Journal of Community Medicine ¦ Volume 46 ¦ Issue 4 ¦ October-December 2021750
affordability, also evident in our study. Proportion of women
belonging to upper socioeconomic status in study participants
consuming adequate amount of fruits and vegetables was
1.7%, whereas proportion of the same in study participants
consuming inadequate amounts of fruits and vegetables was
0.9%. Proportion of women belonging to lower socioeconomic
status in study participants consuming adequate amount
of fruits and vegetables was 2.2% whereas proportion of
same in study participants consuming inadequate amount of
fruits and vegetables was 3.4%. As the socioeconomic status
improved, the frequency of consuming adequate amount of
fruits and vegetables in a day also increased. This association
was statistically significant. This finding is similar to that
of a French study “Socio-economic factors associated with
an increase in fruit and vegetable consumption: a 12-year
study in women from the E3N-EPIC study”[11] About 57.8%
of married participants were eating salty food and snacks
more than once in a week than the unmarried participants
and this association was found to be statistically highly
significant. Preference for salt taste and Westernized trend
of eating processed food could partly explain the high salt
consumption. Married women (74%) were more involved in
moderate and heavy level of physical activity than unmarried
women (26%). This association was statistically significant.
Majority of women were homemakers and doing all the
household chores themselves. This finding is in agreement
with the study done by Abdul Rouf “Physical inactivity and
its association with hypertension in adult female population
of Srinagar, India: A community based cross-sectional study”
in which 73.1% of married women were reported to be
involved in moderate and heavy level of physical activity.[12]
However, the study conducted by Ariarathinam Newtonraj
et al. “Factors associated with physical inactivity among adult
urban population of Puducherry, India: A population based
cross-sectional study” reported 50.1% of study participants
to be physically active.[13]
In our study, employed women and students were less
physically active than housewives (43.5%) in contrast to the
findings by Ariarathinam Newtonraj et al.[13]
conclusIon
Healthy lifestyle must be promoted in young adult females, who
will further inculcate these practices in their families. In our
study, there was high proportion of school and college-going
students who had sedentary lifestyle. Hence, knowledge
regarding healthy lifestyles such as physical activity and
healthy diet should be inculcated in students through curriculum
and teachers should be trained. Consumption of inadequate
Table 1: Association between risk factors of common noncommunicable diseases (physical activity level, waist‑hip
circumference ratio, amount of fruits/vegetable consumption in a day) and socioeconomic status
Socioeconomic
status
Physical activity level WHCR Amount of fruits/vegetables
consumption in a day
Total
(n=585)
Sedentary,
n (%)
Moderate/
heavy
worker, n (%)
Risk absent,
<0.85, n (%)
Risk present,
≥0.85, n (%)
Inadequate (<5 servings [400 g]),
n (%)
Adequate (≥5
servings [400 g]),
n (%)
Upper 1 (0.6) 6 (1.4) 5 (1.4) 2 (0.8) 4 (0.9) 3 (1.7) 7 (1.2)
Upper middle 10 (6.3) 35 (8.1) 30 (8.7) 15 (6.1) 27 (6.5) 18 (10.3) 45 (7.6)
Lower middle 72 (45.5) 187 (43.7) 146 (42.6) 113 (46.5) 179 (43.5) 80 (45.9) 259 (44.4)
Upper lower 70 (44.3) 186 (43.5) 157 (45.9) 99 (40.7) 187 (45.4) 69 (39.6) 256 (43.6)
Lower 5 (3.1) 13 (3.0) 7 (2.0) 11 (4.5) 14 (3.4) 4 (2.2) 18 (3.2)
Total 158 (100.0) 427 (100.0) 342 (100.0) 243 (100.0) 411 (100.0) 174 (100.0) 585 (100.0)
χ2, df, P 5.113, 4, 0.623 7.995, 4, 0.092 11.972, 4, 0.017
WHCR: Waist-hip circumference ratio
Table 2: Association of amount of fruits/vegetables consumption in a day and type of family
Type of
family
Amount of fruits/vegetables consumption in a day Total, n (%)
Inadequate (<5 servings [400 g]), n (%) Adequate (≥5 servings [400 g]), n (%) Nuclear 248 (60.3) 131 (75.2) 379 (64.7) Joint 163 (39.6) 43 (24.7) 206 (35.2) Total 411 (100.0) 174 (100.0) 585 (100.0) χ2=11.971, df=1, P=0.001
Table 3: Association of frequency of eating salty snack
and marital status among study subjects
Marital
status
Frequency of eating salty snacks (pickle,
papad, and cheese)
Total,
n (%)
<1 day/week, n (%) ≥1 day/week, n (%) Married 172 (42.1) 236 (57.8) 408 (69.7) Unmarried 99 (55.9) 78 (44.0) 177 (30.2) Total 271 (46.3) 314 (53.6) 585 (100.0) χ2=9.421, df=1, P=0.002
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Singh, et al.: Association risk factors of common noncommunicable diseases and socio-demographic factors in young adult women.
751Indian Journal of Community Medicine ¦ Volume 46 ¦ Issue 4 ¦ October-December 2021 751
fruits and vegetables in a day was found in majority of study
participants. Awareness activities regarding intake of seasonal
fruits and vegetables in schools as well as in community should
be carried out, which are also relatively cost-effective. There
should be a restriction and its strict implementation on selling
of street and junk food in premises of schools and colleges
to discourage its use. Many of the schools and colleges have
already implemented this, but it has to be further strengthened
and promoted. Mass media campaigns, taxes on unhealthy
food, subsidies on healthy foods, mandatory food labeling,
and marketing restrictions on unhealthy food should be done.
One of the strengths of the present study was that it
addressed the young adults women. Moreover, being a
community-based study, the present study carries more
weightage. The sample size was probability sample which was
based on statistical formula. Sampling method (Systematic
random sampling) was also methodologically correct to
ensure representativeness and therefore our study can be
generalized to similar setting in same population. Validated
questionnaires (GPAQ, GHQ 12), anthropometric and BP
measurements using standard procedures and instrument, were
used in the study to assess the prevalence of risk factors of
NCDs in young adult women. This has reduced the chance of
interviewer bias in the study. Due to time constraints and lack
of affordability, all factors related to all NCDs could not be
assessed, which is a limitation of the present study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
references
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Table 4: Association of physical activity level and employment status of study participant
Employment
status
Physical activity level Total (n=585),
n (%)Sedentary, n (%) Moderate and heavy worker, n (%)
Housewife 48 (30.3) 186 (43.5) 234 (40)
Employed 47 (29.7) 116 (27.1) 163 (27.9)
Students 63 (39.8) 125 (29.2) 188 (32.1)
Total 158 (100.0) 427 (100.0) 585 (100.0)
χ2=21.721, df=2, P=0.04
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Explaining abstinence rates following treatment
for alcohol abuse: A quantiative synthesis of
patient, research design and treatment effects.
Monahan, Susanne C.. Montana State U, Dept of Sociology, Bozeman, US
Finney, John W.
Addiction, Vol 91(6), Jun, 1996. pp. 787-805.
Addiction
19
United Kingdom : Blackwell Publishing
British Journal of Addiction
United Kingdom : Wiley-Blackwell Publishing Ltd.
0965-2140 (Print)
1360-0443 (Electronic)
English
treatment & patient & research design characteristics, abstinence rates following alcohol
abuse treatment, alcohol abusers
Examined the relationships of treatment, patient, and research design characteristics to
treatment outcome (i.e. abstinence rates) in a sample of 150 treatment conditions drawn
from 100 alcohol treatment outcome studies published between 1980 and 1992.
Treatment characteristics were related to abstinence rates: more intensive treatments had
higher abstinence rates than less intensive treatments, whereas treatments with an
expressed goal other than abstinence had lower abstinence rates than treatments with an
abstinence goal. When the public vs private ownership status of the treatment facility was
taken into account, the presence of behavioral elements in the treatment condition also
was related to higher abstinence rates. Research design characteristics were also related
to abstinence rates. Treatment conditions with shorter follow-ups and treatments drawn
from studies that did not use criteria to exclude more impaired subjects had better
outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Journal Article
*Alcohol Abuse; *Sobriety; *Treatment Outcomes; *Substance Use Treatment
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Adult; Alcoholism; Combined Modality Therapy; Female; Follow-Up Studies; Humans;
Male; Outcome and Process Assessment (Health Care); Patient Care Team; Patient
Selection; Research Design; Social Adjustment; Substance Abuse Treatment Centers;
Temperance; United States
Drug & Alcohol Rehabilitation (3383)
Human
Adulthood (18 yrs & older)
Empirical Study
Journal; Peer Reviewed Journal
19960101
20190211
http://dx.doi.org.lopes.idm.oclc.org/10.1111/j.1360-0443.1996.tb03575.x
8696243
1996-04991-001
APA PsycInfo
EXPLAINING ABSTINENCE RATES FOLLOWING
TREATMENT FOR ALCOHOL ABUSE: A
QUANTITATIVE SYNTHESIS OF PATIENT,
RESEARCH DESIGN AND TREATMENT
EFFECTS
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Abstract
We examined the relationships of treatment, patient and research design characteristics to treatment
outcome (i.e. abstinence rates) in a sample of 150 treatment conditions drawn from 100 alcohol
treatment outcome studies published between 1980 and 1992. Treatment characteristics were related to
abstinence rates: more intensive treatments had higher abstinence rates than less intensive treatments,
whereas treatments with an expressed goal other than abstinence had lower abstinence rates than
treatments with an abstinence goal. When the public vs. private ownership status of the treatment facility
was taken into account, the presence of behavioral elements in the treatment condition also was related
to higher abstinence rates. Because of inconsistent reporting in primary studies, we assessed the effects
of only one patient pre-treatment characteristic; treatment conditions with a higher proportion of socially
stable patients had better outcomes. Research design characteristics were also related to abstinence
rates. Treatment conditions with shorter follow-ups and treatments drawn from studies that did not use
criteria to exclude more impaired subjects had better outcomes. We discuss possible reasons why our
findings regarding the effects of treatment intensity and the use of exclusionary criteria differ from those
in previous reviews.
Introduction
The body of research literature on the effectiveness of alcoholism treatment is vast. Emrick (1974)
surveyed 271 studies; a later paper from the same project included an additional 126 studies (Emrick,
1975). For a review of pre-1980 studies, Miller & Hester (1980) reported that they spent 6 months
reading 600 research reports. In 1986 they noted that an additional 300 treatment reports had been
published (Miller & Hester, 1986a). To make sense out of the hundreds of studies on the outcome of
alcoholism treatment, reviewers have used a number of strategies to synthesize research findings:
narrative or qualitative reviews; semi-quantitative, non-statistical reviews; quantitative analyses of effect
sizes; and statistical analyses modeling outcomes.
Until recently, most reviews were qualitative or narrative in nature (see Miller & Hester, 1980; Annis,
1986; Miller & Hester, 1986a; Elkins, 1991; Mackay, Donovan & Marlart, 1991). Reviewers drew
conclusions about treatment effectiveness based on both statistical and non-statistical evidence
presented in research reports: pairwise comparisons, overall treatment effects in the absence of
pairwise comparisons, improvements in treatment groups over time, process analyses, trends in the
data and subjective appraisals of study findings.
In an early effort to quantify the findings of primary studies, Emrick (1974) combined data on treatment
outcome across 113 studies and found that 4591 of a total of 13 570 patients (33.8%) were reported to
be abstinent. Costello and his colleagues (1975a, 1975b; Costello, Biever & Baillargeon, 1977) also
employed a semi-quantitative approach to examine factors associated with treatment outcome. They
used success rates (e.g. percentage of patients who were abstinent, improved, drinking in a controlled
fashion) to cluster studies by outcome and explored whether certain treatment modalities and study
characteristics (e.g. exclusion criteria, mandatory treatment) were associated with outcome groups.
More recently, Holder et al. (1991) assigned a Weighted Effectiveness Index (WEIn) score to each of 33
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treatment modalities, usually based on whether statistical tests of treatment effects in randomized or
matched group studies indicated that a particular modality was superior to some alternative. Based on
the resulting WEIn scores, they concluded that some treatments are more effective than others (for an
adjusted “box-score” approach, see Finney & Monahan, in press).
Analysis of effect sizes is the current method of choice for quantitative research reviews (Cooper, 1989).
When certain conditions hold, such analyses are an effective way to synthesize research on treatment
effects across studies. In particular, when various treatment modalities are compared with the same
treatment or control condition across studies, effect sizes can be calculated that can be meaningfully
compared to assess the relative effectiveness of different treatment modalities. For example, in a
focused meta-analysis, Bien, Miller & Tonigan (1993) compared the effectiveness of brief interventions
for alcohol abuse with that of no treatment and extended interventions.
In the alcoholism treatment outcome literature, however, different treatments are often compared with
different alternatives. For example, in an analysis of effect sizes by Mattick & Jarvis (1993), the
effectiveness of social skills training was compared with that of group discussions, cognitive
restructuring, relaxation training and providing a list of treatment agencies. In contrast, the effectiveness
of marital and family therapy was compared with that of individual therapy, cognitive therapy, social skills
training, disulfiram and individual counseling and brief advice. The average effect size for social skills
training at 12-23 months was 0.78, whereas the average effect size for marital and family therapy at the
same follow-up interval was 0.29. However, because the two treatment modalities were compared with
different alternatives, it is not possible to interpret the difference in effect sizes. Is the difference due to
the relative effectiveness of the two treatments or to differences in the strength of the competition
against which they were pitted? Thus, although an analysis of effect sizes is appropriate when
treatments are compared with a standard treatment or control condition across studies, that state of
affairs does not hold for the body of research on alcoholism treatment outcomes.
Modeling outcomes across studies is an alternative synthesis approach when a research literature is not
well suited to the calculation of effect sizes. Both Emrick (1975) and Costello (1980) employed
quantitative methods to assess the relationship between treatment for alcohol abuse and its outcome.
Using t-tests, Emrick (1975) concluded that treated alcoholics had significantly higher improvement rates
than un-treated alcoholics, but not higher abstinence rates.
In a more elaborate analysis, Costello (1980) used path analysis to predict treatment “success rates”.
