Knowledge Gaps in Drug Prevention Education

Abstract

In Malaysia, there is limited knowledge about drug-awareness and treatment programmes from the viewpoint of students, rehab patients and rehab staff. In recent years, there is an increasing need to re-evaluate drug prevention and treatment programmes due to changes in drug abuse trends. The aims of this study were to obtain insights into drug abuse from multiple perspectives, to understand knowledge gaps in drug prevention education and to conduct a dual-perspective evaluation of patients’ treatment satisfaction. A concurrent, mixed method design was used to survey 460 university students across five states in Malaysia (Selangor, Penang, Federal Territory Kuala Lumpur, Sabah and Sarawak) and interview 30 drug rehab patients and 10 staff from government and private rehab centres in Selangor. Quantitative and qualitative data were analysed iteratively according to the principles of Grounded Theory. The survey findings indicate that there were significant gender differences in university students’ perceptions of drug abuse factors and relapse prevention strategies. Ecstasy and cannabis/marijuana were perceived as drug types that were most commonly abused and easily available. Most students believed that treatment services in private rehab centres were more effective. Students preferred online resources and paper-based media for searching information while social media and conventional mass media (television and radio) were preferred for sharing information. Most students perceived that the ages of 11 to 12 years were most appropriate for exposure to drug prevention education. The interview findings indicate that a drug progression trend was not supported. Most patients and their peers had good family relationships and the patients were generally assertive against drug offers. Findings from thematic analyses and triangulation showed that environmental factors and personal problems were factors for drug abuse and relapse. Factors that motivate behaviour change in patients include impact of drug abuse, personal wish for positive changes and religious guidance. However, the factors that encouraged patients to take action and enter treatment were a combination of intrinsic and extrinsic factors, and religion. Although patients’ satisfaction ratings were at the higher continuum of the scale, three sources of dissatisfaction were identified: inconsistent depth in treatment content, difficulty in managing patients’ issues within group settings, and cancelled treatment sessions for unspecified reasons. In terms of treatment approach, patients preferred a holistic combination of counselling, spiritual studies, vocational training and recreational activities. Both rehab centres would also benefit from an upgrade in treatment approach, facilities and after-care services; enhancing group relationships, provision of job links, and improving staff management and development. An outcome from integrating the mixed method findings was a guideline that encourages collaboration between treatment providers and educators to create an interactive yet current drug education syllabus. This guideline is also useful to treatment providers who are interested in adopting a patient-centred approach to drug counselling and including active participation from patients in treatment. Overall, the findings improve awareness of how individuals view drug abuse and prevention issues from different perspectives. It is hoped that the findings and recommendations in this study will be of guidance to educators and treatment providers.

Keywords: Drug abuse and relapse, student perception, rehab patient experiences, rehab staff perspective, prevention and treatment programme evaluation

Chapter 1: Introduction

Illicit drug abuse and relapse is a public health issue that continues to plague societies worldwide (Scorzelli, 2009). In Malaysia, the first account of drug abuse was in the 8^th century (Gill, Rashid, Koh & Jawan, 2010). This coincides with the occurrence of commercial trading with Arab traders, as well as the assimilation of various Western cultures (e.g., Portuguese, Dutch and British) through exploring expeditions, commerce and war (Gill, Rashid, Koh & Jawan, 2010). According to recent drug statistics by the National Anti-Drug Agency (NADA), there has been a reduction in number of new and repeated users admitted to treatment facilities in Malaysia from the year 2010 to 2012 (NADA, 2014). This was followed by a gradual increase in new and repeat admittance cases from 2012 to 2014 (NADA, 2014). The latest available statistics recorded a total of 26 668 drug users admitted into rehabilitative treatment in 2015 (NADA, 2015). Of this total, 20 289 were new drug users and 6379 were repeated users (NADA, 2015). Nevertheless, these statistics are only representative of drug users who were admitted into treatment. It is difficult to gauge the severity of drug abuse in Malaysia as the actual number of drug users is still unknown and the NADA statistics almost certainly underestimate the true number of users or addicts.

To provide a deeper insight into the drug trends and current situation in Malaysia, global and local drug statistics, local newspaper articles, government guidelines and past research from Malaysia and other countries were reviewed. Comparison between the Malaysian drug statistics with the global analysis by the United Nations Office of Drugs and Crime or UNODC (2010) suggested that the age of initiation to drugs among youths in Malaysia was rather similar to youths in other Western countries. For instance, it was found that between the years 2000 to 2008, adolescents aged 12 in the US and aged 14 in New Zealand, were experimenting and initiating drug abuse (UNODC, 2010). In Australia, it was reported that drug experimentation begins between the ages of 12 – 14 years, progresses further between the 15 – 17 years age group and becomes a problematic spiral between the ages of 18 – 24 years (Mazibuko, 2000). Comparably, the youngest age group detected for drug abuse in Malaysia between the years 2008 to 2009 and from 2012 to 2015 were adolescents between 13 – 15 years (NADA, 2012; 2015). The only exception was in 2010 and 2011, whereby the youngest users reported were below the age of 13 (NADA, 2012). These statistics appear to suggest that adolescents transitioning from early to middle stage adolescence are particularly at-risk for drug abuse. Therefore, it may be beneficial to initiate relevant and proper prevention education interventions before this transition period so that adolescents have heightened awareness against possible risk factors. This point was particularly important since the early initiation of drug abuse was correlated with a myriad of social and behavioural problems such as family deviance, school adjustment problems, bullying or cruelty to people and animals, emotional and sexual abuse, and higher levels of criminal involvement (Gordon, Kinlock & Battjes, 2004). A similar situation was found in Malaysia, whereby adolescents who faced life challenges and distress (e.g., parental neglect or emotional and sexual abuse at home, bullying in school) were more at-risk of engaging in drug abuse at an earlier age (Hashim, 2007). From this, the situation could exacerbate to involvement in destructive behaviour, truancy and commitment of crimes, such as pornography (Mey, 2010).

The analysis of age groups for the highest proportion of drug users in Malaysia indicated fluctuations across 5 years (NADA, 2015). In 2011, the 19 – 24 years age group registered the highest number of drug users. In 2012, there was a major shift in pattern with the 30 – 34 years age group dominating the number of drug cases (NADA, 2012) and this trend continued in 2013 (NADA, 2013). In 2014, the highest proportion of drug users were from the 25 – 29 years age group and in 2015, it shifted back to the 20 – 24 years age group. Such changes in drug user profiles highlights the high risk of more individuals from the working profession or those juggling work and further studies becoming engaged in drug abuse behaviour besides the unemployed.

