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 reemergence 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.,


3

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).


4

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


5

current drinkers in Son La, Thanh Hoa, and Ba Ria-Vung Tau provinces, the
prevalence of alcohol dependence was 6.9%, 5.4%, and 8.9%, respectively (Phuong,
2009).
Due to the high rate of alcohol consumption, Thai Nguyen Psychiatry Hospital
which provides treatment for people with Severity Mental Illness (SMI) including
schizophrenia, depression, and alcohol dependence reported that the number of
patients hospitalized because of alcohol use disorder occupied nearly 42.6% of total
patients (Phuong, 2017). Unfortunately, the treatment of alcohol dependence in Thai
Nguyen is limited (Hershow et al., 2018). Most of the services have focused on
managing alcohol withdrawal syndromes and physical problems due to alcohol
consumption. There is no education about preventing alcohol relapse provided to
clients with alcohol dependence. Besides, there is no follow-up service provided to
the clients after they discharge from hospital. Therefore, most of patients (70%) return
to drink alcohol after discharge (Phuong, 2017).
In addition to the high prevalence of alcohol dependence, the researchers
decided to conduct this study in Thai Nguyen because of the diverse characteristics of
the population in this province. Thai Nguyen has one Ministry of Health hospital
which is considered as a tertiary referral hospital in the Northern region. Besides,
there are eight provincial hospitals with higher-tech medical equipment and higher
quality of care compare to nearby provinces. Therefore, these hospitals provide
services for not only local clients but for clients from other provinces such as Bac

Can, Cao Bang, and Lang Son province (Anh, 2016).
Through the decade of study, it can be said that relapse is a common event of
the recovery process (Witkiewitz & Marlatt, 2007). Although many studies were
conducted the reasons for alcohol relapse and factors correlating to relapse were
varied and different among different group of people and culture (Korlakunta, Chary,
& Reddy, 2012; Kuria, 2013; Sureshkumar et al., 2017). Conducting a contextspecific study could provide information on the local relapse situation and related
factors among Vietnamese people with alcohol dependence in hospitals.
Besides, people with alcohol dependence in the community did not choose to
participate in this study. It is because, in Thai Nguyen, there is no follow-up service
for people with alcohol dependence after they complete treatment in hospitals.
Therefore, it is difficult to identify and approach these persons when they live in their
community.


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The finding of this study is beneficial for the health care system, clinicians, nurses,
psychologist and other healthcare providers in Thai Nguyen and other regions in
Vietnam.
Objectives of the study
1. To study alcohol relapse in persons with alcohol dependence in Thai
Nguyen hospitals, Vietnam.
2. To investigate the relationship between self-efficacy, outcome expectancies,
craving, motivation, coping, emotional states, social support and alcohol relapse in
persons with alcohol dependence in Thai Nguyen hospitals, Vietnam.
Research questions
1. What is the situation of alcohol relapse in persons with alcohol dependence
in Thai Nguyen hospitals, Vietnam?
2. What is the relationship between self-efficacy, outcome expectancies,
craving, motivation, coping, emotional states, social support and alcohol relapse in

persons with alcohol dependence in Thai Nguyen hospitals, Vietnam?
Rationale and Hypotheses
From the literature review, it is not unusual for alcoholics to relapse during the
recovery process of alcohol dependence (Witkiewitz & Marlatt, 2007). It is noted that
although relapse is common occurrence, it is preventable (Hartney & Gans, 2017).
Therefore, it is imperative that relapse should be examined carefully. Further,
understanding factors related to relapse allows the clinicians to provide betterindividualized treatment (Hendershot et al., 2011). Because of these reasons, this study
aimed to explore alcohol relapse situation and its related factors among people with
alcohol dependence in Thai Nguyen hospitals, Vietnam.
In this study, the Relapse Prevention (RP) model which was developed by
Marlatt and Gordon in 1985 was used as a guidance to study alcohol relapse. Based on
this model, the researchers reviewed and identified factors relating to alcohol relapse
from numbers of previous studies. Therefore, the independent variables in this study
were derived from both RP model and the literature review. In particular, many studies


