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FACTORS RELATED TO ALCOHOL RELAPSE IN PERSONS WITH ALCOHOL DEPENDENCE IN THAI NGUYEN HOSPITALS, VIETNAM Mr Trieu Van Nhat A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Nursing Science Program in Nursing Science Faculty of Nursing Chulalongkorn University Academic Year 2018 Copyright of Chulalongkorn University iv v vi ACKNOWLEDGEMENTS I would like to take this opportunity to express my heartfelt gratitude to people who have helped me to complete this study I would first like to express my very great appreciation to my major advisor, Assist Prof Penpaktr Uthis for her guidance and support during the planning and development of this study, for her patience, motivation, and immense knowledge The door to her office has always opened whenever I had a trouble or question about my research I am very grateful to have the opportunity to study under her guidance I would also like to express my high regard and sincere gratitude to my co-advisor, Dr Sunisa Suktrakul for her continuous support, academical and emotional assistance, and constructive advice and suggestions I have been so lucky to have a supervisor who cared so much about my work I would like to extend my sincere appreciation to other committee members, Assoc Prof Jintana Yunibhand and Assist Prof Natkamol Chansatitporn for their insightful comments and suggestions, but also the hard question which helped me broaden my horizon and made my thesis much better I am grateful to Chulalongkorn University and Dean of Faculty of Nursing, Chulalongkorn University for providing academic assistance to pursue my master course in Thailand My sincere thanks also goes to all lectures and staffs in Faculty of Nursing, Chulalongkorn University for their teaching, guidance, and encouragement I am particularly grateful for the assistance given by the Directors, doctors, nurses, and other staffs of Thai Nguyen National Hospital, Thai Nguyen Psychiatry Hospital, Thai Nguyen A Hospital, Thai Nguyen C Hospital, and Thai Nguyen Gang Thep Hospital in Thai Nguyen city, Vietnam for their unconditional support Also, I am grateful to the participants and their families for their beliefs and enthusiasm I wish to acknowledge the help provided by my classmates and friends in the master and Ph.D program for friendship, enthusiasm, and assistance I would also like to thank all my friends in Vietnam and Thailand who have always given me support when needed Last but not means least, I would like to thank my family: my grandparents, my parents, and my brothers for their unconditional and unlimited support, encouragement and love, and without which I would not have come this far TABLES OF CONTENTS ABSTRACT (THAI) iv ABSTRACT (ENGLISH) v ACKNOWLEDGEMENTS v TABLES OF CONTENTS vii LIST OF TABLES x LIST OF FIGURES xi CHAPTER I INTRODUCTION Background and Significance of the study Objectives of the study Research questions Rationale and Hypotheses Scope of the study 10 Operational definitions 10 Expected benefits 12 CHAPTER II LITERATURE REVIEW 13 2.1 Overview of persons with alcohol dependence 14 2.1.1 Description of alcohol dependence 14 2.1.2 Alcohol dependence and brain system 15 2.1.3 Characteristic of persons with alcohol dependence 17 2.1.4 Prevalence and incidence of alcohol dependence 18 2.1.5 The consequence of alcohol consumption 18 2.2 Overview of alcohol relapse 20 2.2.1 Definition of alcohol relapse 20 2.2.2 Prevalence and incidence of alcohol relapse 22 2.2.3 The measuring of alcohol relapse 22 2.3 Overview of alcohol use and treatment and care for alcohol dependence in Vietnam 23 2.3.1 Overview of alcohol use in Vietnam 23 2.3.2 The burden of alcohol drinking behavior in Vietnam 25 2.3.3 Treatment and care for alcohol dependence in Vietnam 26 2.4 The Relapse Prevention Model 29 viii 2.5 Factors related to alcohol relapse among persons with alcohol dependence 30 2.5.1 Overview of factors related to alcohol relapse 30 2.5.2 Relationship between selected factors in this study and alcohol relapse 32 2.6 The conceptual framework in this study 46 2.7 Nursing intervention for persons with alcohol relapse 47 CHAPTER III METHODOLOGY 51 3.1 Research Design 51 3.2 Settings 51 3.3 Population and sample 52 3.4 Research instruments 55 3.4.1 Instrument for the screening of participants 55 3.4.2 Instruments for data collection 56 3.5 Instrument Translation Process 62 3.6 Instrument validity 63 3.7 