There are many factors that could lead to an increase in drug users between the ages of 25 – 34 years such as poor job design as well as unrealistic work performance targets and deadlines use (Department of Occupational Safety and Health, 2004). In addition, conditions that lead to low job satisfaction (e.g., job insecurity, inadequate training, low levels of supervision, lack of communication and limited participation in decision-making) and poor working conditions (e.g., long hours or shift work, monotonous nature of jobs; and hot, dirty, noisy or dangerous workplaces) could also increase the risk of drug abuse (Department of Occupational Safety and Health, 2004). Furthermore, most workers lack an awareness of methods to manage stress without resorting to drug abuse. Therefore, it would be useful to take note of pattern shifts in drug user profiles to help identify the population who are in need of drug prevention interventions. In this case, the pattern shift has important implications towards advocating proper dissemination of help resources and proper interventions to help deal with stressors (work pressure, family issues, economic recession, and work conditions) in the workplace.

Starting from the year 2010, NADA transformed their rehabilitative treatment approach from an institutionalised approach to open concept rehabilitation, as part of efforts to curb drug relapse cases in Malaysia. Previously, drug users who were caught by legal authorities had to undergo compulsory rehabilitative treatment for two years under court orders (Malaysian Psychiatric Association, 2006). However, from 2010 onwards, drug users can voluntarily register for treatment at local community service centres without legal trial and judgment (Harun & Gazali, 2013). This new approach is aimed at helping drug users move on in their life and career without necessarily having the stigma of a criminal record (Priya, 2013a).

Together with a less punitive rehab approach, stringent enforcement via drug busts was carried out by the Malaysian police to prevent the circulation of drugs in 2013. However, drug users and dealers will continue finding new ways to meet the demand for drug supplies in reaction to the implementation of technologically advanced detection equipment and stricter policies (Hamdan et al., 2015). These methods include setting up underground drug laboratories and employing rigorous methods of smuggling (Hamdan et al., 2015). As Malaysia is located at the centre of South-East Asia, it is a vantage transit point for smuggling illicit drugs as well as a final destination (Ismail & Jaafar, 2015). Among the drug smuggling methods that have been detected in Malaysia include drug concealment via the body packing method (involves exploiting children, pregnant women and pets, as they are given less attention by the authorities), cross-border smuggling via land vehicles or shipment, smuggling in double layers of baggage and cases, concealment in fruits, pickles, candy, frozen food and other household items and containers such as boxes of soap, canned pineapples and processed coconut milk (Ismail & Jaafar, 2015). From an overall perspective, the smuggling methods used in Malaysia are still considerably conservative as compared to other innovative methods reported in the US and other European countries. However, it is essential that the authorities from the state and federal government continue monitoring all entry points to Malaysia diligently to reduce the circulation of drug supplies as much as possible.

A recent article by The Star newspaper highlighted the easy availability of marijuana in several local Malaysian colleges and universities through a peer-to-peer distribution system (Lam & Yee, 2014). A student, who was a regular marijuana user, claimed that there was at least one student dealer in most major colleges and universities. Besides the peer-to-peer system, marijuana was also dealt through home delivery (Lam, 2014). The ease of availability as well as the misconception that marijuana is safe to use, partly due to its legalisation in the United States (US), has led to an increase of marijuana use among students. In 2013, over 20% of rehabilitation cases consisted of marijuana users, with students as a majority of its users (NADA, 2013). There are several points of contention around the circumstances of marijuana legalisation, including the financial and economic cost of prohibition, the level of addictiveness, health benefits and side-effects. The Institute of Medicine (1999) in the US acknowledges the benefits of marijuana use in several medical conditions such as its role as a painkiller for patients suffering from chronic pain, overcoming chemotherapy-induced nausea and vomiting among cancer patients, decreasing intraocular pressure in the treatment of glaucoma patients, as well as appetite stimulation among patients with Acquired Immunodeficiency Syndrome (AIDS) and wasting syndrome. The medical benefits of marijuana have also been documented in the prevention of seizures among epileptic patients and the elevation of mood among patients with depression and/or anxiety (Disabled World, 2014).

However, recreational use of marijuana can be dangerous as excessive dopamine released from the ingestion of higher amounts of marijuana could be associated with the development of psychotic symptoms (i.e., delusions, hallucinations and paranoia) (Basu & Basu, 2015). Following controversy over the alleged reasons for supporting and rejecting recreational marijuana laws in the US, Volkow, Baler, Compton and Weiss (2014) reviewed research regarding the adverse health effects of marijuana use. They concluded that despite its various uses from a medical perspective, marijuana can result in addiction just like other drugs, upon early and regular use. Moreover, the effects of a legal or illicit drug are not confined only to the pharmacologic properties (Volkow, Baler, Compton & Weiss, 2014). For instance, because marijuana use affects memory, perception of time as well as hand-and-feet coordination, it could lead to increased occurrence of vehicle accidents during the period of intoxication. In addition, long-term use of marijuana and its effects on cognitive performance are also detrimental towards educational, social and professional achievements. For certain, the legal status of drugs would allow more widespread exposure because its availability will be legally and socially accepted. Nevertheless, these would also mean a rise in number of individuals who may suffer negative health consequences as a result of recreational drug abuse (Volkow, Baler, Compton & Weiss, 2014). Although marijuana use is not legalised in Malaysia, the fact that its use is legalised in some states in the US could influence youths in Malaysia to positively view marijuana use rather than focus on the side-effects of misusing marijuana.

In addition to this, the increasing popularity of electronic nicotine delivery systems (ENDS) or e-cigarettes in Malaysia also contributed to increasing drug abuse among students and young working professionals (Chin, 2015). This invention, which was originally developed as a smoking cessation device, has been misused to vape illicit drugs like synthetic cannabis, amphetamines, methamphetamines and marijuana. As the use of ENDS is unregulated in Malaysia, this has made it more difficult for legal authorities, parents, teachers and employers to identify drug abuse via vaping (Chin, 2015). The evidences above highlight the importance of three issues: (a) keeping abreast to changes in drug trends and issues in the community; (b) educating the public at all levels (school, community, and workplace) about drug risk factors, help resources and treatment options; and (c) the critical need to dispel drug myths through proper discourse with youths in Malaysia.

Due to constant changes in the field of drug abuse research, there is a need to continuously study the phenomenon of drug abuse and relapse to uphold relevance. In the past, there has been much emphasis on identifying the number of drug users, the frequency of drug abuse and types of drugs abused in past research (Sterk & Elifson, 2005). Nevertheless, there are additional challenges with the shifting of social contexts, rising popularity of synthetic drugs and subsequently, new drug trends (i.e., recreational drug abuse) as a result of modernisation and globalisation.