7

reported that there was a strong relationship between self-efficacy, outcome
expectancies, craving, motivation, coping, emotional states, social support and alcohol
relapse. Besides, some variables such as the withdrawal symptom and the abstinence
violation effects were suggested to use to study alcohol relapse with a caution. The
detail was presented below.
Self-efficacy is considered as the perceived of individuals in their abilities to
control alcohol consumption (Witkiewitz & Marlatt, 2007). Many studies indicated
that levels of self-efficacy were related to the rate of relapse, particularly, higher
score of self-efficacy might predict more non-use of substance, in turn, reduce the
probability of relapse. While the lower score of self-efficacy was related to the poorer
rate of abstinence and increase relapse rates (Chavarria, Stevens, Jason, & Ferrari,
2012; Hendershot et al., 2011; Nikmanesh et al., 2017).

Outcome expectancies refer to the anticipation of outcomes of a specific
behavior. Regarding alcohol consumption, they are defined as an individual’s
subjective perception of the effects related to alcohol consumption (Jones, Corbin, &
Fromme, 2001). It is noteworthy that, in Vietnam, there is a high expectation toward
drinking alcohol. Many people believe that drinking is an indispensable pleasure in
their life, a way to relieve their boredom, and facilitate personal and business
relationships (Vietcetera, 2018).
In this study, outcome expectancies were categorized into two groups: positive
outcome expectancies referring to the individual’s expectation as drinking might bring
good effects and negative outcome expectancies reflecting the beliefs that drinking
might lead to adverse consequences (Anthenien et al., 2017). Literature supported that
positive alcohol outcome expectancies were risk factors increasing the motivation to
continue to use alcohol that, in turn, increased the rate of relapse (Anthenien et al.,
2017; Ham, Zamboanga, Bridges, Casner, & Bacon, 2013; Nicolai et al., 2017). In
contrast, negative expectancies were viewed as factors that decreased the motivation
for substance and alcohol use and reduced the probability of relapse (Hendianti &
Uthis,
2018; Morean, Corbin, & Treat, 2012).
Craving is generally defined as the strong desire of an individual to drink
alcohol (Marlatt & Donovan, 2005). Many researchers reported that an increase in the
levels of craving for alcohol might increase in the rate of relapse and vice versa, a
lower


8

percentage of relapse was seen if a lower level of craving was reported (GlocknerRist, Lemenager, & Mann, 2013; Hendianti & Uthis, 2018; Higley et al., 2011; Holt,
Litt, & Cooney, 2012; Sinha et al., 2011).
Motivation is defined as the willingness of an individual to change a particular
behavior (Miller & Rollnick, 2002). The Transtheoretical Model of Change (TTM)

with five stages (pre-contemplation, contemplation, preparation, action, and
maintenance) was commonly used to explain the motivation to change the drinking
behavior (Prochaska & Diclemente, 1982).
In this study, the motivation to change drinking were classified into three
groups: recognition (a combination of contemplation and preparation), taking steps
(action versus maintenance), and ambivalence (interpreting as the extent to which
individuals open the possibility to change their behavior) (Miller, 1999). From the
literature, people with high motivation to change their drinking behavior reported
more engaged to treatment and healthy behaviors, in turn, reduce the probability of
alcohol relapse (Fiabane, Ottonello, Zavan, Pistarini, & Giorgi, 2017; Gaume et al.,
2017).
Coping is defined as an individual’s responses to a situation in order to reduce
danger, correct harm or achieve a satisfaction (Litman, Stapleton, Oppenheim, &
Peleg,
1983). In the RP model, the response of an individual to the risk situations of drinking
might determine if he/she might experience a relapse or not (Larimer, Palmer, &
Marlatt, 1999). In this study, coping was divided into adaptive coping which helps
patients to control their drinking and maladaptive coping that might increase the
likelihood to alcohol use and relapse (Litman, Stapleton, Oppenheim, Peleg, &
Jackson,
1983).
Many studies indicated a positive relationship between maladaptive coping and
harmful drinking that increase the probability of relapse (Metzger et al., 2017;
Opalach et al., 2016). Besides, individuals who remained abstinence to alcohol tended
to use more numbers of effective coping than those who have relapsed (Kaundal,
Sharma, & Jha, 2016; Nagaich, Radha, Neeraj, Sandeep, & Subhash, 2016; Parkash et
al., 2017; Rohit, Shwetha, & Bhat, 2017).
Emotional states are defined as the state of an individual’s emotions which
usually refer to a list of anger, disgust, fear, joy, sadness, and surprise (Cabanac,