Protection of human subjects 65 3.8 Data Collection 66 3.9 Data analysis 67 CHAPTER IV RESULTS 68 4.1 Demographic characteristics of the participants 68 4.2 Description of the dependent variable and independent variables 71 4.2.1 Description of dependent variable 71 4.2.2 Description of independent variables 71 4.3 The relationship between independent variables and alcohol relapse 90 CHAPTER V CONCLUSION AND DISSCUSSION 93 5.1 Conclusion 93 5.2 Discussion 94 5.2.1 Demographic characteristics of the participants 95 5.2.2 The situation of alcohol relapse 98 5.2.3 Factors related to alcohol relapse in persons with alcohol dependence in Thai Nguyen hospitals, Vietnam 100 5.3 Recommendations 116 5.3.1 Recommendations for nursing practice 116 ix 5.3.2 Recommendations for further studies 118 5.3.3 Recommendations for the health care system in Thai Nguyen, Vietnam 119 REFERENCES 113 APPENDICES 135 Appendix A Approval of thesis proposal 136 Appendix B IRB approval 137 Appendix C Permission for data collection 138 Appendix D Permission for using instruments 142 Appendix E List of instrument translators 148 Appendix F List of experts for content validity 149 Appendix G Research instruments 150 Appendix H Participant Information sheet 167 Appendix I Consent form 170 VITA 171 LIST OF TABLES Table Sample size of participants 54 Table The validity and reliability testing of all instruments 65 Table Demographic characteristics of participants (n=110) 68 Table Frequency, percentage, range, mean, and standard deviation of number of alcohol relapse (n=110) 71 Table Frequency, percentage, range, mean, and standard deviation of drinking refusal self-efficacy (n=110) 72 Table Mean and standard deviation of drinking refusal self-efficacy (n=110) 73 Table Range, mean, and standard deviation of outcome expectancies (n=110) 74 Table Mean and standard deviation of outcome expectancies (n=110) 75 Table Frequency, range, mean, and standard deviation of craving (n=110) 77 Table 10 Frequency, percentage, mean and standard deviation of craving (n=100) 78 Table 11 Range, mean, and standard deviation of motivation (n=110) 80 Table 12 Mean and standard deviation of motivation (n=110) 81 Table 13 Range, mean, and standard deviation of coping (n=110) 83 Table 14 Mean and standard deviation of coping (n=110) 84 Table 15 Range, mean, and standard deviation of emotional states (n=110) 86 Table 16 Mean and standard deviation of emotional states (n=110) 87 Table 17 Frequency, percentage, range, mean, and standard deviation of social support (n=110) 88 Table 18 Mean and standard deviation of social support (n=110) 89 Table 19 Correlation coefficients of independent variable and alcohol relapse (n=110) 91 157 Penn Alcohol Craving Scale (PACS) Circle the number that best describes your craving during the past week During the past week how often have you thought about drinking or about how good a drink would make you feel? Never (0 times during the past week) Rarely (1 to times during the past week) Occasionally (3 to times during the past week) Sometimes (5 to 10 times during the past week or to times per day) Often (11 to 20 times during the past week or to times per day) Most of the time (20 to 40 times during the past week or to times per day) Nearly all of the time (more than 40 times during the past week or more than times per day) At its most severe point, how strong was your craving during the past week? None at all Slight, very mild urge Mild urge Moderate urge Strong urge, but easily controlled Strong urge and difficult to control Strong urge and would have drunk alcohol if it were available During the past week how much time have you spent thinking about drinking or about how good a drink would make you feel? None at all Less than 20 minutes 21 to 45 minutes 46 to 90 minutes 90 minutes to hours Between to hours More than hours 158 During the past week how difficult would it have been to resist taking a drink if you had known a bottle were in your house? None at all Very mildly difficult Mildly difficult Moderately difficult Very difficult Extremely difficult Would not be able to resist Keeping in mind your responses to the previous questions, please rate your overall average alcohol craving for the past week Never thought about drinking and never had the urge to drink Rarely thought about drinking and rarely had the urge to drink Occasionally thought about drinking and occasionally had the urge