An example of the shifting social context was increasing awareness about untrue stereotypes related to the profiles of drug users in Malaysia. Past stereotypes viewed drug addicts as individuals who are unemployed or have low socioeconomic status, and thus had to resort to crimes to fund their drug habits. This stereotype was fuelled by national statistics and past research, which generally depicted most drug users as the unemployed, general labourers, and workers from the service, agriculture, fisheries and sales industries (NADA, 2010; 2011; 2012; 2013). The reality is drug users include white collar workers, government servants, college students and children as young as 12, and the number of users from these population have been increasing in line with urbanisation and increasing accessibility to the internet (Priya, 2013b). Some international studies (Luthar & Latendresse, 2005; Humensky, 2010; Patrick, Wightman, Schoeni & Schulenberg, 2012) also indicated that children and adolescents from higher socioeconomic status families were at greater risk of engaging in anxiety- and depression-related drug abuse during the transition to adulthood. A study in the US further suggested that children in more affluent families often experience higher levels of isolation and pressure to achieve from parents with high-flying careers, in addition to experiencing more tolerant attitudes toward drug abuse (Luthar & Goldstein, 2008). Although the studies reviewed above are not from Malaysia, the same trends could be found in Malaysia as it continues to develop and experience social and health problems that occur with urbanisation.

A possible reason for higher rates of drug users from lower socioeconomic status or unemployed could be that individuals from the lower social stratum are least likely to be able to afford good legal representation. Subsequently, this resulted in higher numbers of drug users from the lower social strata entering prison for drug-related offences and admission into rehabilitation via court orders. Although there is limited literature demonstrating this within the Malaysian context, literature from the US have shown that there were discrepancies between rates of drug abuse among the public and the population serving prison sentences for non-violent, drug-related offenses or court-ordered rehabilitation (Moore & Elkavich, 2008). For instance, although the rates of drug abuse between White-Americans and African-Americans were roughly the same and comparatively higher than the Latin Americans, drug users from the African and Latino communities in major cities were more likely to be arrested and prosecuted (Fellner, 2000). Drug users from the African and Latino communities were often from underprivileged backgrounds, experienced missed opportunities for state and government education, employment and health aid and thus, were less likely to afford legal representation (Fellner, 2000; Moore & Elkavich, 2008).

The emergence and rising popularity of new synthetic drugs in Asia (19 countries), mostly in East and South-East Asia and in the Middle East also merits further research and discussion (UNODC, 2013). Synthetic drugs such as methamphetamine, ecstasy and LSD are popular and substantially used in East and South-East Asia (UNODC, 2015) because of the effects they produce and the speed of its effects. In addition to this, a growing number of new psychoactive drugs from the following classes were reported annually by large number of countries and territories worldwide: (a) cathinones; (b) cannabinoids; (c) cocaine; (d) ketamine; (e) phenethylamine; (f) tryptamines; and (g) piperazines (UNODC, 2016). Many of the new psychoactive drugs are experimental derivatives from medical research (Hohmann, Mikus & Czock, 2014) and they contain one or more chemicals which produce similar effects to illicit drugs. The rising popularity of these new synthetic drugs is mostly due to the dangerous and false perception that psychoactive drugs are safe for use and consumption, as they are often marketed as ‘legal highs’ (UNODC, 2013). The easy availability of new synthetic drugs is a growing problem as drug suppliers have managed to evade the authorities by marketing and packaging psychoactive drugs under the names of harmless household items such as herbal incenses, bath salts, room fresheners and plant fertilisers (UNODC, 2013). In addition, new psychoactive drugs are generally undetectable by immunoassay tests for drug screening (Hohmann, Mikus & Czock, 2014). From this, it can be concluded that further research on the effects of these new, synthetic psychoactive drugs is very much needed. In addition, the global community needs to be aware of the presence of these drugs in the market and be educated about the dangers and potential side-effects of abusing it.

The increasing popularity of new drug trends such as recreational drug abuse also spearheaded efforts to gain a deeper understanding of how drugs are recreationally used in social situations. It was discovered that some individuals were able to take drugs such as heroin on a recreational basis without developing dependence (Shewan & Dalgarno, 2005). Ersche et al. (2013) further found evidence of the association between drug dependence with personality traits and neural correlates. Their research compared 27 cocaine users, who have been recreationally using for a minimum period of two years without showing behavioural patterns related to drug dependence, against 50 users with drug dependence. It was found that the recreational cocaine users had lower levels of compulsivity and impulsivity behaviours and were able to maintain control of drug abuse in social situations without affecting their daily functioning (i.e., school and work tasks, family and social relationships) although they scored as high as the dependent group in sensation-seeking (Ersche et al., 2013). From the studies above, it can be concluded that each individual may react differently even to the same type of drug used. Therefore, factors such as the users’ personal history, personality traits and neural correlates need to be considered in creating individualised treatment plans. With the aim of increasing public awareness about the myriad of drug abuse symptoms, information about various drug side-effects as experienced by different individuals should be shared through drug prevention education.

From the discussion above, it is clear that continuous research is necessary towards understanding the complexities of drug abuse and relapse with the presence of new synthetic drugs in the market, the shifting social contexts, and the emergence of new drug trends like recreational drug abuse. Besides the three reasons above, another methodological factor for continuously developing or combining new methods of researching drug abuse is that the dominant approach remains quantitative (EMCDDA, 2000). While quantitative methods have been useful towards providing a measure of drug abuse and drug use behaviours, it has been argued that qualitative research is better suited to construct meaningful interpretations of sensitive and valid data from drug user populations (EMCDDA, 2000). Thus, qualitative methods have been increasingly used as a means of understanding and responding to drug abuse, especially in regards to developing community interventions as well as health and drug policies (EMCDDA, 2000). Qualitative research methods are also useful to researchers who apply a mixed methods approach to drug abuse research as insight into how the targeted respondents perceive their world will lead to the construction of meaningful and structured questionnaires for appropriate statistical analyses.