Treatment success was defined as the proportion of patients in a treatment condition whose drinking
was non-problematic at follow-up. Costello found that success rates at a 1- to 3-year follow-up were
directly affected by patient social stability and directly and indirectly affected by treatment “extensity”. In
particular, more comprehensive treatments and treatments provided to more socially stable (i.e. married
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and employed) patients had higher success rates, and more comprehensive treatments were more likely
to be followed by active aftercare, which in turn was positively associated with success rates.
Researchers frequently report the proportion of patients who were abstinent at follow-up, making the
quantitative analysis of such rates across studies a plausible alternative to an effect size analysis. With a
quantitative synthesis of abstinence rates, the effects of treatment variation can be examined. In
addition, the effects of variation in study and patient characteristics can be determined across studies
and controlled when estimating the effects of treatment variables. Finally, because this approach does
not depend on within-study comparisons, data from both multiple and single group treatment studies can
be included in the synthesis.
In this paper, we follow Costello’s (1980) lead by conducting a quantitative synthesis of treatment
outcome findings from studies of alcoholism treatment published between 1980 and 1992. Included in
the review are studies that (1) reported treatment group outcome in terms of abstinence, (2) had a
minimum follow-up point of at least 3 months and (3) reported data on patients’ marital and/or
employment status. Using multivariate methods, we examine patient social stability, research design
characteristics and treatment elements that may explain variation in abstinence rates across studies.
Factors that may affect treatment outcome
Treatment characteristics
We focused on five characteristics of treatment for alcohol abuse that various researchers (e.g. Costello,
1980; Miller & Hester, 1986a; Holder et al., 1991; Mackay et al., 1991) have identified as important,
effective, or commonplace: (1) treatment goal; (2) treatment intensity; (3) presence of behavioral
treatment techniques; (4) availability of disulfiram and other antidipsottopic medications; and (5)
involvement of family members or significant others in treatment.
Treatment goal. Because abstinence is only one of several possible goals of alcoholism treatment
(Sobell, 1978), the treatment goal should be taken into account when attempting to explain abstinence
rates across treatment groups. Treatments having a goal of abstinence may result in higher abstinence
rates than treatments with alternative goals (e.g. non-problem drinking, reduction in DUI recidivism, self-
selected goals). Lower abstinence rates for treatments with non-abstinence goals do not necessarily
reflect treatment ineffectiveness; instead, abstinence rates may not be an appropriate index of treatment
effectiveness for studies with alternative goals.
Treatment intensity. In their review of brief interventions, Bien et al. (1993) concluded that “brief
intervention yields outcomes . . . often comparable to those of more extensive treatment” (p. 332),
including inpatient treatment. Furthermore, recent reviews of inpatient treatment have concluded that
inpatient treatment is no more effective than outpatient treatment for most alcoholics (Annis, 1986; Miller
& Hester, 1986b). However, Finney, Hahn & Moos (in press) noted that although setting effects did not
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emerge in studies comparing inpatient treatment with high-intensity outpatient treatment (i.e. day
hospital) or with outpatient treatment following inpatient detoxification, inpatient treatment sometimes
had superior effectiveness when compared with low-or middle-intensity outpatient treatments not
preceded by inpatient detoxification. Thus, setting effects may be confounded with those of treatment
intensity. We examine the effects of treatment intensity here by comparing treatments situated in high-
intensity settings–where patients spent a large part of the day in treatment–to treatments offered in
lower-intensity outpatient settings.
Antidipsotropics. When combined with alcohol, disulfiram and other antidipsotropics, such as
Metronidazole and calcium carbimide, cause an adverse physical reaction whose threat is thought to
deter alcohol consumption (Miller & Hester, 1986a). Miller and Hester’s (1986a) review identified
antidipsotropic medication as a common element of treatment for alcohol abuse, although evidence for
its effectiveness is mixed.
Behavioral treatment. Behavioral approaches to the treatment of alcohol abuse focus on changing
maladaptive behaviors that contribute to problematic drinking. Therapeutic techniques include social
skills training, self-control training, aversion therapies, relapse prevention and community reinforcement
treatment (Mackay et al., 1991). Miller & Hester (1986a) noted that although research supports the
effectiveness of behavioral approaches (see also Holder et al., 1991), such techniques were not among
those commonly used in the treatment of alcoholism.
Family involvement. Because there is often a reciprocal relation between alcoholism and family
relationships, several approaches to the treatment of alcoholism incorporate family involvement: family
and marital therapy sessions, family support groups, family member participation in outpatient treatment
and co-admission of family members to inpatient treatment. Studies by McCrady et al. (1979), Hedberg
& Campbell (1974) and Corder, Corder & Laidlaw (1972) found that treatment that included family
involvement had better outcomes than treatment without family involvement.
Patient characteristics
In trying to isolate treatment effects in a quantitative synthesis of the type reported here, it is necessary
to control for patient characteristics. Some research indicates that post-treatment functioning is better
predicted by patient characteristics than treatment characteristics (see Costello, 1980; Polich, Armor &
Braiker, 1981; Moos, Finney & Cronkite, 1990). Some types of patients have a better prognosis than
others; in particular, patients who are more socially stable (i.e. more closely tied to social support
networks via marriage and/or employment) tend to function better following treatment (Gibbs &
Flanagan, 1977; Costello, 1980; Neubuerger et al., 1981).
In research using experimental designs, random assignment of groups should ensure group equivalence
with respect to patient characteristics (e.g. age, race, marital status, employment status); given group
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equivalence, patient characteristics should not affect within-study comparisons. In comparisons across
studies, however, variation in patient pre-treatment characteristics may play an important role in
accounting for variation in post-treatment outcome. Thus, our synthesis across studies assesses the
effects of patient social stability on the outcome of treatment for alcoholism.
Research design characteristics
We also focus on several features of research design that may affect abstinence rates: (1) use of criteria
to exclude more impaired subjects; (2) varying definitions of abstinence; (3) length of the follow-up
window; and (4) follow-up rates.
Exclusion criteria. The use of criteria to exclude more impaired patients from studies may affect
treatment outcome. Studies that exclude more impaired or harder-to-treat patients may have higher
success rates (Costello, 1975a, 1975b).
Definition of abstinence. In some studies, the definition of abstinence allows “slips”. Studies with strict
no-drinking definitions of abstinence may have lower abstinence rates than studies that define
abstinence to include slips.
Follow-up interval There is considerable debate regarding how long patients should be followed after the
termination of treatment. Some researchers argue that 3 months is appropriate because the risk of
relapse is greatest during that period (Hunt, Barnett & Branch, 1971; Mackay et al., 1991). Others,
however, argue for follow-up intervals of at least 1 year in order to assess the longer-term impact of
treatment (see Nathan & Lansky, 1978; Sobell et al., 1987). Most researchers assume, however, that the
relative influence of treatment decreases over time as does its rate of success, at least for several years
following treatment (Emrick, 1982; but see Mc-Crady et al., 1991).
Follow-up rate. The proportion of patients successfully followed may affect data on treatment outcome.
Studies that follow a higher proportion of patients may report lower abstinence rates because they locate
worse-off patients who may be missed by studies with lower follow-up rates (Moos & Bliss, 1978; Polich
et al., 1981; Sobell, Sobell & Maisto, 1984; cf LaPorte et al., 1981).
Moderators of treatment effects
Theories of patient-treatment matching specify that patient characteristics moderate the effects of
treatment on outcome (Project MATCH Research Group, 1993). That is, certain types of patients may do
better in certain types of treatment whereas other types of patients may do better in other types of
treatment. We examine whether patient social stability moderates the effects of treatment for alcoholism:
that is, whether some treatments are more effective for socially stable patients whereas others have
greater effectiveness for less socially stable patients. For example, Welte et al. (1981) found that
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treatments of longer duration were more effective for less socially stable subjects, whereas treatment
length of stay was unrelated to outcome for more socially stable subjects. Although individual primary
studies have examined the matching of individual patients with treatments (e.g. Annis & Chan, 1979;
Dorus et al., 1989; Rohensow et al., 1991), matching has not been addressed at the treatment group
level across a broad set of primary studies.
Summary
In this paper, we use quantitative methods to synthesize findings from alcoholism treatment groups
included in outcome studies published between 1980 and 1992. In particular, we focus on the
relationship of treatment, patient and research design characteristics to treatment outcome (i.e.
abstinence rates). After controlling for patient and research design characteristics in hierarchical
regression analyses, we examine the effects of different treatment elements on patient post-treatment
abstinence rates.
Method
Sample
The sample of studies used in the present analysis was drawn from a larger review (339 studies) of
alcoholism treatment outcome studies that were published in English between 1980-92 (for a description
of that sample, see Floyd et al., in press). Studies were identified using Medline, ETOH, PsychInfo,
PsychLit and Dissertation Abstracts, as well as by examining the reference lists of review articles and
primary studies published after 1980. Studies included multiple-group, comparative studies; multiple-
group, non-comparative studies (i.e. studies that did not use randomization, matching or statistical
adjustments to adjust for patient pre-treatment differences); and single-group studies. For the present
analyses we selected all studies that: (1) reported, for at least one treatment condition or group, the
proportion of patients who were abstinent; (2) at a minimum follow-up of 3 months; and (3) also reported
the proportion of study participants who either were married and/or employed. Thirty-one per cent of the
research projects (n = 108) met the inclusion criteria.
The treatment condition, rather than the study, was the unit of analysis. The sample of 108 projects
reported data on 172 treatment conditions: 65 projects reported one treatment condition, 26 reported
two treatment conditions, 13 reported three treatment conditions, and four reported four treatment
conditions. We excluded 12 of the treatment conditions because they comprised no- or minimal-
treatment control groups. We also excluded 10 of the remaining treatment conditions because inpatient
treatment was provided to some patients and outpatient treatment to others but data for each group
were not reported separately. Because eight of those 10 conditions were from single-group studies, we
were left with 100 studies reporting data on 150 treatment conditions. A list of studies included in this
review is available from the authors upon request.
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We computed chi statistics to determine if our study selection criteria (i.e. a minimum 3-month follow-up
interval, data on marital and/or employment status, outcome data in the form of abstinence rates)
systematically selected certain types of studies. The analyses indicated that we selected a
disproportionate number of studies of high-intensity treatment compared with lower-intensity treatments
(chi =45.51, df= 1, p<0.0001), a disproportionate number of studies conducted by non-university-
affiliated researchers compared with university-affiliated researchers (chi =9.14, df= 1, p<0.01), a
disproportionate number of studies that included family involvement (chi = 4.11), and disproportionate
number of studies that used criteria to exclude more impaired subjects (chi =4.00). Studies of high-
intensity treatments were more likely to report abstinence rates and to have a follow-up point of 3
months or longer than were studies of lower-intensity treatments. Studies conducted by non-university-
affiliated investigators were more likely to report abstinence rates than were studies by university-
affiliated investigators. Studies with family involvement were more likely to have a follow-up point of 3
months or longer than were studies with no family involvement. Finally, studies that used criteria to
exclude more impaired patients were more likely to report marital and/or employment status (from which
we computed the social stability index) than were studies that did not use exclusion criteria. The chi
analyses indicated that our sample was not biased with respect to the provision of disulfiram or
behavioral treatment, or the use of an alternative treatment goal, nor was the sample biased in terms of
the educational attainment of the principal investigator.
Thus, the findings from our sample of studies should not be generalized to all alcoholism treatment
outcome studies. Our sample consists of a more limited group of studies that report abstinence rates at
a minimum 3-month follow-up and basic patient pre-treatment characteristics. Although our selection
criteria limit the representativeness of the sample, our selection criteria were as liberal as possible, while
still allowing a reasonable synthesis to be conducted. If more studies reported a comparable outcome at
a minimally informative follow-up point and also reported patient pretreatment characteristics,
quantitative syntheses such as this could include a broader range of studies.
Because we excluded a disproportionate number of studies by university-based investigators we were
concerned that the methodological quality might be lower in the studies in our review. However, using an
preliminary index developed by Morley et al. (1995) we found that the studies we included in our review
were of significantly higher quality than those that were excluded.
Measures
The criterion variable was the proportion of abstinent patients, taken at the first follow-up point of 3
months or longer (i.e. if data were reported for a 3-month follow-up and a 6-month follow-up, we used 3-
month follow-up data).
We included three sets of predictor variables in the multiple regression models: treatment
characteristics, patient characteristics and research design characteristics. Treatment variables included
2
2
2
2
2
2
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measures of treatment goal, intensity and content.
Alternative treatment goal. If treatment had an expressed goal other than abstinence (e.g., non-problem
drinking, patient-selected goal), a score of ‘1’ was assigned. If the goal of treatment was abstinence, or
was not explicitly indicated, a score of ‘0’ was assigned. We assumed that if a treatment condition had a
goal other than abstinence, the alternative goal would be reported. Thus, those studies that did not
explicitly report treatment goal were assumed to have abstinence-rather than an alternative–as their
goal. We analyzed the data excluding those treatment conditions for which the goal was not explicitly
stated; the results did not differ substantially from the results of analyses that included treatment
conditions for which the goal was not explicitly stated.
Treatment intensity. In constructing a measure of treatment intensity based on treatment setting, we
assumed that: (1) inpatient, residential, day hospital and halfway house settings provided high-intensity
treatments; (2) treatment that included an inpatient component of 2 weeks or longer constituted high-
intensity treatment; and (3) outpatient settings other than day clinics provided lower-intensity treatment.
High-intensity treatments received a score of ‘1’, whereas lower-intensity treatments received a score of
‘0’.
Treatment conditions coded as high intensity provided more treatment to patients than treatment
conditions coded as low intensity. Using information on the duration of treatment in the primary reports,
we calculated the average number of days of inpatient, residential or day-hospital treatment in high-
intensity settings and the average number of hours of treatment in outpatient settings. Data on the
number of days of treatment was available for 97 of the 111 high-intensity conditions; high-intensity
treatments averaged 34.6 days of treatment (SD = 21.2). Assuming 6 hours per day of treatment on
weekdays and no treatment at weekends, high-intensity treatments averaged 148 hours of treatment.
Data on hours of treatment was available for 24 of the 39 low-intensity conditions; low-intensity
treatments averaged 14.1 hours of treatment (SD = 20.0).