to drink Sometimes thought about drinking and sometimes had the urge to drink Often thought about drinking and often had the urge to drink Thought about drinking most of the time and had the urge to drink most of the time Thought about drinking nearly all of the time and had the urge to drink nearly all of the time 159 The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Instructions: Please read the following statements carefully Each one describes a way that you might (or might not) feel about your drinking For each statement, circle one number from to 5, to indicate how much you agree or disagree with it right now Please circle one and only one number for every statement I really want to make changes in my drinking Sometimes I wonder if I am an alcoholic If I don't change my drinking soon, my problems are going to get worse I have already started making some changes in my drinking I was drinking too much at one time, but I've managed to change my drinking Sometimes I wonder if my drinking is hurting other people I am a problem drinker I'm not just thinking about changing my drinking, I'm already doing something about it I have already changed my drinking, and I am looking for ways to keep from slipping back to my old pattern NO! Strongly Disagree No Disagree ? Undecided or Unsure Yes Agree YES! Strongly Agree 160 10 I have serious problems with drinking 11 Sometimes I wonder if I am in control of my drinking 12 My drinking is causing a lot of harm 13 I am actively doing things now to cut down or stop drinking 14 I want help to keep from going back to the drinking problems that I had before 15 I know that I have a drinking problem 16 There are times when I wonder if I drink too much 17 I am an alcoholic 18 I am working hard to change my drinking 19 I have made some changes in my drinking, and I want some help to keep from going back to the way I used to drink 161 Coping Behaviours Inventory (CBI) Instructions: If there are times when you want to start drinking again, how you try to stop yourself? Here is a list of ways some people have tried to stop themselves Which of these ways have you tried? There are four choices: Usually, Often, Sometimes and Never Please circle the number which comes closest to how often you have used these ways to stop yourself from starting to drink again There are no right or wrong answers or trick questions We want to know what you have tried Usually Often Sometime Never 1.Thinking about how much better off I am 2 Telephoning a friend 3 Keeping in the company of non- drinkers Thinking positively Thinking of the mess I've got myself into 3 Staying indoors - hiding Pausing and really thinking the whole 10 Leaving my money at home 11 Recognizing that life is no bed of roses 12 Going to an A.A meeting 13 Knowing that by not drinking I can show 3 without drink through drinking Stopping to examine my motives and eliminating the false ones Thinking of the promises I've made to others alcoholic cycle through but drink is not the answer my face again without fear of what others will think 14 Cheering myself up by buying myself something special instead 162 15 Facing up to my bad feelings instead of 16 Working harder 17 Realizing it's just not worth it 18 Waiting it out until everything is shut 19 Remembering how I've let my friends and 20 Keeping away from people who drink 21.Going for a walk 22 Looking on the bright side and trying to 23 Realizing it's affecting my health 24 Start doing something in the house 25 Considering the effect it will have on my 3 3 29 Eating a good meal 30 Avoiding places where I drank 31.Thinking about all the people who have 32 Saying I am well and wish to stay so 33 Going to sleep 34 Remembering how it has affected my 35 Forcing myself to go to work 36 Trying to face life instead of avoiding it trying to drown them family down in the past stop making excuses for myself family 26 Reminding myself of the good life I can have without drink 27 Getting in touch with old drinking friends who are better now 28 Making up my mind that I'm going to stop playing games with myself helped me family 163 Positive Affect and Negative Affect Schedule (PANAS) Instruction: Please read each item and then list the number from the scale below next to each word Indicate to what extent you feel this way right now, that is, at the present moment OR indicate the extent you have felt this way that make you wanted to use alcohol Very slightly