The current study attempts to obtain insight on drug abuse, drug relapse, drug prevention education and drug rehab treatment through mixed methods research across a multi-level sample. In this study, generalisability is not a goal and the aim of combining quantitative and qualitative research methods is to enable collection of comprehensive data through surveys and interview checklists, which involve a combination of close-and-open ended items and observations. This mixed methods study was also conducted based on the Grounded Theory approach. In grounded theory, research problems and how respondents resolve it in the real world are investigated as experienced by respondents (Glaser & Strauss, 1967). Since the purpose of Grounded Theory is to construct and develop meanings and theories or frameworks (Johnson & Christensen, 2008), the data is analysed with no preconceived ideas or hypothesis (Glaser & Strauss, 1967). With this, the researcher remains sensitive to the data and is able to derive his or her own conclusions when conceptualising theories or frameworks. In the case of the current study, comprehensive data on knowledge gaps about drug abuse and drug relapse issues, as well as evaluative feedback on the drug education system and existing drug rehab programmes were collected from university students, drug rehab patients and rehab staff samples. Together with field observations of the admission and rehab process, quantitative and qualitative data were analysed, interpreted and integrated to form a framework that could guide treatment providers towards developing a treatment environment that accommodates individual differences and the unique background circumstances that accompany each drug user. Furthermore, this framework may be used as a guideline for educators and drug treatment agencies to pool information resources on drug abuse, prevention and treatment to ensure that the drug prevention education syllabus is up-to-date with recent changes in the field of drug abuse.

In the next chapter, definitions of key terms and past research studies related to: (a) type of drugs commonly used and easily accessible; (b) progression of drug abuse; (c) contributory factors of drug abuse; (d) choices of drug information resources; (e) perception, knowledge and attitudes towards drug use; (f) knowledge about drug rehabilitation services; (g) treatment approaches in drug abuse; (h) predictors of treatment outcomes; (i) evaluation of patient satisfaction; (j) reasons and predictors of drug relapse; (k) drug prevention education in school; and (l) drug prevention interventions at tertiary level, are reviewed. In addition, the rationale of the current study in relation to past research and the research questions are also stated in the next chapter.

Chapter 2: Literature Review

As mentioned earlier, the field of drug abuse research focused much on identifying drug trends such as the profile of drug user populations, the types of drugs abused and the prevalence of a drug progression pattern (Sterk & Elifson, 2005). Before reviewing some of these drug trends, it would be prudent to firstly define the term ‘drug abuse’. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), drug abuse (i.e., substance abuse disorder as classified in the DSM-5) is diagnosed when an individual experiences maladaptive craving, strong desires or the urge to use drugs for a period of 12 months. These symptoms are often accompanied by clinically significant distress and impairment, which results in failure to fulfil role obligations and interpersonal relationships as well as engagement in physically hazardous actions. Besides drug abuse, the current study explores the issue of drug relapse, drug rehab treatment and drug prevention education across three perspectives (i.e., university students, drug rehab patients and rehab staff).

1. Type of drugs commonly used and easily accessible

In this current study, the students’ perceptions of drug types that are commonly abused and easily available in the market were explored. The students’ perceptions were compared against the drug use history of rehab patients, to understand similarities and differences between perception and actual experience of drug abuse. A six-year analysis of drug types used by drug users who were admitted into rehabilitation in Malaysia from 2010 to 2015 showed that opiates was most widely used, with more than 49% of drug users used heroin and morphine (NADA, 2015). In the year 2015 itself, 61% of drug users misused opiates (NADA, 2015). The use of cannabis and amphetamine-type stimulants (ATS) (i.e., ecstasy, methamphetamines and amphetamines) remained consistently in the second to fourth place rankings across six years. The use of synthetic drugs such as ketamine and nimetazepam among drugs users admitted for rehab decreased drastically from the year 2011 to 2015 (NADA, 2011; 2012; 2013; 2014; 2015). Comparisons between the year 2014 and 2015 demonstrated that the use of methamphetamines increased almost two-fold in 2015 (8133 users), in contrast to 2014 (4117 users) (NADA, 2015). There was a slight decrease in use of ATS in 2015 (1314 users) as compared to 2014 (1774 users). In addition to this, there was a slight decrease in use of cannabis in 2015 (1389) as compared to 2014 (1919 users). There was an increase in the use of opiates in 2015 (16, 616 users) as compared to 2014 (14,496 users). The use of psychotropic pills also decreased in 2015 (1 user) in contrast to 2014 (6 users). Drugs that were categorised as ‘others’, which includes hallucinogens, anti-depressants, dissociatives, inhalants, and ketum leaves or kratom also demonstrated a substantial decrease in usage in 2015 (26 users) in contrast to 2014 (43 users) (NADA, 2015). It is once again reiterated here that the statistics from NADA were based only on drug users who were admitted into rehabilitation. Thus, it is likely that the actual numbers of drug users are much higher than these.

A study by Tam and Foo (2012) in Malaysia showed that environmental factors such as easy availability of drugs within the community and the sales of drugs in schools were risk factors for increased drug abuse among adolescents and adults. The Youth Risk Behavior Survey in the United States (US) also reported a 3% increase (23% versus 26%) of drug offers and transactions in school grounds among students in school grades 9 to 12, between the year 2009 to 2011 (Robers, Kemp & Truman, 2013). Gender comparisons also revealed that a higher proportion of male students were offered, sold or given drugs as compared to females in each survey year from 1993 to 2011. Two studies (Aldridge, Parker & Measham, 1999; Gunning et al. 2010) in the United Kingdom (UK) noted that there was an incremental growth in rate of drug offers and availability with age. Aldridge, Parker and Measham (1999) conducted a three-year longitudinal study involving a cohort of more than 2000 adolescents from Northumbria and West Yorkshire, to investigate the progress of adolescents’ relationships with drugs into young adulthood. The study involved two age cohorts: (a) a younger cohort from age 13 – 15 years; and (b) an older cohort from age 15 – 17 years. It was found that by the age of 13 years, 4 in 10 adolescents had been in drug offer situations. The drugs that were reportedly offered to this cohort include solvents (27.0%) and marijuana (24.1%), followed by magic mushrooms, amphetamines and LSD. By the age of 16 years, it was found that the rates of drug offers rose incrementally, whereby more than 8 in 10 adolescents had been in drug offer situations. Although marijuana continued being the most available drug at this point, the availability of ecstasy, amphetamines and LSD rose sharply. In addition, 14.0% of adolescents reported having received offers of heroin at the age of 16 (Aldridge, Parker & Measham, 1999). In a survey of 7,296 adolescents between the ages of 11 – 15 years throughout the UK, it was reported that by the age of 11 years, 9% of adolescents had been offered at least one type of drug as compared to 49% of 15 year olds (Gunning et al., 2010). Unfortunately, there are no survey data available involving schools in Malaysia. Hence, a comparison between international and local trends was not feasible.

