Các yếu tố liên quan đến tái nghiện trên những người nghiện rượu tại các bệnh viện tại Thái Nguyên, Việt Nam

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

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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....................................................................................1

Background and Significance of the study ................................................................1

Objectives of the study...............................................................................................6

Research questions.....................................................................................................6

Rationale and Hypotheses..........................................................................................6

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

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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

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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 1 Sample size of participants.............................................................................54

Table 2 The validity and reliability testing of all instruments.....................................65

Table 3 Demographic characteristics of participants (n=110).....................................68

Table 4 Frequency, percentage, range, mean, and standard deviation of number of

alcohol relapse (n=110) ...............................................................................................71

Table 5 Frequency, percentage, range, mean, and standard deviation of drinking

refusal self-efficacy (n=110)........................................................................................72

Table 6 Mean and standard deviation of drinking refusal self-efficacy (n=110) ........73

Table 7 Range, mean, and standard deviation of outcome expectancies (n=110).......74

Table 8 Mean and standard deviation of outcome expectancies (n=110)....................75

Table 9 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

LIST OF FIGURES

Figure 1 Hospitals providing treatment for persons with alcohol dependence in Thai

Nguyen province, Vietnam..........................................................................................28

Figure 2 The original Relapse Prevention model (Marlatt & Gordon, 1985)..............30

Figure 3 The conceptual framework of this study .......................................................47

Figure 4 Diagram of sampling process........................................................................55

CHAPTER I

INTRODUCTION

Background and Significance of the study

Alcohol dependence is one of the major health and social problems seen in

nearly all countries. Globally, number of people with alcohol use disorders including

alcohol dependence and alcohol abuse were estimated at 107 million in 2017, measured

across both sexes and all ages (Ritchie & Roser, 2018). In the United States, this

corresponding rate was 15.1 million of the adult population (NIAAA, 2016). Regarding

European countries, the prevalence of alcohol dependence was reported at 6-8% of the

total population (Parkash, Sharma, & Sharma, 2017). In Asia, the high rate of alcohol

dependence was found in South Korea (4.7%), Kazakhstan (3.3%), and Uzbekistan

(3.3%) (Monzavi, Afshari, & Rehman, 2015). In Vietnam, 2.9% of the Vietnamese

were diagnosed with alcohol dependence (Monzavi et al., 2015).

Alcohol dependence is defined as “a group of physiological, behavioral, and

cognitive phenomena in which the use of alcohol is a much higher priority for a person

than other behaviors” (WHO, 1992). It is also accepted as a psychiatric disorder with

harmful physical, mental and social consequences. For example, alcohol dependence

was the cause of 3 million deaths in 2016 (WHO, 2018). Besides, it has various effects

on both health and economic status of alcoholics such as physical illness (Rehm, Taylor,

et al., 2010); unemployment, loss of earning, and family conflicts (WHO, 2010).

Additionally, there is a negative impact of alcohol dependence on other people who are

spouses, children, relatives, friends, and even strangers (APA, 2018).

Despite preventive efforts, many people fall into relapses after a period of

abstinence. According to the National Institute of Alcohol Abuse and Alcoholism

(NIAAA), evidence shows that in the Unite Stated, 90% of alcohol-dependent patients

have experienced at least one relapse within 4 years after the treatment completion

(NIAAA, 1989). Similarly, other researchers reported the high rate of alcohol relapse

among people with alcohol use disorder ranging from about 37.6% to 60.5% by the 16-

year follow-up (Moos & Moos, 2006). In Asian countries, alcohol relapse is also a

common problem. For example, a study in China showed that nearly 80% of patients

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with alcohol dependence had experienced relapse after completing treatment (Xie &

Liu, 2015).

Relapse is a term used to display the return to previous levels of symptomatic

behavior and considered as a complex multidimensional phenomenon (Dawson et al.,

2005). Historically, it was seen as an ominous sign and had a negative meaning (Marlatt

& George, 1984). While modern researchers considers relapse to alcohol as a

transitional process from the abstinence period to the addiction to alcohol (Hartney &

Gans, 2017). In recent years, for mostly acceptable, alcohol relapse is defined as re￾emergence of alcohol dependence syndrome as per International Classification of

Disease Tenth Version (ICD-10) diagnostic criteria after a period of abstinence for at

least one month (Kaundal, Sharma, & Jha, 2016; Parkash et al., 2017)

Alcohol relapse is significant for nursing practice. For a long time, substance

and alcohol abuse was addressed as an important nursing problem and nursing has

become more involved in the spectrum of substance use disorders (Nies & McEwen,

2011). It is noteworthy that preventing relapse is one of the favorable nursing outcomes

during treatment of alcohol dependence. The goal is to help people with alcohol

dependence to identify trigger situations of relapse so that the period of abstinence can

be lengthen over time (Varcarolis, 2013). In addition, understanding relapse as normal

process can help nurses feel less pressured to get patient into treatment and easily

maintaining an accepting, nonjudgment-mental attitude (Nies & McEwen, 2011).

Exploring factors that contribute to relapse is a crucial part of relapse prevention

strategies (Witkiewitz & Marlatt, 2007). In the literature, many theories have been

developed to explain the occurrence of relapse (Simonelli, 2005). Among which, the

Relapse Prevention (RP) model is widely used (Marlatt & Gordon, 1985). Based on this

model, factors related to relapse are divided into two broad categories: intrapersonal

determinants which refer to emotional states, self-efficacy, coping, motivation,

outcome expectancies, craving, and abstinence violation effects and interpersonal

determinants including relationship conflicts, peer pressure, social pressure, and social

support (Marlatt & Witkiewitz, 2005).