We characterized treatment elements using three dichotomous variables indicating the presence or
absence of certain components in the treatment description. Treatment descriptions varied widely in the
detail provided. For example, 16 treatment conditions provided no information on the treatment provided
except for the setting (i.e. inpatient, outpatient) of the treatment. If a component was not reported, we
assumed that it was not provided.
Antidipsotropics. Antidipsotropics was scored ‘1’ if disulfiram, calcium carbimide or Metronidazole was
prescribed or made available to patients, and ‘0’ if the availability of those medications was not
mentioned in the treatment description.
Behavioral therapy. Behavioral therapy was scored ‘1’ if the treatment was described as having a
behavioral orientation or if any of the following modalities was included in the treatment description:
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aversion therapy, covert sensitization, behavior contracting, behavioral marital therapy, community
reinforcement therapy, relapse prevention, cognitive therapy, self-control training, social skills training,
stress management training, relaxation training, assertion training, systematic desensitization. In the
absence of any of these modalities, a score of ‘0’ was given to the treatment condition.
Family involvement. Family involvement was scored ‘1’ if the treatment was described as involving active
family participation, and ‘0’ if no family participation was described.
Because of the incomplete reporting of patient data, we were only able to include one measure of
patient characteristics.
Patient social stability. Social stability was computed as the maximum of either the proportion of patients
who were married or the proportion who were employed at treatment entry. Thus, if a treatment condition
reported marital but not employment status of patients, the social stability index would be the proportion
of married patients; if the treatment condition reported employment but not marital status, the social
stability index would be the proportion of employed patients. If both were reported, the social stability
index was the greater of the two proportions.
We included four variables related to research design.
(1) Abstinence definition. We included a dichotomous variable with ‘1’ indicating that drinking (e.g. slips)
was permitted in the definition of abstinence; otherwise, a score of ‘0’ was assigned.
(2) Exclusion criteria. Treatment conditions were assigned a score of ‘l’ if criteria were used to exclude
more impaired patients (e.g. those with psychiatric diagnoses, organic brain disorder, impaired cognitive
functioning, severe dependence symptoms) from the study, and ‘0’ if more impaired patients were not
excluded from the study. We viewed the use of criteria to exclude more impaired patients as a rough
measure of the range of patient impairment for each treatment condition: that is, we thought that
treatment programs that did not explicitly exclude more impaired patients would be more likely to treat
such patients than would more exclusive treatment programs.
(3) Follow-up interval. Follow-up interval was measured in months. For treatments with an inpatient
component and other high-intensity treatments, length of follow-up was measured from discharge; for
treatments without an inpatient component (i.e. outpatient therapies, drug treatments), follow-up was
measured from the initiation of treatment. Length of follow-up for day-hospital treatment was measured
from the initiation of treatment because patients were released to their homes only during evenings and
at weekends, thus making day-hospital a high-intensity form of outpatient care. We coded the first
follow-up point of 3 months or longer for which a study reported abstinence data. Because this variable
had a skewed distribution, we used a log transformation of the follow-up interval in the analyses. We
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originally planned to include the duration of assessed abstinence in the analyses. It was excluded,
however, because it was highly correlated (r = 0.79) with the length of the follow-up interval.
(4) Follow-up rate. Follow-up rate was computed as the number of patients followed, divided by the
number of patients who started treatment. Thirty-four treatment conditions did not report the number of
patients starting treatment (i.e. they were drawn from retrospective studies); in those cases, we assigned
the mean follow-up rate of the other studies (75%). We conducted additional analyses excluding those
treatment conditions for which the follow-up rate was unavailable; the results were not substantially
different from the analyses that included treatment conditions for which we estimated the follow-up rate.
Reliability of coding. We assessed the reliability of measures by double-coding a randomly drawn set of
26 studies. Correlations were computed for interval-level variables: proportion abstinent, proportion non-
problem drinkers, proportion socially stable, follow-up interval and follow-up rate. Correlations between
original coding and reliability coding ranged from 0.90 (proportion socially stable) to 0.96 (proportion
abstinent). Percentage of agreement was computed for the dichotomous variables: goal, intensity,
behavioral treatment, antidipsotropics, family involvement, exclusion criteria and abstinence definition.
Goal, intensity and antidipsotropics had more than 95% agreement. Percentage of agreement was
somewhat lower for the other variables: 74% for abstinence definition, 81% for family involvement and
85% for exclusion criteria and behavioral treatment.
Analyses
Data were analyzed using ordinary least squares (OLS) regression. A basic assumption of OLS
regression (i.e. independent cases) was violated by our sample because we drew more than one
treatment condition from some of the projects. To assess the possible effects of non-independent cases,
we compared the results of analyses of the total sample of treatment conditions with those of a smaller
set of independent cases that included all single-group studies and one randomly selected treatment
condition from each multiple-group study (see Buchanan, Maccoby & Dombusch, 1991 for a discussion
of the treatment of non-random cases). The complete sample had 150 treatment conditions; the reduced
sample had 100 treatment conditions. Descriptive data on both samples are presented in Table 1; no
significant differences were found between the samples. We discuss the results of analyses of the
independent cases when they differ in statistical significance or magnitude from the analyses for the
sample as a whole.
Results
In all, 27 407 patients were treated in the 150 treatment conditions drawn from 100 studies. Treatment
groups ranged in size from nine to more than 8000 patients. The average number of patients in each
group was 183 patients (SD = 694) and the median number of patients was 53. Abstinence rates ranged
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from 0 to 91% across treatment conditions, and averaged 43%. In the average treatment condition,
approximately 60% of the patients were employed and/ or married.
The average follow-up point was 10.6 months, although there was wide variation ranging from 3 to 96
months. The variable measuring the follow-up interval was bimodal, with one mode at 3 months (40
treatment conditions) and another mode at 6 months (36 treatment conditions).
Fifty-eight per cent of the treatment conditions used criteria to exclude more impaired patients from the
study. Slips were included in the definition of abstinence in only 11% of the treatment conditions.
Most of the treatment conditions (74%) took place in high-intensity settings. In only a few (9%) of the
treatment conditions was it indicated that antidipsotropics were available to patients. About a fifth of the
treatment conditions had family involvement, and just over a quarter used behavioral treatment elements
or a behavioral orientation. Only 5% of the treatment conditions had a treatment goal other than
abstinence.
As Table 2 indicates, the zero-order correlations among the predictor variables were generally low
(ranging from – 0.15 to 0.15). Although some were statistically significant at p<0.05, none was large
enough to present a problem with multi-collinearity in the multivariate analyses. In general, the
correlations among the variables in the sample of independent cases were similar to those of the sample
as a whole.
By using hierarchical regression analyses to predict abstinence rates across studies we were able to
assess the cumulative effects of each set of predictor variables and control for patient and research
design characteristics before examining treatment effects. We entered patient characteristics, then
research design characteristics and, finally, treatment characteristics. Within each class of predictors,
the independent variables were entered simultaneously. Table 3 presents the parameters estimated in
the final step of the analyses predicting abstinence rates in the total sample of treatment conditions and
the randomly drawn set of independent cases.
Main effects of predictor variables
The social stability index was entered into the model first; it explained 4% of the variance in abstinence
rates. When the variables associated with research design were added to the model, explained variance
increased to 17% (F = 5.56, p = 0.0003) The addition of the final set of variables, those related to
treatment characteristics, increased the explained variance of the model to 34% (F = 7.49, p <
0.0001).
Patient social stability. Patient social stability was positively associated with abstinence rates. Controlling
for the other predictors, treatment conditions with a higher proportion of socially stable patients reported
change
change
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higher abstinence rates at follow-up; an increase of four percentage points in the proportion of socially
stable patients was associated with an increase of about one percentage point in abstinence rate.
Research design characteristics. Abstinence rates were predicted by three of the four research design
characteristics: follow-up interval, the use of exclusionary criteria and follow-up rate. The follow-up
interval was negatively associated with abstinence rates. Because log transformations do not produce
linear relationships, the interpretation of this parameter estimate is not straightforward; but, for example,
the predicted abstinence rate of a group followed 12 months after treatment was, on average, seven
percentage points lower than that of a group followed 3 months after treatment. Initially we predicted
abstinence rates using the untransformed follow-up interval; the coefficient estimate for the
untransformed follow-up interval was not statistically significant (B = 0.17, SE = 0.12) and, overall, the
model did not fit as well as the model predicting abstinence rates with the log transformation of follow-up
interval (overall F = 6.54, R = 0.32, adjusted R = 0.27 versus overall F =7.25, R =0.34, adjusted R
= 0.30). Thus, it seems reasonable to assume that over time abstinence rates decrease at a decreasing
rate.
Surprisingly, studies that used criteria to exclude more impaired patients had lower abstinence rates–by
an average of 10 percentage points. The negative relationship persisted even when the definition of
exclusionary criteria was expanded to include the exclusion of less-impaired subjects: that is, we found
that treatment conditions in studies using any inclusion or exclusion criteria reported lower abstinence
rates at follow-up (r = – 0.30, p = 0.003) than conditions in studies that did not use such criteria. We
suspected that the finding regarding exclusionary criteria was a spurious relationship driven by research
quality: that is, higher quality studies may be more likely to use (or report their use of) inclusion and
exclusion criteria, and also may have more accurate (i.e. uninfiated) reports of success rates. Our
analyses indicated that higher quality studies reported lower abstinence rates: the correlation between
methodological quality and abstinence rates was negative and statistically significant (r = – 0.17, p =
0.03). In addition, there was a borderline relationship between methodological quality and the use of
exclusion criteria (r = -0.14, p=0.08), indicating that higher quality studies were more likely to report the
use of exclusionary criteria. These relations are weak, however, and do not entirely account for the
unexpected association between exclusionary criteria and success rates.
As expected, studies with higher follow-up rates had lower abstinence rates. For each additional five
percentage points in follow-up rates, abstinence rates decreased by about one percentage point. The
definition of abstinence–that is, whether slips were permitted–was not associated with abstinence rates.
Treatment characteristics. Of the treatment-related variables, intensity and alternative goal were
significant predictors of abstinence rates. Treatment conditions in high-intensity settings (e.g. inpatient,
residential, halfway house, dayclinic) had higher abstinence rates–15 percentage points higher–than
conditions in lower-intensity, outpatient settings, Controlling for the other predictors, abstinence rates for
treatments with an abstinence goal averaged 26 percentage points higher than rates for treatments with
raw
2 2
log
2 2
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alternative goals. Family involvement, the use of behavioral elements and the use of antidipsotropics
were not associated with abstinence rates.
Analysis of independent cases. Some of these relationships were weaker in the sample of independent
cases: the parameter estimates for social stability and follow-up rates were consistent in their direction
but were not statistically significant. The magnitude of the parameter estimate for social stability
decreased by almost one-half in the sample of independent cases, while the standard error increased
slightly. The magnitude of the parameter estimate for follow-up rate also decreased in the sample of
independent cases–although by only about 15%-and its standard error was also slightly higher.
Weighted regression analysis. In the analyses reported thus far each of the 150 treatment conditions
contributed equally to the findings, irrespective of the number of patients in the treatment condition. We
also analyzed the data using regression weighted by the number of patients in each treatment condition.
The statistical significance and the magnitude of the effects were not substantially different from the un-
weighted analyses, except that in the weighted regression, treatment conditions that included family
involvement had predicted abstinence rates that were on average 10 percentage points less than
treatment conditions that did not include family involvement (B = – 10.5, SE = 4.6, t = – 2.28, p < 0.05).
Additional analyses. Given the results of previous studies that found little difference between high- and
low-intensity treatments (see a review by Miller & Hester, 1986b), the positive relation between high-
intensity treatment and abstinence rates was unexpected. An anonymous reviewer suggested that the
high-intensity treatment conditions in our sample may have been drawn predominantly from private, for-
profit, inpatient treatment facilities that de facto exclude individuals with poor prognoses for treatment
outcome. This exclusion process would explain the relationship we found between treatment intensity
and treatment outcome: high-intensity treatment conditions in private facilities generally treat patients
with good prognoses. A concentration of high-intensity treatment conditions in private programs would
also explain the perplexing negative relationship between the use of exclusion criteria and abstinence
rates: private treatment facilities tend not to be accessible to more impaired patients, thus obviating the
need for criteria to exclude such patients from treatment and studies of that treatment.
To explore this interpretation our findings, we coded whether each treatment condition occurred in: (1) a
private, for-profit treatment program; (2) a public (e.g. VA Hospital; other military hospital; state, county
or city hospital) or non-profit treatment program; or (3) an unidentified treatment program. Sixty-four of
the treatment conditions occurred in public or non-profit settings (mean abstinence rate = 36.5%, SD =
21.1), whereas 65 of the treatment conditions were set in private, for-profit treatment facilities (mean
abstinence rate=49.7%, SD=22.1). We were unable to determine the facility status of 21 treatment
conditions; 17 of those were in treatment facilities outside the United States. The mean abstinence rate
for the unidentified treatment conditions was 40.9%. Thus, we concluded that we had a reasonable
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distribution of public/non-profit and private, for-profit programs in our sample; in addition, the unidentified
treatment programs had a mean abstinence rate more typical of the public than the private programs.
We examined the zero-order correlations between treatment facility type (public facilities were coded ‘0’
and private facilities were coded ‘1’) and the predictor and criterion variables; some of the correlations
were statistically significant at p<0.05. Conditions in private treatment facilities had patients who were
more socially stable (r=0.20), and--as indicated above--reported higher abstinence rates (r= 0.29)
following treatment; in addition, private treatment facilities were: (1) less likely to use behavioral
treatment elements (r= -0.21); (2) less likely to include slips in the definition of abstinence (r = - 0.20);
and (3) less likely to use criteria to exclude more impaired patients (r = -0.23).
Because facility type (i.e. public or private) might be an important predictor of treatment success rates
and confounded with some of the other predictors, we added the facility-type variable to the multiple
regression analysis predicting abstinence rates for the 129 treatment conditions for which the facility-
type variable was available. Because this sample excludes 21 treatment conditions for which we could
not determine the facility type, we present in Table 4 a re-analysis of the original model for the sample of
129 cases next to the augmented model that includes the facility type variable: the magnitudes of the
slope estimates and their degree of statistical significance varies little across the full- and the reduced-
sample models.