Some international studies (Forman, 2006; Forman, Marlowe & McLellan, 2006; Gijsbers & Whelan, 2004) have highlighted the role of the Internet towards the rise in availability of drugs to a larger user demographic. Although the Internet provides greater access to a wider source of information, it can be dangerous because adolescents and young adults can easily order drugs online (Gijsbers & Whelan, 2004). The Internet is an ideal site to conduct illicit drug transactions due to the ease of anonymity (Forman, 2006). Some drugs such as marijuana and ecstasy have been sold on the net as herbal supplements (Forman, Marlowe & McLellan, 2006), which have led adolescents to purchase illegal drugs unwittingly. Furthermore, Tam and Foo (2012) reported that in Malaysia, underground websites were used by drug suppliers to keep in contact with buyers to promote new designer drugs and ensure continuous transactions. Nevertheless, two studies (Parker, Aldridge & Egginton, 2001; Parker, Williams & Aldridge, 2002) from the UK argued that aggressive drug dealing does not occur only on the Internet. According to Parker, Aldridge and Egginton (2001), most drug users obtain supplies through social networks and ‘friends-of-friends’ chains. Their statement was supported by Parker, Williams and Aldridge (2002), whose five-year longitudinal study found that only 14.5% sourced drugs directly from drug dealers, with a majority preferring to obtain it from their friends. From both international and local studies, it can be surmised that both environmental factors (i.e., sales of drugs in school, social networks and the community) and the Internet are involved the rising availability of drugs among adolescents and young adults.

2. Progression of drug abuse

Illicit drugs are loosely classified based upon their effects on the nervous system. According to the Addiction Science Network (2007), hard drugs such as heroin, amphetamine, methamphetamine and cocaine have the ability to cause physical addiction. Alternately, soft drugs such as marijuana, LSD and cannabis may lead to a psychological dependence but do not cause physical addiction. There are also illicit drugs that exhibit both characteristics of hard and soft drugs, such as ketamine and ecstasy (MDMA). Attempts to establish the prevalence of a drug abuse progression were made in the current study by tracking the rehab patients’ drug use history. Therefore, identifying the classification of drugs according to its dependency is an essential component to this study.

Past international studies (Yamaguchi & Kandel, 1984; Kandel, Yamaguchi & Chen, 1992) had suggested a progression in the trends of drug abuse from ‘soft’ drugs to ‘hard’ drugs but Peele and Brodsky (1997) dismissed it as a cultural myth. Coffield and Gofton (1994) supported Peele and Brodsky’s statement through their focus group research with drug users, whereby it was discovered that drug users did not categorise drug abuse on a continuum from soft to hard. Moreover, marijuana use was considered highly correlational to heroin and cocaine use rather than causal (Coffield & Gofton, 1994). However, rapid progression in drug abuse from soft drugs to the use of harder drugs, with age was found in a study by Bracken, Rodolico, and Hill (2013). Their study involved 939 adolescents who were admitted into the McLean Child and Adolescent Drug Treatment Programme in the US. The Adolescent Chemical Dependency Questionnaire, which was designed for clinical diagnosis and treatment plan development, was administered at the point of admission into treatment. Findings from the McLean data were than compared against published findings from the US national survey, Monitoring the Future (MTF), which involved 560,300 adolescents from 8th, 10th, and 12th grade. To compare the McLean data to the MTF data, published percentages of trends in lifetime drug abuse prevalence for various drugs from the 1995–2010 surveys were averaged. Within the McLean data, there was an accelerated progression to harder drugs that increases with age. However, this trend was not found in the MTF data. Averaging the data proved to be one of the limitations of Bracken, Rodolico and Hill’s (2013) study, since averaging the data eliminated contextual differences that existed between adolescents in the McLean and MTF cohort. For instance, many of the adolescents in the MTF data were school students who chose to simply sample hard drugs and never progressed to more extreme drug abuse patterns. However, nearly half of the adolescents from the McLean data were from populations with poor school attendance or had dropped out. This cohort chose to use hard drugs a few times and continued to use them relatively frequently. These contextual differences have significant implications towards the development of treatment plans. For example, treatments plan that was formulated for adolescents who used hard drugs for a few times would be less effective for adolescents who were using hard drugs on a weekly basis.

From the research evidences above, it can be surmised that findings related to the prevalence of a drug abuse progression trend is inconclusive across different drug user samples. It would be of interest to examine whether a progressive trend in drug use exists within the sample of rehab patients in the current study.

3. Contributory factors of drug abuse

The current study also explored students’ perceptions about factors for drug abuse. The students’ perceptions were compared against the drug use history of rehab patients and responses from rehab staff to understand similarities and differences between perception and actual experience of drug abuse. Family factors and peer influence were found to be the main factors for drug abuse in most Western literature. Parental drug abuse was the most significant predictor of drug abuse since children tend to model parental behaviours (Glynn, 1981). There is a greater chance that the adolescent would be a drug user if the parent is (Andrews, Hops, & Duncan, 1997). Alternatively, Cooper, Peirce and Tidwell (1995) showed that family conditions, such as being chaotic and unsupportive, play a greater role in drug abuse rather than family members’ drug abuse behaviour.  However, the distinct boundaries between these two variables are indistinguishable as they often link and influence each other.  On the same note, Clark (2001) investigated the effect of family support on adults with mental illness and drug abuse and found that family economic support was associated with recovery from drug abuse, while caregiving duration was linked to reduction in drug abuse.

Family factors such as open parent-child communication about drug abuse and a positive parent-child relationship were found to be protective factors against drug abuse among African-American adolescents (Wills, Gibbons, Gerrard, Murry & Brody, 2003). Family structures such as being raised in a single-parent or an adopted family, put adolescents at greater risk of initiating marijuana use (Lonczak, Fernandez, Austin, Marlatt, & Donovan, 2007). Recent studies (Ahmad, Ismail, Ibrahim & Nen, 2015; Chooi, 2011; Razali & Madon, 2016) conducted in Malaysia also indicated that various family factors (i.e., lack of familial support and encouragement, pressure from parents, parent-child conflict, low levels of family members’ expressiveness, weak family cohesion, the presence of drug-addict parents, low parental supervision and poor family management) contribute significantly towards drug abuse among adolescents and young adults.