A Little Moderately Quite a bit Extremely or Not at all Interested _ 11 Irritable _ Distressed _ 12 Alert _ Excited _ 13 Ashamed _ Upset _ 14 Inspired _ Strong _ 15 Nervous _ Guilty _ 16 Determined _ Scared _ 17 Attentive _ Hostile _ 18 Jittery _ Enthusiastic _ 19 Active _ 10 Proud _ 20 Afraid _ 164 Multidimensional Scale of Perceived Social Support (MSPSS) Instructions: We are interested in how you feel about the following statements Read each statement carefully Indicate how you feel about each statement Circle the “1” if you Very Strongly Disagree Circle the “2” if you Strongly Disagree Circle the “3” if you Mildly Disagree Circle the “4” if you are Mildly Disagree Circle the “5” if you Mildly Agree Circle the “6” if you Strongly Agree Circle the “7” if you Very Strongly Agree Very Strongly Mildly Mildly Mildly Strongly Very Strongly Disagree Disagree Disagree Agree Agree Strongly Disagree There is a special Agree 7 7 person who is around when I am in need There is a special person with whom I can share joys and sorrows My family really tries to help me I get the motional help & support I need from my family I have a special person who is a real source of comfort to me 165 My friends really 7 7 7 try to help me I can count on my friends when things go wrong I can talk about my problems with my family I have friends with whom I can share my joys and sorrows 10 There is a special person in my life who cares about my feelings 11 My family is willing to help me make decisions 12 I can talk about my problems with my friends 166 9: Six - Item Cognitive Impairment Test (6 - CIT) Question What year is it? Score Range 0–4 Correct - 0points What month is it? Incorrect ––34points Correct – points – points Give the patient an address phrase to remember Incorrect with components Eg: John, Smith, 42, HighSt, Bedford About what time is it (within hour) 0–3 Correct – points Count back-wards from 20-1 Incorrect –– 43 points Correct – points Say the months of the year in reverse error – points – – points More than 10error Correct- 0points Repeat address phrase 1error – points – 10 More than01error–4points John, Smith, Correct – points 42, HighSt, Bedford error – points errors – points errors – points errors – points All wrong – 10 points Total score – 28 Score 167 Appendix H Participant Information sheet Title of study: Factors Related to Alcohol Relapse in Patients with Alcohol Dependence in Thai Nguyen, Vietnam Researcher’s name: Mr Trieu Van Nhat Office Address: Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand Home Address: Thai Nguyen University of Medicine and Pharmacy 284, Luong Ngoc Quyen street, Thai Nguyen city, Vietnam Cell phone: (+84) 368 271 372 Email: nhathoang2601@gmail.com I would like to invite you to participate in this study I strongly believe that information given by you is very valuable It will help the healthcare workers in improving the healthcare services Please understand that your participant is being helpful for us and for individuals who have the same situation like yours in the future Before you decide to participate, please take your time to read and understand the following short paragraph about the reason why this research is being conducted and what it will involve I would like to explain more about the study and not hesitate to ask if anything is unclear or if you would like more information Objectives of this study a To study alcohol relapse risk in persons with alcohol dependence in Thai Nguyen, Vietnam b To explore the relationship between self-efficacy, outcome expectancies, cravings, motivation, coping, emotional states, social support and alcohol relapse risk in persons with alcohol dependence in Thai Nguyen, Vietnam The benefits of this study a Findings from this study will contribute to the body of knowledge of nursing science in alcohol addiction in Vietnam b The nurses and other health care providers may use the findings of this study to use the best of limited resource to set up plan and integrate interventions that meet the individual’s needs in order to prevent relapse in the future 168 c The nurses and other researchers can use the findings of this study to develop future research related to alcohol relapse risk and its related factors in Vietnam 10 In this study, I would like to invite individuals with alcohol dependence and getting treatment at Thai Nguyen National Hospital in Thai Nguyen city, Thai Nguyen Psychiatry