Based on the RP model, many studies have been conducted to identify factors

which might contribute to develop relapse or create a high-risk situation for relapse

(Adamson, Sellman, & Frampton, 2009; Charney, Zikos, & Gill, 2010; Evren et al.,

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2010; McKay, 2011). From the literature, many factors were found to be correlated to

relapse such as self-efficacy (Ibrahim, Kumar, & Samah, 2011; Nikmanesh, Baluchi,

& Motlagh, 2017), outcome expectancies (Anthenien, Lembo, & Neighbors, 2017;

Nicolai, Moshagen, & Demmel, 2017), coping strategies (Metzger et al., 2017; Opalach

et al., 2016), emotional states (Bravo, Pearson, Stevens, & Henson, 2016; Oliva et al.,

2018; Sureshkumar, Kailash, Dalal, Reddy, & Sinha, 2017), motivation (D’Souza &

Mathai, 2017; Gaume, Bertholet, & Daeppen, 2017), cravings (Kharb, Shekhawat,

Beniwal, Bhatia, & Deshpande, 2018; Sinha et al., 2011; Stohs, Schneekloth, Geske,

Biernacka, & Karpyak, 2019), and social support (Atadokht, Hajloo, Karimi, &

Narimani, 2015; Githae, 2016; Yang, Xia, Han, & Liang, 2018).

This is worrisome as relapse after treatment of alcohol dependence causes

various problems. For example, it might cause such negative consequences as

impairment of cognitive, medication non-adherence, personal distress, and

hospitalizations (Pigott et al., 2003). Relapse is also the main reason of increasing the

cost of treatment, excessing of health care services utilization, and losing of

productivity (Nancy, Pacula, Kilmer, Lundberg, & Chiesa, 2009). According to the

Center for Substance Abuse Treatment (CSAT), relapse is the cause of negative effects

on the relationship between family members such as role modeling, trust, and concept

of normative behavior (CSAT, 2004). In addition, it might contribute to numbers of

social and economic problems, for example, unemployment, poor job performance, and

increase in crime rates (Parrott, Morinan, Moss, & Scholey, 2004).

In Vietnam, alcohol is commonly used in society. It has been observed in many

events from casual gathering, celebrations to important ceremonies (Lincoln, 2016).

There are many acceptable standard of drinking alcohol such as a quoting “a hundred

percent” - requires the drinkers to down shots of liquor in tandem or “not drunk not

going home” - a pressure for the drinkers to consume more alcohol, even drink to

intoxication (Craig, 2002). As a consequence, alcohol consumption is one of the main

causes of medical and social burden. In the country, 7.3% of all-cause deaths were

estimated as related to alcohol consumption for 2016 (WHO, 2016). For the same year,

nearly 10% of Vietnamese’s men aged 50 to 69 years old died of alcohol-related liver

cancer (Vietcetera, 2018).

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Unfortunately, in Vietnam, treatment for people with alcohol dependence is

heavily biased toward medication (Cuong, 2017). The psychiatric nurses provide

interventions for patients with alcohol dependence mostly focus on medical technique

such as injection and infusion. While the psycho-education or psychosocial treatments

are rarely provided. (Niemi, Thanh, Tuan, & Falkenberg, 2010). It is might due to the

lack of the guidance and evidence-based nursing intervention that can guild the nurse

to provide effective intervention for their clients.

Besides, there is a lack of social support system and follow-up services provided

to alcohol-dependent patients when they discharge (Hoa, 2014). Although, health care

services are available at the community, it limited to case-management of schizophrenia

and epilepsy (Giang, Dzung, Kullgren, & Allebeck, 2010). Therefore, alcohol relapse

has become a common problem. A study conducted in Hanoi, Vietnam reported that

62.8% of patients with alcohol dependence had relapsed more than once after one year

of discharge (Mai & Viet, 2014).

There is no doubt that relapse prevention is an essential part of treatment for

alcohol dependence (Witkiewitz & Marlatt, 2007). Understanding factors relating to

relapse allows the clinicians to develop effective relapse prevention strategies

(Hendershot, Witkiewitz, George, & Marlatt, 2011). However, in Vietnam, to the best

of our knowledge, only one study mentioned above was conducted to explore alcohol

relapse - it did not evaluate the association between alcohol relapse and its related

factors. Therefore, few evidence-based interventions were available. For this reason,

this study was designed to fill the gap of exploring alcohol relapse by describing the

relapse situation and investigating the relationship between alcohol relapse and several

psychological factors in individuals with alcohol dependence.

In Vietnam, Thai Nguyen is a province with high prevalence of alcohol

consumption (Go et al., 2013; Hang, 2010). In this province, alcohol is easy to buy at

markets and restaurants. Local residents highly believe that drinking is an indispensable

part of society and refuse to drink may be noticed as rude or worse (Hershow et al.,

2018). In 2010, 61.3% of male respondents in Thai Nguyen city were harmful drinkers.

Among them, 19.7% reported likely to display alcohol dependence (Hang, 2010). This

number is far higher when compared to other provinces. For example, among the