The relationship between peer influence and drug abuse in adolescence and adulthood has been established in many Western literatures. A longitudinal study by Dishion and Owen (2002) tracked a sample of 206 males from early adolescence (age 13-14) to young adulthood (age 22-23). It was found that drug abuse in adulthood was predicted by peer influence during adolescence. The social pressure of belonging and being accepted impelled some adolescents to conform to expectations from their peer group and experiment with drugs. A similarity found in past international studies (Hundleby & Mercer, 1987; Andrews, Tildesley, Hops, & Li, 2002; Dishion & Owen, 2002) was peers’ drug abuse is the most significant predictor of drug abuse among adolescents, through socialisation. Peers may influence one’s behaviour knowingly or unknowingly through constant association and reinforcement and this easily predisposes youth to drug abuse behaviour (Dishion & Owen, 2002). Conformity to group identity was also found by Verkooijen, de Vries, and Nielson (2007) to have an impact on youth drug abuse in the Netherlands. Increased probability of marijuana use was more highly associated with identification with hippie, techno, pop, or hip-hop groups rather than sporty, quiet, religious, or computer nerd groups. Youths were more likely to follow and use drugs when they adopt a group identity whose group members were associated with drug abuse (Verkooijen, de Vries & Nielson, 2007). In addition, William and Derek (2007) found that conformity to masculine norms also contributed to drug abuse among 154 Asian-American men who engaged in the use of marijuana (18%), illicit drugs (8%), and cocaine (3%). According to the national statistics in Malaysia, peer influence was the top contributory factor of drug abuse from the year 2010 to 2015 (NADA, 2015). Recent studies (Razali & Madon, 2016; Saad, Jalil, Denan & Tahir, 2016) in Malaysia also indicated a positive relationship between peer influence and drug abuse. This means that the more their peers influence them, the more likely adolescents and young adults would use drugs (Saad, Jalil, Denan & Tahir, 2016). Razali and Madon (2016) explained that in order to maintain friendships and receive acknowledgement from their peers, peer pressure often led youths to disregard their studies and engage in drug abuse.

The use of drugs as a coping mechanism against stress is also prominent among university students, in which some are also working to pay for school fees or making ends meet. According to a report from the Georgetown University Center on Education and the Workforce in the US, besides the fact that going to college and university has become more widespread and much more expensive, the increasingly demanding job market and struggling economy has seen changes in the student demographics (Carnevale, Smith, Melton & Price, 2015). Previously, university students were often full-time residential and financially dependent students but financial and economic circumstances has seen rising numbers of students in need of work (working learners) and the more experienced workers in need of higher learning qualifications (learning workers) (Carnevale, Smith, Melton & Price, 2015). As such, the academic demands, peer pressure and work stress experienced by young adults have led to use drugs for the same reasons as older adults, which includes relaxation, fun, coping with pressure and frustrations, relieving stress, anxiety or pain, and dealing with inhibitions (Nielsen, 1996). Boys, Marsden and Strang’s (2001) interviews with 264 young poly-drug users in the UK revealed that the most frequent reasons for using methamphetamines, cocaine, cannabis, ecstasy and LSD were to relax (96.7%), be intoxicated (96.4%), stay awake for night-time socialising (95.9%), enhance performance in study, work, music or sports (88.5%) and to lighten depressed moods (86.8%). Findings from Western literature show that the reasons for drug abuse have changed since the 1990s and similar trends are found in Malaysia since an increasing number of college and university students are juggling studies and work to maintain a more comfortable lifestyle (Priya, 2013b).

Innate curiosity and a wish to seek enjoyment are also cited as factors for drug abuse among adolescents and young adults in Western literature. A research study by Pedersen (1990) in Norway showed that a vast majority of adolescents began using drugs out of curiosity or to rebel and express dissatisfaction with traditional norms and values. Among young users, addictive and highly dangerous recreational drugs such as stimulants, psychedelics, depressants, dissociatives, inhalants and narcotics are increasingly used as a means of personal enjoyment (APA, 2010). The desire to satisfy their curiosity and seek enjoyment can also be attributed to neurodevelopmental changes that occur in adolescence. In addition to hormonal changes, developments in the limbic system of the brain will enhance adolescents’ responses to emotions, pleasure and rewards (WHO, 2014). The evolving cognitive and emotional capacities during adolescence will affect perception of risks, their reaction towards communication about risky behaviours such as drug abuse, their thoughts about the present and future, and reasons to their ideas and actions (WHO, 2014). Although most drug users are aware of the potential harm of drugs even when used moderately, they continue using it due to the positive effects and feelings or ‘high’ (Kelly, 2005). The ‘high’ is a feeling that results from electrical stimulation to the brain’s reward centre (i.e., the ventral tegmental area, nucleus accumbens and substantia nigra), which is part of the limbic system (Butler Center for Research, 2015). Dopamine, which is associated to feeling of pleasure and rewards, is the neurotransmitter that activates electrical stimulation to the reward system. The positive effects and feelings felt when drugs are used will reinforce drug abuse behaviour in the future (Butler Center for Research, 2015). Furthermore, the normalisation of ‘sensible’ recreational drug abuse has led to a rise in perception that recreational drug users are not the same as conventional drug users (Parker, Williams & Aldridge, 2002). This has resulted in a worrying trend, in which recreational drug users seek help from treatment facilities only when they have severe problems (Siliquini, Morra, Versino & Renga, 2005).

In Malaysia, curiosity and enjoyment were also common factors for drug abuse. According to the NADA (2015) statistics, curiosity (16.5%) and enjoyment (9.3%) were ranked as the second and third highest contributory factor for drug abuse, after peer influence (61.7%). Razali and Madon (2016) stated that reduced levels of control from parents and the authorities during the transition into college and university provide adolescents and young adults with the freedom to satisfy their curiosity about drugs. Additionally, more adolescents were experimenting with drugs for personal enjoyment without considering the consequences. Once they experienced the thrill, pleasure and comfort in drug abuse, it was more likely that drug abuse behaviour would be repeated until it became a habit (Razali & Madon, 2016).

Unemployment is a unique factor, which can function as a predictor and outcome of drug abuse. While unemployment is a significant risk factor, clinically severe drug abuse also increases the risk of unemployment and maintaining an occupation (Henkel, 2011). Henkel’s (2011) comprehensive review on drug abuse and unemployment literature published within the time period of 1990 to 2010, concluded that unemployed adolescents and young adults were more liable to engage in risky behaviours such as drug abuse (see also Poulton, Brooke, Moffitt, Stanton, & Silva, 1997; Kestila et al., 2008; Legleye, Beck, Peretti-Watel & Chau, 2008). Supportive studies (Andrews, Henderson & Hall, 2001; Fryers, Melzer & Jenkins, 2003; Jacobi et al., 2004; Pirkola et al., 2005) proposed that unemployment resulted in higher rates of mental disorders, which led to the use of prescription drugs such as sedatives, anti-depressants and hypnotics. However, excessive usage of prescription drugs without supervision could result in the development of substance abuse disorders. Various studies have also shown that severe drug abuse will affect educational attainment and reduce the chances of finding work (Yamada, Kendix & Yamada, 1996; Krohn, Lixotte & Perez, 1997; Brook, Ritcher, Whiteman & Cohen, 1999; Lynskey & Hall, 2000; Ringel, Ellickson & Collins, 2006). Moreover, individuals with drug addiction problems were 15-23% more likely to be dismissed from their jobs as compared to normal employees (Baldwin, Marcus & De Simone, 2010). A similar trend was found in Malaysia. According to the national drug statistics, the rate of unemployment among drug users in Malaysia who were admitted for treatment was 14.67% in 2015 (NADA, 2015). However, a review of literature yielded limited research studies that focused primarily on unemployment as a factor or outcome of drug abuse in Malaysia.