Facility type was a significant predictor of abstinence rates following treatment for alcohol abuse.
Controlling for the other predictors, private programs reported abstinence rates that were an average of
10 percentage points higher than rates reported by public treatment pro-grams. The inclusion of the
facility-type variable did not, however, alter the findings with respect to (1) the positive relationship
between high-in-tensity treatment and abstinence rates; or (2) the negative relation between the use of
criteria to exclude more impaired patients and abstinence rates. High-intensity treatment conditions
reported higher abstinence rates than low-intensity conditions, even controlling for facility type. Similarly,
even controlling for facility type, conditions that excluded more impaired patients reported lower
abstinence rates than programs that did not report the use of exclusion criteria.
Behavioral treatment emerged as a significant predictor of abstinence rates in the regression model that
included the facility-type variable. Treatment conditions that included behavioral elements had higher
abstinence rates–by about nine percentage points–following treatment than did treatments without
behavioral elements.
Alternative measures of treatment outcome. We explored the possibility of using a measure of drinking-
related outcome other than abstinence rate (non-problem drinking rate). Non-problem drinking rates
were reported by only 24 of the eligible studies, and by only six studies that did not also report
abstinence rates. Separate analyses of non-problem drinking rates were thus not feasible because of
the lack of statistical power to detect significant effects. When we combined abstinence and non-
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problem drinking rates in the 156 studies to form a measure of treatment “success”, we found that
treatment success rate was highly correlated with abstinence rate (r= 0.91). The results of the
multivariate analyses of success rate differed in only one respect from the analyses of abstinence rates:
treatment conditions that used behavioral elements reported significantly higher success rates–by about
7 percentage points–at follow-up (B = 7.2, SE = 3.5, t = 2.04, p < 0.05) than did conditions not including
behavioral elements. Of the outcome variables widely available in this literature, abstinence and non-
problem drinking rates were the most prevalent. We did not analyze other measures of treatment
success or improvement because such measures had low cross-study reliability.
Moderators of treatment effects
Finally, we explored whether the social stability of patients moderated the effects of treatment on
abstinence rates. Using mean-centered deviation scores (see Jaccard et al., 1990; Aiken & West, 1991),
we computed product terms to model potential interactions between social stability and each of the five
treatment characteristics. None of the product terms was a significant predictor of abstinence rates.
Discussion
Using quantitative methods, we synthesized findings from 100 studies of alcoholism treatment outcome
published between 1980 and 1992. We focused on studies that reported the social stability of patients
and abstinence rates at a minimum follow-up of 3 months.
Only 31% of the studies published between 1980 and 1992 met the three inclusion criteria for this
synthesis. Our focus on abstinence rates allowed us to maximize the number of studies included in the
analysis, while minimizing the error inherent in having too broad a definition of treatment “success”.
Although we explored the possibility of examining a success measure that combined abstinence and
non-problem drinking rates, fewer than 10% of all studies reported the proportion of non-problem
drinkers, and most of those studies also reported abstinence rates. Thus, the expansion of the outcome
measure to include non-problem drinking added only six studies to our analysis and provided similar
results. Had we focused on outcome measures other than abstinence or non-problem drinking rates
(e.g. consumption measures), few studies could have been analyzed. Optimally, all alcoholism treatment
outcomes studies would provide quantitative information on alcohol consumption. In lieu of that,
research syntheses would be facilitated if those researchers who report quantitative measures of alcohol
consumption also reported abstinence and/or non-problem drinking rates. Although some researchers
may be reluctant to report abstinence rates if abstinence was not the goal of treatment, the present
study demonstrates that it is possible for research syntheses to control for the effects of alternative
treatment goals on abstinence rates.
We found that variation in abstinence rates was systematically related to patient, research design and
treatment characteristics. Our results indicate that treatment is related to treatment outcome, although
not necessarily in ways suggested by past research. Most striking was the strong relationship between
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the intensity of treatment and abstinence rates. Previous reviews have concluded that brief interventions
are as effective as more intensive interventions (Bien et al., 1993) and outpatient treatment is as
effective as inpatient treatment (Annis, 1986; Miller & Hester, 1986b). However, we found that high-
intensity-mostly inpatient–treatment conditions had higher abstinence rates than less intensive–
predominantly outpatient–treatment conditions, after controlling for other variables including patient
social stability.
Several factors may account for the discrepancy between our findings and those cited in previous
reviews. We examined the plausible explanation that treatment intensity, the use of exclusion criteria,
and abstinence rates were all related to facility type. That is, private, for-profit facilities may be less likely
to use exclusionary criteria and tend to provide higher intensity treatment. However, they also attract
patients with better prognoses. That may be the reason they have higher abstinence rates following
treatment. Zero-order correlations indicated that private programs had higher abstinence rates and were
less likely to use exclusion criteria; facility type was not related to treatment intensity. When facility type
was added to the multiple regression model, it was a significant predictor of abstinence rates (i.e.
patients in private facilities had higher abstinence rates), but it did not affect the positive relationship
between high-intensity treatment and abstinence rates. Even controlling for facility type, high intensity
treatments had higher abstinence rates than lower intensity treatments; nor did the addition of facility
type to the multiple regression model affect the negative relation between the use of exclusionary criteria
and abstinence rates. Even controlling for facility type, treatment conditions that used exclusionary
criteria had lower abstinence rates than those that did not use exclusionary criteria.
Because we did not limit our review to randomized clinical trials, many patients in the studies we
reviewed selected a particular treatment rather than being randomly assigned to it. In fact, the majority of
the studies in our review were inpatient studies where patients presented for and received inpatient
treatment. Such patients may differ along important dimensions from those who seek other types of
treatment (Skinner, 1981; Timko et al., 1994). Although undoubtedly many patient characteristics affect
treatment selection, we controlled for only three: patient social stability, patient impairment (indirectly, by
adjusting for the use of criteria to exclude more-impaired patients from the study) and patient’s ability to
pay for treatment (indirectly, by adjusting for the public/private nature of the treatment facility). Patients
who select high-intensity treatment may experience better outcomes than those who: (1) present for
outpatient treatment (Timko et al., 1993); (2) do not have a preference for what kind of treatment they
receive (i.e. are willing to accept random assignment to any treatment–a preselection criterion in most
randomized clinical trials); or (3) receive treatment they were not expecting.
Thus, the surprising finding regarding treatment intensity might have resulted from confounding of
treatment and patient effects. That is, the finding may reflect a treatment effect, but it may also be a
function of patient characteristics: better prognosis patients may be drawn to high-intensity treatment.
The same is true of the findings with respect to treatment facility type: private treatment is not
necessarily “better” than public treatment, even though its post-treatment abstinence rates are higher.
Rather, private treatment may be a prow for patient characteristics, in that patients with a better
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prognosis may be drawn to private treatment. Thus, although we can conclude that treatment groups
exposed to certain treatment elements have higher post-treatment abstinence rates than treatment
groups not exposed to those elements, characteristics of members of the treatment group—rather than
the treatment itself–may be the causal factor in the relationship between the treatment received and
post-treatment abstinence rates. Our analyses, however, controlled for a number of factors that
represent potentially influential patient characteristics (i.e. patient social stability, patient impairment,
public/private treatment facility). In spite of this, the positive effects of high-intensity treatment persisted.
The difference in the sample of studies we examined may also partly explain the divergence between
our findings and those of earlier reviews. Most narrative and meta-analytic reviews use the study as the
unit of analysis and focus on comparisons between treatment conditions within a study. By focusing on
treatment condition abstinence rates rather than paired comparisons, we were able to incorporate
studies that did not explicitly compare higher-intensity with lower-intensity treatments (e.g. multiple-
group studies of variations in inpatient treatment and single-group studies of inpatient treatment).
Finally, the difference in intensity between the high- and low-intensity conditions we examined is greater
than that evaluated in some of the relevant randomized controlled trials. For example, Edwards et al.
(1977) compared extended treatment with a single session of “advice”. During the first year of the study,
however, the advice group received additional treatment whereas the second group was given planned
extended treatment on an “as needed” basis. After 1 year, the average member of the extended
treatment group had received three times as many hours of treatment as the average member of the
advice group (97 hours vs. 30 hours). In contrast, the high-intensity conditions in our sample received on
average 10 times as many hours of treatment as low intensity conditions (148 hours vs. 14 hours).
In their review of the research literature on setting effects, Finney et al. (in press) note that inpatient
treatment has sometimes been compared with intensive outpatient treatment (e.g. McLachlan & Stein,
1982; Longabaugh et al., 1983; McKay et al., 1995). Even in those cases where inpatient treatment has
been compared with less intensive outpatient treatment, the number of hours of treatment generally did
not differ by a factor of 10 (but see Eriksen, 1986; Chick, 1988), as it did in the present analysis. Thus,
the effects of treatment intensity may have emerged in our analysis because of the striking difference
between high-and low-intensity treatments in the number of hours of treatment provided.
Other treatment-related factors were also related to outcome. Although only about 5% of the treatment
conditions had an alternative goal (e.g. non-problem drinking, self-selected goal), those conditions had
significantly lower abstinence rates than treatment conditions with an abstinence or unspecified goal.
Ideally, treatment outcome should be assessed along dimensions that treatment is supposed to affect.
For example, one would expect treatment with a non-problem drinking goal to affect non-problem
drinking rates but not necessarily abstinence rates. Thus, in our analysis of abstinence rates across
studies, we controlled for the goal of treatment. Nonetheless, we were struck by the small number of
studies that explicitly examined treatment goals other than abstinence. Our emphasis on abstinence
rates did not, however, exclude many studies with non-abstinence goals: only two studies (with six
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treatment conditions) that (1) reported non-problem drinking rates but not abstinence rates and (2) met
the other inclusion criteria for this study had alternative treatment goals.
Consistent with reviews by Holder et al. (1991) and Finney & Monahan (in press), we found that the type
of treatment makes a difference. In the analysis that included public/private treatment facility, treatments
that included behavioral elements had higher abstinence rates. This relation is striking because
behavioral treatments were positively correlated with the use of an alternative treatment goal, and the
use of an alternative treatment goal was negatively correlated with abstinence rates. Thus, although one
might expect behavioral treatments to be associated with lower abstinence rates (in conjunction with
higher non-problem drinking rates), behavioral treatment was associated with higher abstinence rates.
Also, we did not distinguish between behavioral approaches that have more or less evidence of
effectiveness (Holder et al., 1991; Finney & Monahan, in press). The other measures of treatment
content–antidipsotropics and family involvement–were not associated with treatment outcome, however.
Should we infer that, with the exception of behavioral approaches, type of treatment is unrelated to
treatment outcome? Probably not. First, there are treatment elements that we did not examine (e.g. AA,
aftercare). More importantly, we suspect that our measures of treatment content may have lacked
validity because they were derived from descriptions of treatment included in primary reports. For many
studies it was difficult to code treatment content with confidence. As we reported earlier, 16 treatment
conditions did not include any information about treatment except for its setting. The descriptions of
many other treatment conditions were vague or stressed a single element in a multi-modal treatment
program. If a treatment element was not mentioned we assumed it was not used; thus, we may have
underestimated the prevalence of various treatment elements. There was no way to know whether a
treatment description was complete; nonetheless, the more detailed the description, the more
confidence we had coding the treatment elements examined here. In addition, we simply coded whether
or not a treatment element was reported; we did not code the amount of that type of treatment or the
relative importance of each element in the entire treatment package. Nor did we have any information on
the quality of treatment implementation.
The inadequacy of our measures of treatment content may have also affected our analysis of the
moderating effects of social stability on the relation between treatment and outcome. Clear and complete
descriptions of treatment in primary reports would not only facilitate an understanding of the study’s
findings, but also the integration of those findings into the wider body of research on alcoholism
treatment outcomes.
Primary reports also did not provide consistent data on patients’ pre-treatment characteristics. Due to
the spottiness of such data we were able to assess the effects of only one patient pre-treat-ment
variable: patient social stability. Consistent with reviews of within-study findings at the individual patient
level (e.g. Gibbs & Flanagan, 1977), we found that treatment conditions with a higher proportion of
married and/or employed subjects had higher abstinence rates, although the magnitude of the effect
decreased to a non-significant level in the random sample of independent cases. Because of insufficient
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reporting of the relevant data, we were unable to include patient pre-treatment severity of alcohol abuse
in our models. If researchers were required by journal editors or funding sources to report such data in a
standardized manner (e.g. years of problem drinking, number of dependence symptoms, diagnostic
status), the effects of patient pre-treat-ment severity could be assessed in future syntheses.
In the absence of a direct measure of patient pre-treatment severity, we included a dichotomous
measure indicating if more-impaired patients were excluded from the study. We initially thought that
studies excluding more impaired subjects would pre-select people with a better prognosis and would
thus have higher abstinence rates. We found, however, that treatment conditions in studies that used
exclusion criteria had significantly lower abstinence rates. It is possible that more impaired patients who
have “hit bottom” may be more motivated to abstain after treatment for alcohol abuse. In addition, there
was some evidence that the use of exclusion criteria and reports of treatment outcome were both related
to study quality: that is, higher quality studies were more likely to use exclusion criteria and to have lower
abstinence rates.
The length of the follow-up interval was also associated with treatment outcome. Abstinence rates
decreased over time following treatment. Although not unexpected, this finding has an alternative
explanation: it may be that the length of time over which abstinence was assessed (i.e. the window of
observation), and not the length of time after treatment at which follow-up data were collected (i.e.
follow-up interval), accounts for this relation. For example, one would expect higher rates if abstinence
were based on no drinking over the 3 months immediately preceding a 12-month follow-up than if it were
based on no drinking over the entire 12 months of the follow-up interval. There was, however, a high
correlation between the length of follow-up interval and the length of observation window for determining
abstinence (r = 0.79). It is difficult, if not impossible, to disentangle the independent effects of two such
highly correlated variables.
The consolidation of research findings is a vital part of the research process (Cooper, 1989). The results
of primary studies represent pieces of a puzzle; when those pieces are assembled through a process of
synthesis, a more complete picture of research findings emerges. Qualitative, semi-quantitative and
quantitative reviews play different roles in the process of synthesis. A synthesis modeling outcomes,
such as the one conducted here, does not depend upon within-study comparisons to draw conclusions
about the effectiveness of treatment, and thus can incorporate a wider range of treatment studies (e.g.
single-group studies, non-comparative studies) that might otherwise not be integrated into the body of
research on alcoholism treatment.