9

2002). In this study, the researchers evaluate the influence of the state of emotions on
drinking


10

alcohol. Through the decade of study, emotional states were classified into two groups
including positive and negative emotional states (Larimer et al., 1999).
From the literature review, negative emotional states such as anger, depression,
anxiety, and frustrated were reported most frequently as the main cause of alcohol
relapse (Armeli, Sullivan, & Tennen, 2015; Bravo et al., 2016; Oliva et al., 2018).
While, positive emotional states, for example, joy, interest, and love were reported as
the protective factors that reduce alcohol relapse rates (Schlauch, Gwynn-Shapiro,
Stasiewicz, Molnar, & Lang, 2013).
Social support can be defined as “the assistance and protection are given to
others, especially to an individual. In this study, social support refers to the support
that a person received from their family, friends, and significant others in order to help
them to maintain abstinence from alcohol. Broadly, positive social support is highly
predictive of the treatment maintenance and, in general, reduce the probability of
relapse; while negative social support has been reported as a factor that increases the
severity of alcohol and drug abuse, in turn, increase the probability of relapse (Dixit,
Chauhan, & Azad, 2015; Githae, 2016; Hafez, Kazemeini, & Shayan, 2015).
In addition, the two variables, alcohol withdrawal syndrome (AWS) and
abstinence violation effects (AVE) were suggested to used based on the phenomena of
each study. In this study, the population was in-patients diagnosed with alcohol
dependence. They were treated by the standard medication to reduce and prevent
withdrawal symptoms. As a consequence, there might be a bias in measuring the

influences of AWS on alcohol relapse. Therefore, the researchers did not use the AWS
as an independent variable.
Regarding AVE, many researchers suggested that this variable should be
measured immediately after the first violation of an abstinent rule (Cormier, 2000;
Fletcher, 2007). However, in this study, patients were having treatment in the hospitals
and the use of alcohol was not allowed. Besides, most patients might not come to seek
treatment after their first drink but a long period of alcohol consumption. There might
be a bias of recalling the cognitive and affective reactions of patients to their first
drink of alcohol. Thus, the AVE did not use as an independent variable in this study.
To conclude, self-efficacy, outcome expectancies, craving, motivation,
emotional states, and social support were selected as the independent variables to
study


11

alcohol relapse. While the AWS and AVE did not used as an independent variable
because they were not fitted with the phenomena of this study.
Based on the reasons above, the hypotheses in this study were:
1. Self-efficacy, negative outcome expectancies, motivation (recognition,
ambivalence, taking steps), adaptive coping, positive emotional states, and social
support were negatively related to alcohol relapse.
2. Positive outcome expectancies, carving, maladaptive coping, and
negative emotional states were positively related to alcohol relapse.
Scope of the study
This study was conducted in five hospitals which provide treatment for
patients with alcohol dependence in Thai Nguyen province, Vietnam. A total of 110
patients were purposely selected based on the inclusion criteria: age 18 years and
over, fulfills the criteria for alcohol dependence, had at least one relapse, and
willingness to participate in the study. The dependent variable was alcohol relapse.