The experience of persistent pain among some individuals is also a lesser discussed factor leading to the misuse of illicit drugs and overuse of prescribed medication. There was epidemiological evidence in the US that pain may be more prevalent among chemically dependent patients, such as patients suffering from persistent physical illness or psychiatric illnesses whilst receiving methadone maintenance therapy or inpatient residential treatments (Rosenblum et al., 2003). For instance, a study by Jamison, Kauffman and Katz (2000) on 248 patients receiving methadone maintenance therapy at three centres revealed that 61.3% of patients reported experiencing chronic pain. The varying degrees of functional impairment experienced as a result of the level of pain severity have led some patients to self-medicate with psychoactive drugs. Patients who experienced chronic severe pain were also more likely to be prescribed medication to manage pain such as opioids (Rosenblum et al., 2003). The patients in Jamison, Kauffman and Katz’s (2000) study who reported experiencing pain also recounted significantly more health problems and psychiatric issues, besides more prescription and non-prescription medication use, in contrast to patients without pain. Additionally, 44% of patients with pain believed that the opioids which were prescribed to manage pain had resulted in an addiction as they always needed to use some drug (i.e., opioid or alcohol) to feel normal again. Following this line of research, Ives et al. (2006) investigated opioid misuse among 196 patients with chronic pain, who were referred to a chronic pain management programme in the US. Over a one year period, opioid misuse occurred among 32% of patients and was reportedly more frequent in patients with a self-reported history of cocaine or alcohol abuse. In Malaysia, the national drug statistics showed that 617 (2.25%) drug users reported pain management as a factor for drug abuse and dependency (NADA, 2015). However, it is difficult to compare rates of opioid abuse between the US and Malaysia because there is insufficient data and research studies on opioid abuse among patients managing chronic pain in Malaysia (Zin & Ismail, 2017). Nevertheless, the Ministry of Health Malaysia (2010) reported that opioid consumption was considerably lower in Malaysia than the global average. Manjiani, Kunnumpurath and Kaye (2014) reported that physicians in Malaysia were less likely to prescribe opioid medication to patients because they lacked the medical knowledge to manage cancer-related pain and were wary of side-effects such as respiratory depression and dependency. There is cause for caution because the effects of opioid therapy can be adverse. A review of international studies by Jamison, Serraillier and Michna (2011) stated that most patients who were on long-term opioid medication often developed physical dependence and tolerance to the medication, to the point of death from overdosing.

4. Choices of drug information resources

The current study also investigates students’ preferred medium to search and share information about drug abuse and prevention using a mixed methods approach. The students provided quantitative ratings of their selected medium and shared the reasons for their selection through a series of open-ended items. Choosing credible and trustworthy resources for information on illicit drugs and drug prevention strategies is essential to ensure accurate and updated information is conveyed to the public. An online survey by Stetina, Jagsch, Schramel, Maman and Kryspin-Exner (2008) on 9268 young recreational drug users in Australia, North America, as well as English and German-speaking European countries found that 74.02% searched for information from the internet, friends and acquaintances (71.32%), radio and television (17.16%), magazines (15.72%) and daily newspapers (15.40%). The least popular resource was public health authorities (9.32%) and school (5.42%). The survey respondents also rated the level of trust towards information resources in which friends (18.38%) were rated as the most trustworthy source, followed by drug advice centres (14.67%). The internet (14.52%) was viewed to be nearly as trustworthy as drug advice centres.

In the UK, a National Health Service (NHS) report also described findings on information resources about drugs that were considered helpful by secondary school students in 2009 (Gunning et al., 2010). The students were most likely to get helpful information from the television (71%) and parents and teachers (63%), while help-lines (18%) were the least preferred resource. This report also found gender differences in preferences for information resources, whereby males were more likely than females to cite family members such as parents, siblings and relatives as useful sources of information. Females were more likely to cite General Practitioners (GPs), the police and the radio as helpful resources; and were also more likely than males to find useful information in newspapers and magazines (51% versus 46%). Similar results were found in a survey on school children from Bermuda aged between 8 to 14 years. Parents, guardians and family (72.5%) were rated as the most commonly sought resource across all grade levels and gender, followed by teachers or counsellors (67.3%) and the television (53.0%) (Department for National Drug Control, 2013).

Findings from the Singaporean Youth Perception Survey 2013 indicated that television (63.1%) was the most important information resource about drugs and drug abuse (National Council against Drug Abuse, 2013). In addition, parents and teachers in Singapore played an effective role in educating youths about drugs and drug abuse. One in two youths reported that they would approach their family, especially their parents, in regards to any questions about drugs. Two in five youths also reported that they would refer to their teachers and counsellors for more in-depth information. In total, 40.6% of youth respondents reported having had conversations with their parents about drugs. Parents and teachers in Singapore also have a more effective role in preventing youths from engaging in drug abuse. It was reported that 96.5% of youths had parents who had initiated conversations about drugs and credited those discussions as a deterrent towards drug abuse (National Council against Drug Abuse, 2013).

Identifying the preferred and trusted information resource for seeking information about drug abuse has a huge impact towards tailoring and disseminating information to the public as well as facilitating drug prevention. Besides being able to reach a wider audience, it is also cost-efficient as information can be tailored to different modes, age groups and genders to increase its impact.

5.   Perception, knowledge and attitudes towards drug abuse

As mentioned earlier, the current study attempts to gain insight into perceptions and knowledge of drug abuse among university students in Malaysia. Despite having no experience with drug abuse, these students were exposed to drug prevention education at least once during primary or secondary education. Before it was mandatory for the counselling unit in all Malaysian schools to conduct drug prevention education annually, a pioneer research was conducted by Tay (1996), with the collaboration of the Malaysian Anti-Narcotics Task Force. This study examined knowledge, perceptions and opinions on drug abuse and prevention practices from multiple sources, including students, parents and educators in Malaysia. The findings indicated a good understanding about common drug types such as cannabis and heroin among the student cohort in 1995, but less familiarity with drugs like hashish and amphetamines. Additionally, they were not knowledgeable about the effects of drugs on the individual such as physical health risks and mental health side effects. Educators had a good understanding about general knowledge questions such as information on drug sources and agencies that provided assistance, but had difficulties identifying the uses of different drugs and their terminologies. The parents also had a fair level of knowledge about drugs and were able to identify common drug types.