Perhaps, as a result, the present quantitative synthesis revealed some surprising findings, most notably
that more intensive treatment had better outcomes than less intensive treatment. Future primary studies
can determine whether differences in treatment intensity of the magnitude examined here are linked to
differences in abstinence rates and other outcome variables.
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Acknowledgements
This research was supported by NIAAA Grant No. AA08689, by the Department of Veterans Affairs (VA)
Health Services Research and Development Service, and by the VA Mental Health and Behavioral
Sciences Service. A number of people made important contributions to the research reported in this
paper. Annette Hahn began working on the study at its inception, was involved in the development of
initial coding forms and was instrumental in helping to get the project “off the ground”. She, along with
Kent Harber, Michelle Pearl, Anthony Floyd, Jeanne Bart Morley and Jennifer Noke, conducted
electronic searches of bibliographic databases, coded studies, key-entered data, and/or ran statistical
analyses. We are also grateful to Keith Humphreys, Rudolf Moos, Hams Cooper and three anonymous
reviewers for their helpful comments on earlier drafts of this paper.
Table 1. Descriptive statistics for the total sample and the
sample of independent cases
Randomly drawn,
All cases independent cases
(n = 150) (n = 100)
Criterion variable
Mean proportion abstinent (SD) 42.9 (22.6) 43.9 (22.8)
Predictor variables
Patient characteristics
mean proportion socially stable 60.1 (24.4) 61.2 (23.7)
Research design characteristics
mean follow-up point in months (SD) 10.6 (12.4) 11.4 (13.2)
mean log (follow-up point) (SD) 0.86 (0.35) 0.89 (0.36)
mean follow-up rate 0.75 (0.16) 0.75 (0.16)
% that allowed slips in
the definition of abstinence 11 12
% excluding more impaired patients 58 56
Treatment characteristics
% with a non-abstinence goal 5 6
% high-intensity treatments 74 77
% offering or using antidipsotropics 9 10
% using behavioral treatment 28 23
% using family involvement 21 22
Table 2. Zero-order correlations among criterion and predictor
variables (n = 150 treatment conditions)
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Legend For Chart:
A – Variable
B – (1)
C – (2)
D – (3)
E – (4)
F – (5)
G – (6)
H – (7)
I – (8)
J – (9)
K – (10)
A
B C D E F
G H I J K
(1) % Abstinent
— — — — —
— — — — —
(2) % Socially stable
0.19[a] — — — —
— — — — —
(3) Follow-up interval (log)
-0.13 0.14 — — —
— — — — —
(4) Follow-up rate
-0.12 0.17[a] 0.10 — —
— — — — —
(5) Slips allowed
-0.09 -0.10 -0.02 -0.10 —
— — — — —
(6) Exclusion criteria
-0.30[b] -0.13 -0.07 -0.03 0.09
— — — — —
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(7) Alternative goal
-0.29[b] 0.09 0.01 0.07 0.10
0.14 — — — —
(8) Intensity
0.32[b] -0.02 0.12 0.06 0.07
-0.07 -0.06—- — — —
(9) Antidipsotropics
-0.06 0.10 0.22[b] 0.05 -0.04
0.13 -0.08 -0.07 — —
(10) Behavioral treatment
0.05 -0.13 -0.13 -0.08 0.10
0.08 0.12 0.07 -0.05 —
(11) Family involvement
0.02 0.07 0.05 -0.04 -0.03
0.10 0.10 0.08 0.06 -0.02
a p < 0.05; b p < 0.01.
Table 3. Results of multiple regression predicting abstinence
rates with treatment, patient and research design
characteristics
Abstinence
Abstinence (independent
Predictor variables (all cases, n = 150) cases, n = 100)
Patient characteristics
Social stability 0.23[c] 0.13
(0.07) (0.08)
Research design characteristics
Follow-up interval (log) -12.30[b] -13.02[a]
(4.71) (5.57)
Follow-up rate -0.20[a] -0.17
(0.10) (0.12)
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Definition of abstinence -4.45 -8.18
(5.01) (5.93)
Exclusion of more
impaired patients -10.49[b] -12.36[b]
(3.30) (4.01)
Treatment characteristics
Treatment goal other
than abstinence -25.60[c] -28.95[c]
(7.23) (8.40)
Treatment intensity 16.39[d] 16.87[c]
(3.64) (4.60)
Antidipsotropics 0.16 4.17
(5.63) (6.72)
Behavioral treatment 4.07 3.56
(3.57) (4.67)
Family involvement 1.83 2.64
(3.92) (4.83)
Constant 49.31[d] 55.06[d]
(9.40) (11.74)
Re 0.34 0.38
Adjusted R 0.30 0.31
a p < 0.05; b p < 0.01; c p < 0.001; d p < 0.0001.
Table 4. Results of multiple regression predicting abstinence
rates with treatment, patient, research design
characteristics and treatment type[1]
Abstinence
Abstinence (independent
Predictor variables (n = 129) n = 129)
Patient characteristics
2
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Social stability 0.25[c] 0.23[b]
(0.07) (0.07)
Research design characteristics
Follow-up interval (log) -14.00[b] -14.68[b]
(4.98) (4.84)
Follow-up rate -0.24[a] -0.23[a]
(0.10) (0.10)
Definition of abstinence -5.18 -2.60
(5.58) (5.49)
Exclusion of more impaired patients -11.72[b] -9.91[b]
(3.54) (3.49)
Treatment characteristics
Treatment goal other
than abstinence -26.41[b] 24.82[a]
(9.90) (9.62)
Treatment intensity 15.06[c] 15.08[d]
(3.92) (3.80)
Antidipsotropics -0.61 1.74
(5.98) (5.87)
Behavioral treatment 7.36[e] 8.99[a]
(3.86) (3.79)
Family involvement 6.11 5.69
(4.48) (4.35)
Private treatment 9.98 [b]
(3.48)
Constant 51.57[d] 45.79[d]
(9.75) (9.68)
R 0.36 0.412
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Adjusted R 0.31 0.35
1 Excluding those conditions for which public/private treatment type could not be determined. e p< 0.10;
a p References ANNIS, H. M. (1986) Is inpatient rehabilitation of the alcoholic cost effective? Con position, Advances in ANNIS, H. M. & CHAN, D. (1979) The differential treatment model: empirical evidence from a personality BIEN, T. H., MILLER, W. R. & TONIGAN, J. S. (1993) Brief interventions for alcohol problems: a review, BUCHANAN, C. B., MACCOBY, E. E. & DORNBUSCH, S. M. (1991) Caught between parents: CHICK, J., RITSON, B., CONNAUGHTON, J., STEWART, A. & CHICK, J. (1988) Advice versus COOPER, n.M. (1989) Integrating Research: A Guide for Literature Reviews, 2nd erin (Newbury Park, CORDER, B. F., COP, DER, R. F. & LAIDAW, N. D. (1972) An intensive treatment program for alcoholics COSTELLO, R. M. (1975a) Alcoholism treatment and evaluation: in search of methods, International COSTELLO, R. M. (1975b) Alcoholism treatment evaluation: in search of methods, II. Collation of two- COSTELLO, R. M. (1980) Alcoholism treatment effectiveness: slicing the outcome variance pie, in: 2 1/18/23, 2:55 AM Explaining abstinence rates following treatment for alcohol abuse: A quanti…: GCU Library Resources – All Subjects https://eds-s-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=2&sid=a2feb20f-15d0-4f81-a7cc-5f463b51efcb%40redis&bdata=JnNpdGU9ZWRzLWxpdm… 28/32
University Park Press).
COSTELLO, R. M., BIEVER, P. & BAILLARGEON, J. G. (1977) Alcoholism treatment programming: DORUS, W., OSTROW, D.G., ANTON, H. et al. (1989) Lithium treatment of depressed and non- EDWARDS, G., ORFORD, J., EGERT, S. et al. (1977) Alcoholism: a controlled trial of ‘treatment’ and ELKINS, R. L. (1991) An appraisal of chemical aversion (emetic therapy) approaches to alcoholism EMRICK, C. D. (1974) A review of psychologically oriented treatment of alcoholism: I. The use and EMRICK, C. D. (1975) A review of psychologically oriented treatment of alcoholism: II. The relative EMRICK, C. D. (1979) Perspectives in clinical research: relative effectiveness of alcohol abuse EMRICK, C. D. (1982) Evaluation of alcoholism psychotherapy methods, in: PATTISON, E. M. & EMRICK, C. D. & HASEN, J. (1983) Assertions regarding effectiveness of treatment for alcoholism: fact ERIKSEN, L. (1986) The effect of waiting for alcoholism treatment after detoxification: an experimental FINNEY, J. W. & MONAHAN, S.C. (in press) The cost effectiveness of treatment for alcoholism: a FINNEY, J. W., HAHN, A. C. & MOOS, R. H. (in press) The effectiveness of inpatient and outpatient 1/18/23, 2:55 AM Explaining abstinence rates following treatment for alcohol abuse: A quanti…: GCU Library Resources – All Subjects https://eds-s-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=2&sid=a2feb20f-15d0-4f81-a7cc-5f463b51efcb%40redis&bdata=JnNpdGU9ZWRzLWxpdm… 29/32
of setting effects, Addiction.
FLOYD, A., MONAHAN, S.C., FINNEY, J. W. & MORLEY, J. B. (in press) The nature of alcoholism FULLER, R. K., BRANCHEY, L., BRIGHTWELL, D. R. et al. (1986) Disulfiram treatment of alcoholism: a GIBBS, L. & FLANAGAN, J. (1977) Prognostic indicators of alcoholism treatment outcome, International HEDBERG, A. G. & CAMPBELL, L. III (1974) A comparison of four behavioral treatments of alcoholism, HOLDER, H., LONGABAUGH, R., MILLER, W. R. & RUBONIS, A. V. (1991) The cost effectiveness of HUNT, W. A., BARNETT, L. W. & BRACH, L. G. (1971) Relapse rates in addiction programs, Journal of JACCARD, J., WAN, C. K. & TURRISI, R. (1990) The detection and interpretation of interaction effects LA PORTE, D. J., McLELLAN, A. T., ERLDEN, F. R. & PARENTE, R. J. (1981) Treatment outcome as a LONGABAUGH, R., McCRADY, B., FINK, E., STOUT, e., McALULEY, T., DOYLE, C. & McNEILL, D. MACKAY, P. W, DONOVAN, D. M. & MARLATT, G. A. (1991) Cognitive and behavioral approaches to MATFICK, R. P. & JARVIS, T. J. (Eds) (1993) An Outline for the Management of Alcohol Problems: 1/18/23, 2:55 AM Explaining abstinence rates following treatment for alcohol abuse: A quanti…: GCU Library Resources – All Subjects https://eds-s-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=2&sid=a2feb20f-15d0-4f81-a7cc-5f463b51efcb%40redis&bdata=JnNpdGU9ZWRzLWxpdm… 30/32
Wales, Australia).