The independent variables were self-efficacy, outcome expectancies, craving,
motivation, coping, emotional states, and social support.
Operational definitions
Persons with alcohol dependence are patients both males and females age at
least 18 years old, who were diagnosed with alcohol dependence based on the
diagnostic criteria of international classification of disease tenth (ICD-10) (WHO,
1992).
Alcohol relapse is defined as number of the re-emergence of alcohol
dependence syndrome in the last 12 months as per ICD-10 diagnostic criteria
following a period of abstinence for at least one month (WHO, 1992). In this study,
Question 10 in the General Information Form was developed by the researchers to
gather the data on alcohol relapse. Any re-consumption of alcohol after a period of
abstinence for at least one month was considered as a relapse if it leads the drinkers to
fulfill the criteria of alcohol dependence based on the ICD-10 (WHO, 1992).
Self-efficacy is defined as the perception of persons with alcohol dependence
about their abilities to remain abstinence from alcohol and also capable to use their
skills


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to resist drinking alcohol in a given situation. It was measured by the Drinking Refusal
Self-Efficacy Questionnaire (Hang 2010).
Outcome expectancies are defined as the expectations of persons with alcohol
dependence toward the effects that might occur after drinking. In this study, this
variable is divided into positive outcome expectancies and negative outcome
expectancies.
- Positive outcome expectancies are defined as individuals expected that
they would get benefits from alcohol consumption.
- Negative outcome expectancies are defined as individuals believed that

drinking would bring harmful effects to them.
These variables were measured by the Drinking Expectancy Questionnaire
(Lee, et al., 2003).
Craving is defined as a strong need or compulsion of persons with alcohol
dependence to drink alcohol during a treatment program or an abstinent period. It was
measured by the Penn Alcohol Craving Scale (Flannery, Volpicelli, & Pettinati, 1999).
Motivation is defined as the willingness and readiness of persons with alcohol
dependence to change their drinking behavior. In this study, motivation is classified
into three groups including recognition, ambivalence, and taking steps.
- Recognition refers to the extent to which individuals realized that they
were having drinking problems and the adverse effects might come if they did not
change their alcohol consumption.
- Ambivalence is defined as the extent to which individuals were considering
about their drinking behavior and open to the possibility of changing their drinking
problems.
- Taking steps refers to the extent to which individuals reported that they had
already changed their drinking behavior.
The motivation is measured by the State of Change Readiness and Treatment
Eagerness Scale version 8.0 for alcohol (SOCRATES 8A) (Miller & Tonigan, 1996).
Coping is defined as the strategies that persons with alcohol dependence used
to deal with the risk situations of alcohol consumption. In this study, coping is divided
into two groups: adaptive coping and maladaptive coping.
- Adaptive coping is defined as coping strategies that helped individuals to
control their drinking and prevent re-consumption of alcohol.


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- Maladaptive coping refers to coping strategies that might not help
individuals to control their alcohol consumption and increased the probability of

relapse.
These variables were measured by the Coping Behaviours Inventory
(Litman et al., 1983).
Emotional states are defined as feelings and emotions of persons with alcohol
dependence that were considered as the risk situations causing the consumption of
alcohol. In this study, emotional states were measured in both positive and negative
states.
- Positive emotional states are the person’s perception of experiences
positive feelings such as joy, interest, and alertness.
- Negative emotional states are the person’s perception of experiences
negative feelings and poor self-concepts such as anger, guilt, and fear.
Emotional states were measured by the Positive Affect and Negative Affect
Schedule (Watson, Clark, & Tellegen, 1988).
Social support is defined as the person’s perception of support from their
family, friend, and significant others who can help them to stay abstinence and prevent
relapse. It was measured by the Multidimensional Scale of Perceived Social Support
(Zimet, Dahlem, Zimet, & Farley, 1988)
Expected benefits
1. Findings from this study will contribute to the body of knowledge of nursing
science in alcohol addiction in Thai Nguyen and Vietnam.
2. The nurses and other health care providers working at psychiatric hospital or
specific ward in general hospital in Thai Nguyen may use the findings of this study to
provide more effective interventions in order to improve the treatment of alcohol
dependence and prevent alcohol relapse.
3. Other researchers can use the findings of this study to develop other
research related to intervention of alcohol relapse in the future.