Hospital, Thai Nguyen A Hospital, Thai Nguyen C Hospital, and Thai Nguyen Gang Thep Hospital in Thai Nguyen city, Vietnam to participate in this study The participants will be selected based on the inclusion criteria as follows: age at least 18 years old, the absence of psychiatric disorder, be able to speak, read, and understand Vietnamese language, fulfilling the criteria for alcohol dependence based on the ICD10, showing the willingness to participate in the study Total 127 participants will be recruited 11 The participants will be asked to answer several questionnaires about general information and other issues (alcohol relapse risk, self-efficacy to resist drinking alcohol, expectations to the effects of alcohol consumption, levels of craving to drink alcohol, motivation to change drinking behavior, coping skills, emotional states, and social support) The researcher will explain the way to answer the questionnaires When the participants understand the method, they will answer all the questionnaires by themselves When the questionnaires are completed, the researcher will check if all the information were completed In case of any item are incomplete, the researcher will ask the participants to fill out the missing items 12 I assure that there will be no harm to your health during participating in this study However, you may feel tired or bored to answer the questions You can stop or withdrawal at any time as you wish for participating in this study You also not have to explain the reason of the leaving Either participate or not, the normal healthcare procedures to you will not be affected 13 Protect the right of the individuals who volunteered as subjects by having each sign a consent form which demonstrates that participants have read and understood the purpose of the study, the research process, the risks and benefits of participating in this study 14 All questionnaires will be kept confidentially by the researchers No information related to your personal identification is disclosed during data analysis and result report Information is only used for the purpose of this study 169 15 Participants can contact with the researcher at any time as you wish to Please not feel hesitate to contact via address: Name: Mr Trieu Van Nhat Address: Faculty of Nursing, Thai Nguyen University of Medicine and Pharmacy, 284 Luong Ngoc Quyen street, Thai Nguyen city, Vietnam Mobile: (+84) 368 271 372 Email: nhathoang2601@gmail.com 170 Appendix I Consent form Date:………………………… Participant’s Code Number:…………………………… Research title: Factors Related to Alcohol Relapse Risk in Persons with Alcohol Dependence in Thai Nguyen, Vietnam Declaration by Participant I have read through the Participant Information Sheet I have an opportunity to ask questions about information provided and I am satisfied with the answers I have received I understand the purposes, procedures and risks of the research I feel freely to participate in this research and accept the procedures as described in the information sheet I know that I am free to withdrawal at any time during the project without affecting my healthcare status I am willing to participate in this study under the above conditions Name of participants:………………………………… …Please sign:…………… Name of witness:…………… ……………………………Please sign:……………… Declaration by Researcher I have given an explanation of the research project, its procedures and risks to the participants I believe that the participants have understood that explanation Name of researcher:…………………………………….Please sign:……………… 171 VITA NAME TRIEU VAN NHAT DATE OF BIRTH 26 January 1991 PLACE OF BIRTH Vietnam INSTITUIONS Thai Nguyen University of Medicine and Pharmacy, ATTENDED Vietnam HOME ADDRESS Chiem Hoa District, Tuyen Quang Province, Vietnam PUBLICATION Status of Depression Disorder Among Cancer Patients At Thai Nguyen Oncology Center In 2016 ... dependence in Vietnam 2.3.1 Overview of alcohol use in Vietnam 2.3.2 The burden of alcohol drinking behavior in Vietnam 2.3.3 Treatment and care for alcohol dependence in Vietnam 2.4 The relapse... treatment and care for alcohol dependence in Vietnam 2.3.1 Overview of alcohol use in Vietnam 2.3.1.1 The drinking culture in Vietnam In Vietnam, alcohol has become an essential part of society... care for alcohol dependence in Vietnam 23 2.3.1 Overview of alcohol use in Vietnam 23 2.3.2 The burden of alcohol drinking behavior in Vietnam 25 2.3.3 Treatment and care