McCRADY, B. S., PAOLINO, T. J. JR., LONGABAUGH, R. & Rossi, J. (1979) Effects of joint hospital MCCRADY, B. S., STOUT, R., NOEL, N., ABRAMS, D. & NELSON, H. F. (1991) Effectiveness of three McKAY, J. R., ALTERMAN, A. I., MCLELLAN, A. T., SNIDER, E. C., & O’BRIEN, C. P. (1995) Effect of McLACHLAN, J. F. C. & STERN, R. L. (1982) Evaluation of a day clinic for alcoholics, Journal of Studies MILLER, W. R. & HESTER, R. K. (1980) Treating the problem drinkers: modem approaches, in: MILLER, W. R. & HESTER, R. m. (1986a) The effectiveness of alcoholism treatment: what research MILLER, W. R. & HESTER, R. K. (1986b) Inpatient alcoholism treatment: who benefits? American MOOS, R. H. & BLISS, F. (1978) Difficulty of follow-up and outcome in alcoholism treatment, Journal of Moos, R. H., FINNEY, J. W. & CRONKITE, R. C. (1990) Alcoholism Treatment: context, process, and MORLEY, J. B., FINNEY, J. W., MONAHAN, S.C. & FLOYD, A. (in press) The quality of alcoholism NATHAN, P. E. & LANSKY, D. (1978) Common methodological problems in research on the addictions, 1/18/23, 2:55 AM Explaining abstinence rates following treatment for alcohol abuse: A quanti…: GCU Library Resources – All Subjects https://eds-s-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=2&sid=a2feb20f-15d0-4f81-a7cc-5f463b51efcb%40redis&bdata=JnNpdGU9ZWRzLWxpdm… 31/32
NEUBUERGER, O., HASHA, N., MATARAZZO, J. D., SCHMITZ, R. E. & PRATT, H. H. (1981) POLICH, I. M., ARMOR, D. J. & BEAIKER, H. B. (1981) The Course of Alcoholism: four years after PROJECT MATCH RESEARCH GROUP (1993) Project MATCH: rationale and methods for a multisite ROHENSOW, D. J., MONTI, P.M., BINKOFF, J. A., LIEPMAN, M. R. & NIRENBERG, T. D. (1991) SKINNER, H. A. (1981) Different strokes for different folks: differential treatment for alcohol abuse, in: SOBELL, M. B. (1978) Goals in the treatment of alcohol problems, American Journal of Drug and SOBELL, M. B., BROCHU, S., SOBELL, L. C., ROY, J. & STEVENS, J. A. (1987) Alcohol treatment SOBELL, L. C., SOBELL, M. B. & MAISTO, S. a. (1984) Follow-up attrition in alcohol treatment studies: TIMKO, C., FINNEY, J. W., Moos, R. H., Moos, B. S. & STEINEAUM, D. P. (1993) The process of TIMKO, C., MOOS, R. H., FINNEY, J. W., & MOOS, B. S. (1994) Outcome of treatment for alcohol WELTE, J., HYNES, G., SOKOLOW, L. & LYONS, J.P. (1981) Effect of length of stay in alcoholism 1/18/23, 2:55 AM Explaining abstinence rates following treatment for alcohol abuse: A quanti…: GCU Library Resources – All Subjects https://eds-s-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=2&sid=a2feb20f-15d0-4f81-a7cc-5f463b51efcb%40redis&bdata=JnNpdGU9ZWRzLWxpdm… 32/32
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Abstract
Purpose Design/methodology/approach Findings Practical implications Originality/value 2
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Making female �rst‐line nurse Emotional intelligence Giving sense and changing Understanding the Technological A review on China’s constructed Abstract Background
Theoretical framew
Ghana’s health-car Methods
Results
Discussion
Conclusion
Implications for nu Study strength and Recommendation Leadership competencies of �rst-line nurse managers: Yennuten Paarima, Atswei Adzo Kwashie, James Avoka Asamani, Adelaide Maria Ansah Ofei
Leadership in Health Services Article publication date: 3 January 2022
Issue publication date: 28 June 2022
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Keywords
Leadership competencies Nurse managers
First-line nurse managers
Citation Publisher: Emerald Publishing Limited Background Leadership is a process whereby people are in�uenced by an Leadership competencies are “the ability to inspire individual and Download as .RIS
Hong Zhang et al., Journal of Assessment Model of Cloud Powered by https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=Leadership+competencies https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=Nurse+managers https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=First-line+nurse+managers https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=Yennuten%20Paarima https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=Atswei%20Adzo%20Kwashie https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=James%20Avoka%20Asamani https://www-emerald-com.lopes.idm.oclc.org/insight/search?q=Adelaide%20Maria%20Ansah%20Ofei https://www-emerald-com.lopes.idm.oclc.org/insight/publication/issn/1751-1879 https://doi-org.lopes.idm.oclc.org/10.1108/LHS-05-2021-0047 http://jsuese.scu.edu.cn/jsuese_en/ch/reader/view_abstract.aspx?file_no=201900429&flag=1&utm_source=TrendMD&utm_medium=cpc&utm_campaign=Advanced_Engineering_Sciences_TrendMD_1 https://www.trendmd.com/how-it-works-readers 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 3/21
behaviors to enlist the support of individuals or groups in the First-line nurse managers (FLNMs) are essential to any health-care According to Chase (2010), FLNMs need fourteen leadership As asserted by Mosley and Pietri (2015), delegation is essential in 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 4/21
among successful persons. Due to the absence of policy on Con�ict resolution has been identi�ed as a unique leadership Several studies have also cited decision making as a key leadership Earlier researchers have reported a positive association between In this study, we de�ned FLNM as a registered nurse or midwife 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 5/21
supervising, directing, organizing and coordinating the work of To accomplish these essential roles require leadership Theoretical framework 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 6/21
planning, signi�cance, relationships, aspirations, and courage” Ghana’s health-care system At the district level, is the primary health care made of the district 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 7/21
(Asamani et al., 2019). Their principal mandate is to provide Nurses are the single largest health professionals constituting However, FLMNs sometimes feel overwhelmed by competing values Methods Design 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 8/21
Setting The Eastern is in the southern part of Ghana. The region is the third These hospitals comprised one regional hospital, one specialized Population and sampling technique 2 2 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 9/21
Data collection tool and procedure We obtained consent to modify the instrument from Linda K. Chase Once o�cial consent was obtained from the management of each Ethical clearance mailto:lindachase2619@gmail.com mailto:Ichase@iuhealth.org 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 10/21
Validity and reliability Table 1.
Statistical analysis Results Participants’ characteristics 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 11/21
Leadership competencies of �rst-line nurse managers 95) . Details are illustrated in Table 3.
The in�uence of leadership competencies of �rst-line = 2.781, p = 0.016]. However, a more detailed examination of the Discussion Participant characteristics Most of the participants were in the Nursing O�cer’s designations. 2 95) 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 12/21
However, because of the prevailing environment, they are forced to Leadership competencies of �rst-line nurse managers The current study further revealed a high knowledge and ability to Also, nurse managers had high knowledge and ability to apply 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 13/21
Rand (2019) in which unit-level FLNMs in South Africa appeared to E�ective decision-making is an essential leadership competency in Research has a tremendous impact on professional nursing The current study revealed that participant characteristics (gender, Although this �nding may not be new in the advanced health-care 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 14/21
long service with little or no consideration to competencies and This �nding is congruent with a US study by Anderson (2016) in Conclusion Implications for nursing management Study strength and limitation 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 15/21
a self-reported questionnaire. Therefore, the results may vary in Like all other theories and models of leadership, the Chase Recommendation for future studies Cronbach’s alpha coe�cient of knowledge and ability to apply Statement
Knowledge of Scale Scale Corrected Cron Decision- 50.63 60.938 0.731 0.92
Power and 50.82 59.429 0.767 0.92
Participants characteristics
Variable Frequency (n) (%)
Gender Table 1. Table 2. 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 16/21
List of nurse manager leadership competencies (Chase, 2010)
Statement Knowledge Ability to N Mean SD Mean SD Leadership 117 3.91 0.60 3.76 0.66 0.
Decision 121 4 09 0 68 4 03 0 70 0 0
The in�uence of nurse manager characteristics on leadership Predictors Standardized Model B (Constant) 134.829 11.764 11.46 References Alomairi, S.B., Seesy, N., El. and Rajab, A.A. (2018), “Managerial and Anderson, R. (2016), Assessing Nurse Manager Competencies in a Asamani, J.A., Naab, F. and Ofei, A.M.A. (2016), “Leadership styles in Asamani, J.A., Amertil, N.P., Ismaila, H., Akugri, F.A. and Nabyonga- Table 3. Table 4. 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 17/21
Asamani, J.A., Amertil, N.P., Ismaila, H., Francis, A.A., Chebere, M.M. Asiri, S.A., Rohrer, W.W., Al-Surimi, K., Da, O.O. and Ahmed, A. (2016), Chase, L. (2010), Nurse Manager Competencies, University of IA.
Chisengantambu-Winters, C., Robinson, G.M. and Evans, N. (2020), Cummings, G.G., Tate, K., Lee, S., Wong, C.A., Paananen, T., Micaroni, Dudley, N., Miller, J., Breslin, M., Lou Chapman, S.A. and Spetz, J. Erjavec, K. and Starc, J. (2017), “Competencies of nurse managers in Ganz, F.D., Wagner, N. and Toren, O. (2014), “Nurse Middle manager García, A.G., Pinto-Carral, A., Villorejo, J.S. and Marqués-Sánchez, P. Ghana Health Service (2005), Restructuring the Additional Duty Hahn, C.A. and Lapetra, M.G. (2019), “Development and use of the 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 18/21
Heinen, M., van Oostveen, C., Peters, J., Vermeulen, H. and Huis, A. Kantanen, K., Kaunonen, M., Helminen, M. and Suominen, T. (2017), Karathanasi, K., Prezerakos, P., Maria, M., Siskou, O. and Kaitelidou, Katz, R.L. (1974), “Skills of an e�ective administrator”, Havard Kinicki, A. and Williams, B.K. (2018), Management: A Practical Lega, F., Prenestini, A. and Spurgeon, P. (2013), “Is management Lehane, E., Leahy-Warren, P., O’Riordan, C., Savage, E., Drennan, J., Migliore, L., Chouinard, H. and Woodlee, R. (2020), “Clinical research Moeta, M.E. and Du Rand, S.M. (2019), “Using scenarios to explore Mosley, D.C. and Pietri, P.H. (2015), Supervisory Management: The Mueller, C. and Vogelsmeier, A. (2013), “E�ective delegation: 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 19/21
Munyewende, P.O., Levin, J. and Rispel, L.C. (2016), “An evaluation of Ofei, A.M.A. and Paarima, Y. (2021a), “Exploring the governance Ofei, A.M.A. and Paarima, Y. (2021b), “Perception of nurse managers Ofei, A.M., Ansah Paarima, Y., Barnes, T. and Kwashie, A.A. (2019), Ofei, A.M., Ansah Sakyi, E.K., Buabeng, T., Mwini-Nyaledzigbor, P. and Ofei, A.M.A., Paarima, Y. and Barnes, T. (2020a), “Exploring the Ofei, A.M.A., Paarima, Y., Barnes, T. and Kwashie, A.A. (2020b), “Stress Ofei, A.M., Ansah Kwashie, A.A., Asiedua, E., Twum, N.S. and Akotiah, Paarima, Y., Kwashie, A.A. and Ofei, A.M.A. (2021), “Financial Paarima, Y., Ofei, A.M.A. and Kwashie, A.A. (2020a), “Managerial Paarima, Y., Ofei, A.M.A. and Kwashie, A.A. (2020b), “Managerial 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 20/21
Polit, D.F. and Beck, C.T. (2014), Essentials of Nursing Research: Riisgaard, H., Nexøe, J., Le, J.V., Søndergaard, J. and Ledderer, L. Roshanzadeh, M., Vanaki, Z. and Sadooghiasl, A. (2019), “Sensitivity in Sabri Gassas, R. (2017), “Nurse managers’ attitude and competency Salmela, S., Koskinen, C. and Eriksson, K. (2017), “Nurse leaders as Siirala, E., Peltonen, L.M., Lundgrén-Laine, H., Salanterä, S. and Tingen, M.S., Burnett, A.H., Murchison, R.B. and Zhu, H. (2009), “The Tompkins, F. (2016), “Delegation in correctional nursing practice”, Yoon, J., Kim, M. and Shin, J. (2016), “Con�dence in delegation and Acknowledgements The authors wish to sincerely thank the management hospitals and Funding: The authors received no funding either from individuals, 1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight https://www-emerald-com.lopes.idm.oclc.org/insight/content/doi/10.1108/LHS-05-2021-0047/full/html 21/21
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Con�icting interests: The authors declared no competing interest Author Contributions statement.
Study conception and design: YP, JAA, AMAO, AAK.
Data collection: YP.
Data analysis and interpretation: YP and JAA.
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Critical revision of article: All authors.
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/ Leadership competencies of �rst-line nurse managers: a quantitative study
This paper aims to examine the leadership competencies of �rst-
line nurse managers (FLNMs) at the unit level in the eastern region
of Ghana.
The paper is a quantitative cross-section design.
Nurse managers exhibited a moderate level of knowledge and
ability to apply leadership competencies. Gender, rank, quali�cation,
professional experience, management experience and
management training jointly predicted the leadership competencies
of FLNMs [(R = 0.158, p = 0.016]. However, only management
training was a signi�cant predictor in the model.
Inappropriate leadership competencies have severe consequences
for patients and sta� outcomes. This situation necessitates a call for
a well-structured program for the appointment of FLNMs based on
competencies.
This study is the �rst in Ghana which we are aware of that examined
the leadership competencies at the unit level that identi�es
predictors of leadership competencies.
managers more e�ective: a
Delphi study of occupational
stress
Robert Loo et al., Women in
Management Review, 2004
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individual characteristics
Mary Pat McEnrue et al., Journal
of Management Development,
2009
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implementation of the
performance management
system in public sector
organisations in developing
countries
Frank Louis Kwaku Ohemeng et
al., International Journal of Public
Sector Management, 2018
Landscape of Home Health
Aides: Scoping Literature Review
and a Landscape Analysis of
Existing mHealth Apps
Elizabeth Fong-Chy Kuo et al., J
Med Internet Res, 2022
wetlands in recent three
decades: Application and
practice
system
management
limitation
future studies
a quantitative study
: 1751-1879
(International
Standard
Serial
Number.)
Paarima, Y., Kwashie, A.A., Asamani, J.A. and Ofei, A.M.A. (2022),
“Leadership competencies of �rst-line nurse managers: a
quantitative study”, Leadership in Health Services, Vol. 35 No. 3, pp.
338-354. https://doi-org.lopes.idm.oclc.org/10.1108/LHS-05-2021-
0047
Copyright © 2021, Emerald Publishing Limited
Health-care systems across the world have become complicated
and confronted with several multifaceted challenges including
increasing workload, inadequate sta�ng and the rising cost of care
(AL-Dossary, 2017; Asamani et al., 2016). As the largest health-care
professionals, nurses are often at the center of these issues.
Consequently, health-care managers are constantly searching for
the “best” approach to enhance both sta� and patient outcomes
amid these challenges (Asamani et al., 2016). In addressing these
challenges and other health-care-related issues, nurse managers
are required to exhibit practical leadership.
individual to work toward the attainment of a mutually agreed goal
willingly and enthusiastically (Cummings et al., 2018). On the other
hand, management is de�ned as “the pursuit of organizational goals
e�ciently and e�ectively by integrating the work of people through
planning, organizing, leading, and controlling the organization’s
resources.” (Kinicki and Williams, 2018). Given the nature of health
care, managers are required to provide leadership, as well
supervision and coordination of health-care activities. In this study,
leadership is operationally de�ned as a process whereby an
individual leads a group of people by applying his or her leadership
knowledge and ability to translate organizational goal(s) into action
for optimum performance. To achieve this call for e�ective display
of leadership competencies.
organizational excellence, create a shared vision and successfully
manage change to attain an organization’s strategic ends and
successful performance”(Hahn and Lapetra, 2019). According to
Chase (2010), leadership competencies are the knowledge and
ability to direct the operations of an organization using skills and
Environmental Sciences, 2021
Service Security Level Based on
Standardized Security Metric
Hierarchy
LI Xiang et al., Advanced
Engineering Sciences, 2019
achievement of a shared goal. Chase (2010) identi�ed leadership
competencies as a signi�cant domain of competencies essential at
all levels of management. Heinen et al. (2019) also acknowledged
leadership competencies as an important tool that frontline nurse
managers can use to initiate changes in nursing to a�ect the
attitudes of their subordinates.
organization. Their functions are complex, vital, and often tricky.
FLNMs’ primary duties are to ensure the delivery of quality and safe
care (Ofei et al., 2018) and serve as the bridge between the top
management and nurses. They are also in charge of building and
maintaining healthy and safe working environments, which has a
positive impact on both sta� and patient outcomes and reduces
mortality rates in all health care systems (Alomairi et al., 2018). This
signi�cant position is characterized by varying degrees of rigor and
scope (Erjavec and Starc, 2017), which require FLNMs to possess
the requisite leadership competencies to ensure e�ciency and
e�ectiveness at the unit.
competencies, that is, “decision making, power and empowerment,
delegation, change process, con�ict resolution, problem-solving,
stress management, research process, motivational strategies,
organizational unit work, policy and procedure, sta� education, time
management, and interdisciplinary care coordination”. Chase (2010)
emphasized that any nurse manager de�cient in knowledge and
ability to apply these leadership competencies loses the chance of
being a successful manager as the position is dynamic and
challenging.
managing the unit as many nurses assume managerial
responsibilities without formal training. Delegation allows FLNMs to
distribute and entrust activities and related authority to their
subordinates. However, they retain accountability for the task,
ensuring tasks are accomplished safely and correctly (Yoon et al.,
2016). The ability to allow nurses to participate in the management
of the unit actively prepares them adequately for the future, though
the process must be well-structured, done cautiously, and when the
right condition prevails with the right supervision (Ofei et al., 2020a,
2020b). Undoubtedly, delegation has the potential to build
competencies and resilience of inexperienced nurses, thus
promoting con�dence and increased performance (Dudley et al.,
2021). The challenge with delegation is that many FLNMs do not
evaluate and reward performance or give adequate feedback to the
delegates, whereas some also ignore supervision of the delegated
tasks (Tompkins, 2016). One obvious challenge with delegation in
Ghana is the blatant lack of well-established organizational methods
and procedures for delegation in the health system (Ofei and
Paarima, 2021a, 2021b). Hence, in most instances, there is lack of a
well-structured coordination and communication during delegation,
as well as a lack of properly de�ned duties and spheres of authority
(Ofei and Paarima, 2021a, 2021b). Again, the act of delegation
requires an emotional maturity which apparently is rare even
delegation in most institutions, the work experience of FLNMs has
not taught them the practice. Thus, FLNMs are reluctant to take that
risk involved in depending on others. Another challenge with
delegation is that the FLNM should be organized to plan work in
advance to delegate appropriately.
competency that FLNMs require to e�ectively manage con�icts that
may arise at the unit (Mueller and Vogelsmeier, 2013). Con�ict
feels uncomfortable and awkward to many, it is an inevitable part of
life and is prevalent among nurses at the unit which can negatively
a�ect patient care. FLNMs’ ability to e�ectively resolve con�icts that
ensue at the unit is one endeavor crucial to all managerial work
(Ofei et al., 2020a, 2020b). However, many FLNMs at the unit are
not endowed with con�ict resolutions skills to enable them
e�ectively manage con�icts hence, resorting to ine�ective measures
such as avoidance and accommodation, which allow other
professionals and junior colleagues alike to brand them as
ine�ective leaders (Ofei and Paarima, 2021a, 2021b)
competency through which all the responsibilities and activities of
FLNMs are accomplished (Roshanzadeh et al., 2019; Salmela et al.,
2017). Decisions of FLNMs have a signi�cant impact on care
coordination, work�ow, patient safety and sta� well-being
(Chisengantambu-Winters et al., 2020). Thus, decisions made at
the wrong time, and the wrong place are substantial and can
become expensive for health-care delivery (Siirala et al., 2016).
Therefore, FLNMs need to clarify what decisions are made at the
unit to elicit the necessary support from their subordinates. The
challenge with decision-making among FLNMs is the lack of
engagement. Decisions are solely made by FLNMs without
consultation and colleagues have to just accept them without
complaints.
leadership competencies and improved performance as well as the
sustainability of health-care institutions (Lega et al., 2013). Similarly,
Asamani et al. (2016) reported a signi�cant correlation between
nurse managers’ leadership competencies and nurses’ perceived
productivity at the unit. Given this positive impact of leadership
competencies, it is essential to strengthen the capabilities of FLNMs
and empower them to develop and maintain these competencies
for optimum health-care delivery (Asamani et al., 2016; Kantanen
et al., 2017). However, studies originating from advanced health-
care systems have reported a moderate level of leadership
competency among nurse managers (García et al., 2020; Kantanen
et al., 2017). Similarly, Munyewende et al. (2016) reported
moderate leadership competencies score among South African
clinical nurse managers.
who has o�cially been appointed to head a ward/unit irrespective
of his/her professional rank. In Ghana’s health system, they are
appointed by executive nurse managers and their duties include
nursing sta� at the unit level. However, because the entry-level of
professional nursing in Ghana is a diploma, there are countless
nursing units with nurses in the lower ranks as unit-level managers.
Also, due to the geographical location of some hospitals, nurses
with higher certi�cation and ranks refuse posting to these hospitals
therefore, those in the lower ranks who accept posting to these
hospitals assume unit-level managerial positions. Despite their
limited management and professional expertise, they are required
to provide e�ective leadership at the unit level.
competencies to navigate and e�ciently manage dwindling health
care resources (Paarima et al., 2020b). Despite these signi�cant
roles of FLNMs, it is intriguing to know that most of them are
appointed based on clinical expertise and long service with little or
no consideration to competence (Ofei et al., 2019; Paarima et al.,
2020a, 2020b). Also, there is no research information assessing and
measuring the leadership competency of FLNMs in Ghana.
Therefore, this study aimed at examining the leadership
competencies of FLNMs at the unit level in the Eastern Region of
Ghana. The study objectives were to examine the leadership
competency level of FLNMs at the unit level and to examine the
in�uence of demographic characteristics on the leadership
competencies of FLNMs at the unit level
Though several competencies’ theories exist, we used Katz’s
conceptual framework. Katz’s conceptual framework originally has
three distinct dimensions: technical, conceptual and human
relationship competencies (Katz, 1974). Chase used the Katz
framework to investigate nurse managers’ competencies and
identi�ed two additional competencies; thus, leadership and
�nancial management competencies (Chase, 2010). Technical
competencies refer “to the pro�ciency when working with tools,
based on speci�c knowledge, in a particular �eld of work” (Paarima
et al., 2020a, 2020b). Technical competencies are important for
“operational level managers, less important for middle managers,
and least important for executive managers”. Human relationship
competencies are the “pro�ciency when working and relating with
people based on one’s knowledge of people and how they behave,
operate in groups, the way to e�ectively communicate with them,
and their feelings, attitudes, and motives” (Paarima et al., 2020a,
2020b). Human relationship competencies are vital to all the levels
of management (Ofei et al., 2020a, 2020b). Conceptual
competencies are the “ability to think through the ideas or concepts
that form the foundation of the organization, its vision, and goals”
(Paarima et al., 2020a, 2020b). These competencies are essential
for executive managers, less signi�cant for middle managers, and
least important for operational-level managers. But lower-level
managers need to develop and demonstrate conceptual
competencies to be promoted to higher managerial positions.
Leadership competencies are the “ability to engage and motivate
others in followership using personal mechanisms of strategic
(Chase, 2010). Leadership competency is ultimately about creating
a way for people to contribute to making something extraordinary
happen (Chase, 2010) and is essential at all levels of management.
Financial management competencies are “management related to
the �nancial structure of the company and therefore to the
decisions of source and use of �nancial resources, that is re�ected
in the size of the �nancial income and/or charges” (Chase, 2010)
and important for all managers. According to Paarima et al. (2020a,
2020b), any manager de�cient in each competency loses the
chance of being a successful manager. Chase’s conceptual
framework was used to guide a bigger study that investigated the
managerial competencies of FLNMs in Ghana. The framework was
selected over others because its constructs best accommodate the
study objectives. It has expansive variables of assessing the
technical, conceptual, human relationship, leadership, and �nancial
management skills which was the main purpose of the big study.
The technical, human, conceptual and �nancial management
dimensions have already been reported (Paarima et al., 2020a,
2021). Therefore, this paper is reporting only the leadership domain
aspect of the study to give the full picture of the situations in
Ghana. The leadership domain of the Chase framework has
fourteen variables namely decision making, power and
empowerment, delegation, change process, con�ict resolution,
problem-solving, stress management, research process,
motivational strategies, organizational unit work, policy and
procedure, sta� education, time management and interdisciplinary
care coordination.
Ghana operates a three-level health-care delivery system. At the top
(tertiary level) are the Teaching Hospitals that are autonomous and
serve as national referral facilities. They are mandated to provide
excellent services, take care of complex conditions, train health
professionals and conduct research. Each Tertiary Hospital is linked
with a public university to enhance its functions. There are also
Regional Hospitals that are mandated to provide a secondary level
of specialized health-care services. They serve as referral facilities
for each of the 16 administrative regions of Ghana. Regional
Hospitals are required to provide health services to about two
million populaces.
hospitals, health centers and the community-based health planning
and services (CHPS) compounds. The district hospitals serve as
referral centers at the district level. They are mandated to provide
emergency and basic health care to about 200,000 population. The
district level is further divided into subdistricts. Health care at the
subdistricts is delivered by the health center, which provides
promotive, preventive and basic curative services. Their catchment
area covers up to about 20,000 inhabitants. At the bottom of the
district/primary health, hierarchy are the community-based health
planning and services (CHPS) compounds, whose key strategy is the
provision of basic primary health-care services in the communities
preventive services and treatment of minor ailments using over-the-
counter medications to about 750 households or a population of
about 5000. Additionally, there are also government own
specialized hospitals, quasi-government hospitals and private-for-
pro�t health-care facilities (Asamani et al., 2019).
about 60% of the total workforce in Ghana’s health system
(Asamani et al., 2019). Nursing administration is organized at three
functional levels: the top level, the middle level and the unit level
(Ofei et al., 2020a, 2020b). The top (executive) nurse managers are
responsible for making organizational strategic decisions and
developing strategic plans for the entire organization. The middle-
level nurse managers are heads of departments, that make tactical
decisions and plans for the department as well as manage the work
of unit-level nurse managers, whereas the unit-level nurse
managers are in the wards operating as operational managers in
the health-care facility (Ofei and Paarima, 2021a, 2021b). The �rst-
level nurse managers manage all the activities in the unit,
coordinating all the activities of the nurses, other health
professionals and the support sta�. They make operational
decisions and plans for the department and are considered �rst-
line managers.
and demands e�ciency and quality. Inability to e�ectively address
these competing demands will result in loss of con�dence and trust
in them and the organization which can result in sta�
dissatisfaction. Given this, FLNMs are required to e�ectively handle
challenges and problems that arise at the unit level. They need to
show responsiveness and support their sta� by ensuring a
favorable work environment that will encourage trust and open
communication where the safety and wellbeing of sta� are
prioritized. Their ability to develop a friendly environment in which
nurses feel valued and supported will enable them to be inspired
and show organizational commitment leading to improved
performance. To accomplish these essential roles, call for e�ective
leadership competencies. Therefore, our study was centered on the
unit-level managers (FLNMs) who constitute the greater proportion
of health-care managers in Ghana’s health system. The FLNMs were
purposefully chosen because of their pivotal role in the delivery of
quality health care in Ghana. While this study with FLNMs, the paper
focus is to investigate leadership due to series of problems that
continually occur in the FLNM role.
The research investigated the leadership competencies of FLNMs
using the quantitative cross-sectional design. This design allows the
researcher to collect original data that is su�cient for generalization
to the population of interest (Polit and Beck, 2014).
We conducted the study in the Eastern Region of Ghana. Ghana is
in West Africa and is bordered to the north by Burkina Faso, to the
west by Côte d’Ivoire, to the east by Togo, and to the south by the
Gulf of Guinea and the Atlantic Ocean. Ghana occupies a total
landmass of 92,099 Square miles (238,535 km ). Ghana has 16
administrative regions and 260 district assemblies with an
estimated population of 30,000, 000.
most populated with a total population of 3,244,834, representing
10.4% of Ghana’s population in 2019. It is the sixth-largest region
occupying a landmass of 19,323 km . The region has 26
administrative districts with Koforidua being the regional capital. We
conducted the study in ten public district hospitals constituting 42%
of hospitals in the region (GHS, 2015). The hospitals are Koforidua
Regional Hospital in the New Juaben Municipality, Presbyterian
Hospital in the Kwahu Afram Plains North District, Kwahu
Government Hospital in the Kwahu South District, Holy Family
Hospital Kwahu West Municipality, Kibi Government Hospital East
Akim District, Saint Dominic Hospital in the Kwaebibirem district,
Nsawam Government Hospital Nsawam Adoagyire municipality, St.
Joseph Hospital in New Juaben municipality, Suhum Government
Hospital Suhum Municipality and Akuse Government Hospital in the
Lower Manya Krobo District.
hospital and eight district hospitals which were chosen purposefully
to represent both primary and secondary levels of health care in
the region. They were also selected to represent the two largest
health-care agencies in the region, Ghana Health Service and the
Christian Health Association of Ghana. We chose the region and the
hospitals for the study because most of these hospitals are in rural
and peri-urban towns whose proximities are far from the national
capital with inadequate social amenities.
All FLNMs in the ten hospitals were eligible to participate in the
study. FLNMs at least with one year of management experience
who agreed to take part in the study were all included. We excluded
top (executive) level managers, trainee nurses, national service
personnel and nurses who were not FLNMs. We used a census
approach in administering the questionnaires. A census approach is
a “data collection method that allows the researcher(s) to collect
data from all elements of the accessible population and to
investigate one or more characteristics of those elements” (Polit
and Beck, 2014). We chose this approach to enable us to have an
adequate representation of each hospital since FLNMs are not
many.
We adopted the Nurse Managers Competencies Instrument (Chase,
2010). The instrument was slightly modi�ed to suit the study’s aim
and objectives. The questionnaire has �ve dimensions (technical,
conceptual, human, leadership and �nancial management), but this
study adapted only the leadership dimension. The leadership
competency dimension had 14-items. The original instrument is
measured on a four-point Likert scale (1 to 4) however, in this study,
the authors modi�ed the instrument into a �ve-point scale (1 =
poor, 2 = fair, 3 = Good, 4 = very good 5 = excellent).
the originator of the instrument via
lindachase2619@gmail.com/Ichase@iuhealth.org. In this study,
the �fth point was added to indicate the highest level of knowledge
and ability to apply the competencies, which is consistent with
earlier authors using the instrument in similar studies (Karathanasi
et al., 2014; Paarima et al., 2020, 2021). The questionnaire was
clustered into sections A and B. Section A gathered data on
participants’ sociodemographic characteristics, whereas section B
gathered data on the leadership competencies of nurse managers.
hospital, the researchers proceeded with the data gathering
process. We allocated each hospital with a speci�c number of
questionnaires based on the strength of FLNMs. At the unit/ward
level, each FLNM was approached individually. After an extensive
explanation of the study’s purpose and objectives, those who
accepted to take part in the study were given a voluntary consent
form to sign, after which the questionnaires were given out. Due to
the busy schedules of FLNMs, the questionnaires were given to
them to complete at their convenience. The study recorded a 98.4%
response rate. We used three months for data gathering, from
January to March 2018.
The Ethics committee of the Noguchi Memorial Institute for Medical
Research (023/17–18) approved this current study. We also
obtained o�cial permission from the hospitals’ management. The
study had neither psychological, physical nor emotional harm to
participants as it was nonexperimental, and the questionnaire did
not contain variables that may cause fear or anxiety in participants.
Participating in this current study was exclusively voluntary. Each
participant was appropriately briefed on the research purpose. The
right to withdrawal from the study at any time without assigning a
reason(s) was explained. To maintain anonymity, we did not collect
any identifying biodata of the study participants. Participants signed
consent before the authors commenced the administration of the
questionnaire. Con�dentiality was maintained throughout the study
by ensuring that participants’ rights were protected, and
information divulged to researchers was not disclosed to
unauthorized persons.
We maintained the validity of the instrument mainly through
content and face validity. To maintain face validity, the questions
were arranged to re�ect the study objectives. Content validity was
ensured through a thorough conceptualization of the constructs to
adequately capture the content domains. We also made sure
research objectives are precise and have been captured adequately
by the questionnaire. Again, the instrument was also validated by
nursing administration and management experts. To safeguard
reliability, the instrument was pre-tested at a di�erent hospital with
�fteen FLNMs. The outcome of the pretest was used to correct
grammatical mistakes and to adjust areas of ambiguity. The overall
Cronbach’s alpha coe�cient of the original instrument was 0.92 and
the overall knowledge of competency was 0.883 whereas the ability
to apply the competency was 0.803. In this study, the overall
Cronbach’s alpha coe�cient of instrument was 0.97, knowledge of
competency 0.930, and ability to apply competency 0.944. Because
we modi�ed the instrument to a �ve-point scale, a psychometric
analysis was performed. The Cronbach’s alpha coe�cient of
knowledge of competency ranged from between 0.922 and 0.930
whereas that of the ability to apply competency ranged between
0.751 and 0.758 which is considered acceptable (Polit and Beck,
2014). Details are presented in
We analyzed data using descriptive and linear regression analyses.
Participants’ characteristics and leadership competencies were
summarized, and results presented in frequencies, percentages,
means, and standard deviations using descriptive statistics. Multiple
linear regression analysis was conducted to determine the in�uence
of participant characteristics (rank, gender, quali�cation,
professional experience, management experience and
management training) on leadership competencies. Scores were
interpreted as 1-very low, 2-low, 3-moderate, 4-high, 5-very high.
Higher scores showed a higher level of leadership competencies
among the nurse managers.
Females accounted for 73.6% (n = 89) of the 121 (100%) nurse
managers, while males accounted for 24.7% (n = 30). Most of the
participants (n = 66, 54.6%) were between the ages of 30 and 39. In
addition, 38.8% (n = 47) of the participants had the title of Nursing
O�cer. Furthermore, �rst-degree holders made up 47.9% (n = 58)
of the participants, while master’s degree holders made up just
7.4% (n = 9). Finally, most of the participants (n = 21, 17.4%) work in
specialist units/wards. Table 2 provides more details.
The average score of knowledge of leadership competencies was
3.91 (SD = 0.60) and the ability to apply the competencies was 3.76
(SD = 0.66). The highest-rated leadership competency was
knowledge of delegation (mean = 4.15, SD = 0.73) and ability to
apply delegation (mean = 4.03, SD = 0.83). This competency was
followed by knowledge of con�ict resolution (mean = 4.09 SD =
0.68) and the ability to apply con�ict resolution (mean = 4.03, SD =
0.06). The lowest score of leadership competency was knowledge of
research process (mean = 3.35, SD = 0.96) and ability to apply the
research process (mean = 3.18, SD = 0.
nurse managers
The results in Table 4 shows that, participant characteristics
(gender, rank, quali�cation, professional experience, management
experience and management training) together accounted for
15.8% of the variance in leadership competencies [R = 0.158, F
predictors showed that only management training was statistically
signi�cant (p = 0.001) in the regression model.
Participants within the age group of 30–39 years bracket constituted
the majority. Our �nding agrees with the average age of nurses in
Ghana, which is projected to be between the age of 25–40 years
(Asamani et al., 2019, 2020). This �nding suggests a young cohort
of nurses in Ghana’s health-care system. It implies that these
FLNMs might possess limited or no leadership competencies. This
may stem from the fact that some FLNMs are in the Sta� Nurse and
Senior Sta� Nurse ranking with limited management and
professional experience. Furthermore, 73.6% of the participants
were female which reinforced the assertion that nursing is a
women-dominated profession. This view is gradually shifting, with
many males in Ghana preferring nursing as a career.
This suggests that, depending on their starting grade, most of the
participants have served for 3 to 5 years or more. This contradicts
the �ndings of Ofei et al. (2018), who found that most participants
were Senior Sta� Nurses. Even though both studies were
performed in Ghana’s Eastern Region, Ofei et al. (2018) conducted
their research in three hospitals with 45 nurse managers, while this
current study used 121 FLNMs in ten health-care facilities. The
�nding is also inconsistent with the Ghana Health Service job
description of nursing and midwifery sta� which requires that a
nurse manager should be at least a Senior Nursing O�cer (Ghana
Health Service, 2005). This means that most of the participants in
this study are not quali�ed to be occupying these key positions.
(6,
assume the responsibilities of FLNM without the necessary
experience and competencies. The situation can have severe
consequences on patient and sta� outcomes. The study found a
di�erent level of educational background which illustrates the entry-
level of professional nursing in Ghana. As asserted by Ofei et al.
(2020a, 2020b) and Paarima et al. (2020a, 2020b), the educational
level of FLNMs can greatly a�ect their appreciation of leadership at
the unit level.
Leadership is a critical concept in nursing since health-care delivery
even at the small unit is immeasurably complex (Asamani et al.,
2016; Paarima et al., 2020a, 2020b) and the appropriate leadership
competencies are required to avoid errors, waste and confusion.
The study found a moderate level of leadership competencies
among FLNMs. This �nding means that the FLNMs exhibited
satisfactory leadership competencies at the unit. FLNMs in Ghana
are faced with several challenges including poor work environment,
inadequate remuneration, and leadership challenges. This
information partially explains the moderate leadership
competencies among participants in this current study. Several
studies have reported similar �ndings (Asamani et al., 2016; Ofei et
al., 2014; Karathanasi et al., 2014). These studies attributed the
moderate level of leadership competencies to a lack of mentorship,
coaching, leadership training and experiential learning.
apply delegation. This implies that FLNMs in this recent study
e�ectively delegate responsibilities to their subordinates in the unit.
The researchers observed that FLNMs do delegate with the
appropriate authority and resources, but improvement would be
appreciated. Delegation in nursing is crucial in managing the unit as
most nurses assume management roles without formal training.
Therefore, FLNMs must allow subordinates to take active roles in
managing the unit to prepare them adequately for the future,
though the process must be structured and done cautiously
(Paarima et al., 2020b). Delegation can e�ectively be used as a form
of succession planning for nurses if managed well. FLNMs should
be encouraged to delegate when the prevailing conditions are right.
Researchers in Denmark and Saudi Arabia have reported similar
�ndings (Sabri Gassas, 2017; Riisgaard et al., 2016).
con�ict resolution at the unit. This �nding suggests that nurse
managers have the needed skills in con�ict resolution. As nursing
units are human societies, con�icts are inevitable. However, poor
management of con�ict has been linked to low morale, decreased
productivity, job dissatisfaction, �nancial loss for organizations and
poor work�ow (Moeta and Du Rand, 2019). Therefore, resolving
con�icts that arise at the unit level is an essential endeavor critical
to all FLNMs. In dealing with challenges that occur at the unit,
FLNMs must be competent, experienced and able to relate well with
their sta�. Ganz et al. (2014) reported a similar �nding in Israel.
However, the result is inconsistent with the work of Moeta and Du
have challenges in dealing with con�ict between individuals or
generally in the unit and intervened inappropriately.
nursing. FLNMs’ ability to make e�ective clinical decisions is the
most crucial factor a�ecting the sta� and patient outcomes
(Chisengantambu-Winters et al., 2020). FLNMs in this current study
showed higher decision-making skills. This �nding implies that
FLNMs can e�ectively gather, process and prioritize critical patient
information to choose the best nursing actions, implement and
evaluate the outcomes. If nurses can participate in the decision
process, it would enhance their con�dence, competence, improve
care and increase their organizational commitment. Participating in
decision-making deepens democratic values, increases team spirit,
stimulates the work environment as well as improves sta�
satisfaction and productivity. This �nding conforms to the work of
Asiri et al. (2016) which a�rmed that an e�ective decision-making
process signi�cantly predicted nurses’ commitment and
performance among Saudi nurses.
practice, thus rendering it an essential component of the FLNMs
competencies (Tingen et al., 2009). Even though research is critical
in nursing care, participants in this current study showed moderate
knowledge and ability to apply the research process. The �nding
suggests that nurse managers exhibit a satisfactory level of the
research process. It is, therefore, essential that FLNMs acquire the
necessary skills, knowledge, and attitudes towards research to
enable them to lead their sta� in conducting and utilizing research
�ndings in health-care delivery. This information calls for future
directions to help nurses build and maintain research skills. The
�nding is inconsistent with the work of Lehane et al. (2019) and
Migliore et al. (2020) which reported a high level of clinical research
competencies among nurses.
rank, quali�cation, professional experience, management
experience, and management training) accounted for 15.8% of
di�erences in the leadership competencies of FLNMs. However,
only management training statistically contributed to the model.
This �nding implies that training in management improves
leadership competencies. Thus, management training build-up
FLNM competence and con�dence. Periodic training of FLNMs and
adequate preparation for this position are very relevant and
hospitals must be encouraged to provide systematic training. A
structured in-service training, as well as mentorship and coaching,
should be encouraged at the unit level to help young nurses build
their leadership competencies by learning from experienced
nurses. Also, hospitals should support current and potential nurse
managers to take leadership and management courses as
approved by the GHS.
settings, it is a vital �nding in the context of Ghana where the
appointment of nurse managers is based on clinical expertise and
management/leadership training.
which attending a management academy signi�cantly predicted the
managerial knowledge and skills of military nurse managers. The
call for nurses to receive leadership and management training
before they assume management positions are in the right
direction as well as the development of better remuneration
packages to boost their worth to the hospital. In addition, all the
predictors identi�ed only 15.8% of the variance, a greater
proportion of the variance remains unknown. This calls for further
studies to establish whether other factors may account for FLNMs’
leadership competencies.
The study investigated the leadership competencies of FLNMs in
the Eastern Region of Ghana. The study identi�ed that FLNMs are
essential stakeholders in addressing the myriad of nursing and
health-care challenges. Therefore, FLNMs must possess the
relevant and appropriate leadership competencies to enable them
to address these challenges. The �ndings showed that FLNMs
exhibited all the leadership competencies of the Nurse Managers
Competency Instrument. The results also demonstrated that age,
gender, quali�cation, professional experience, managerial
experience, and training in management explained a substantial
proportion of the leadership competencies of FLNMs. However,
only managerial training contributed to the model. A well-structured
educational, experiential, and mentorship programs are required to
provide a framework for leadership development for FLNMs.
Generally, we found a satisfactory level of leadership competencies
among FLNMs. This �nding implies a need for improvement in these
competencies to e�ectively create a favorable work environment for
quality and safe patient care. Training in management explained a
signi�cant portion of FLNMs’ leadership competencies. This implies
that nurses need training in management before or after their
appointment as FLNMs. This training will equip them with adequate
knowledge, abilities, and skills to navigate the increasingly complex
health-care environments. This situation necessitates the
identi�cation of potential nurse managers and their adequate
preparation through regular training in leadership and
management.
As far as the author knows, this is the �rst study to investigate the
leadership competencies of FLNMs in Ghana. However, due to its
limitations, the research results should be interpreted with caution.
The study was conducted only in the Eastern Region of Ghana using
other regions of Ghana. However, the selected hospital has the
characteristics of Ghanaian health-care facilities.
framework has some weaknesses. First, the framework lacks key
skills such as inspiration, innovations, teamwork and goal(s) setting
among other critical skills needed for e�ective leadership. The lack
of these critical skills may be due to the fact; the framework is not a
leadership framework but rather nurse managers competency
framework. Therefore, the �ndings of this study should be
interpreted in the context of nurse managers’ competencies as
outlined in Chase Nurse Managers Competencies (Chase, 2010).
The authors recommend future studies to consider using mixed-
method and other theoretical approaches in examining leadership
competencies in health care.
leadership competencies
competency
mean if
item
deleted
variance
if item
deleted
item-total
correlation
alph
item
dele
making
empowerment
Male 30 24.7
Female 89 73.6
Missing values 2 1.8
Total 121 100
Age
20–29 10 8.3
30–39 66 54.6
40–49 10 8.3
of
competency
apply
competency
M
di
competencies
(Mean score)
competencies
Unstandardized
coe�cients
coe�cients t
Std.
Error Beta
Gender −3.696 4.212 −0.093 −0.88
Rank 2.063 2.256 0.122 0.914
Q li� ti 2 932 2 994 0 111 0 98
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Declarations Ethics: Approval to conduct the study was obtained
from Noguchi Memorial Institute for Medical Research (CPN
023/17–18) before the start of the research. O�cial permission to
gather data was sought and received from the management of the
hospitals. Written informed consent was granted by all the
respondents.
all the nurse managers who participated in the study.
not-for-pro�t organizations, or commercial entities.
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Adelaide Maria Ansah Ofei can be contacted at:
adelaideaofei@yahoo.com or aansahofei@ug.edu.gh