Analysis of factors contributing to drug abuse indicated that students viewed peer group influence, the need to experiment and assert individuality, being happy, the lack of family support and environmental influences such as family conflict and disharmony as the key reasons (Tay, 1996). Educators rated peer group influence, curiosity, parental neglect and inactivity as the main factors for drug abuse. Students reported that concerns regarding negative effect on health and mortality rates due to drugs were primary prevention factors against drugs. General responses toward drug rehabilitation showed that students, parents and educators viewed that drug users could be rehabilitated with assistance and rehab was not considered as wasteful of government resources. However, there were mixed responses on whether drug users should be reintegrated into society. Although this study may be dated, there are some conclusions that are still relevant to this day such as the reasons for using drugs. It is expected that there will be differences in exposure towards drug types and their terminologies in the current youth cohort with the increase in Internet accessibility, as postulated by Gijsbers and Whelan’s (2004) study.

Another study that investigated the relationship between sociodemographic factors and knowledge and attitudes towards drug addiction from multiple perspectives (public, parents and youth) was Elarabi, Hamedi, Salas and Wanigaratne (2013). In a sample of 1531 respondents from Abu Dhabi, United Arab Emirates (UAE), 63.2% viewed drug addiction to be a moderate to large issue while 77.9% perceived youths to be at high-risk of drug abuse and addiction. Most adolescents and youths also perceived illicit drugs such as cannabis, as addictive (83.7%) while 11% have considered experimenting with drugs. In regards to the need for treatment services, 93.2% expressed a need for more addiction treatment centres. Besides examining public knowledge about drug abuse and addiction, the respondents perceived weakened religiosity (34.2%), peer pressure (28.3%) and having too much leisure time (26.6%) as three main reasons for drug abuse. The social stigma of being identified as a drug user (46.5%) and fear of prosecution (31.7%) was perceived as the main barriers to treatment. It was found that 65.2% of respondents felt that no legal actions should be taken against drug users who entered treatment voluntarily while 34.8% viewed that all drug users should face prosecution. In relation to attitudes towards drug users, most respondents were accepting of drug users whom they perceived as victims (50.3%) and patients (33.0%). Yet, there were some respondents who perceived drug users as deviants (10.7%) and criminals (6%). In terms of attitudes towards patients in rehab, most respondents (65.8%) perceived themselves as accepting of patients in recovery with 95% of respondents in support of recommending treatment to a drug user (Elarabi, Hamedi, Salas & Wanigaratne, 2013).

Research by Cirakoglu and Isin (2005) with Turkish university students noted gender differences in perception of drug abuse causes, and strategies to overcome drug abuse. Females were more likely to perceive problem-coping as a reason for drug abuse while males tend to view sensation-seeking as an important factor to use drugs. Significant gender differences were found in perceptions of drug relapse prevention strategies. Females were less likely to perceive help-seeking and avoidance, self-change and social activity as effective relapse prevention strategies. Instead, a multidimensional change was deemed as a necessary measure. A study by Kauffman, Silver and Poulin (1997) found that females had a significant tendency to attribute biological predisposition, family history and environmental stress as reasons for drug abuse. However, lack of willpower and poor moral character were perceived equally by both genders to be contributory factors of drug abuse.

Research on the attitudes, knowledge, and perceptions of medical and rehab staff involved in drug abuse treatment is also lacking. Hence, the current study investigated the perceptions and knowledge of rehab staff about drug abuse, relapse and the most effective strategies to help patients prevent relapse. A study by Barry, Tudway and Blissett (2002) examined the attitudes, beliefs and knowledge of illicit drug and drug abuse among 98 psychiatric nursing staff in the UK. They comprised of 35 qualified nurses, 29 non-qualified nurses and 34 non-clinical staff members who were administered anonymous self-report questionnaires and a follow-up questionnaire one month after the initial questionnaire. The findings naturally indicated that qualified nurses had higher levels of drug knowledge than unqualified nurses did while the unqualified nurses were more knowledgeable than non-clinical staff. Significant differences were found in responses towards reasons for drug abuse. Qualified nurses rated criminality and lacking financial funds as the main reasons for drug abuse whereas unqualified nurses rated self-medication as the top reason. Alternatively, non-clinical staff perceived social pressure as a reason for drug abuse. The overall attitudes towards patients were non-punitive and the pattern shows that staff members who were more qualified and possessed more drug knowledge were less punitive towards patients in comparison, despite no significant differences.

Nevertheless, the overall results in Barry, Tudway and Blissett’s study (2002) indicated that staff members were inadequately trained to deal with drug abuse. Although qualified nurses in this sample demonstrated the highest level of knowledge as compared to other groups, the analysis indicated that they were responding correctly to only half of the items in the questionnaire, on average. The findings for this study have insightful implications towards the training syllabus and professional development programmes for clinical staff. Training and professional development programmes should not only include basic drug knowledge and its effects, but also increase awareness of attitudes and beliefs towards drug users. Moreover, the promotion of positive attitudes based on evidence-based practice rather than stereotypes should be amplified.

6. Knowledge about drug rehabilitation services

In the current study, students’ exposure to information about drug rehabilitation services was investigated. Review of past literature revealed that an underlying issue related to treatment of drug abuse was low awareness among public and youth groups about information and contact resources regarding rehabilitative services. A household nation-wide survey by Low, Zulkifli, Yusof, Batumalail and Aye (1996) on 474 parents and youths in Peninsular Malaysia found that only 23.63% of parents and 33.55% of youths were aware of treatment services at rehabilitation centres. A similar trend was found in literature from other countries such as Canada, in which a Ministry of Health report revealed that a mere 34.7% of the public had knowledge about court-referred drug treatment programmes whilst 54.7% had heard of methadone maintenance programmes (Health Canada, 2006). The difference was a majority (82.5%) of the Canadian public were aware of needle exchange programmes. A recent cross-sectional study by Nebhinani, Nebhinani, Misra and Grewal (2013) on high school and college students in India also found that although most students (91%) had adequate knowledge about drugs and their harmful effects, they lacked knowledge about treatment options and services. A notable finding was that 81% of students believed that drug users could quit their addiction through willpower alone regardless of their drug use history, while 26% even perceived that there is no treatment for drug addiction.

The research studies above indicated that knowledge and awareness about drug treatment services was still lacking in Canada, Malaysia and India although the public in Canada had more awareness of harm reduction programmes. However, limited literature in Malaysian settings has made it difficult to determine the level of public awareness and knowledge of drug rehabilitation services in recent years.

7. Treatment approaches in drug abuse

A review of literature in the United States by Fletcher, Tims and Brown (1997) revealed four common types of drug abuse treatment:

1. Outpatient methadone programmes: to reduce cravings for heroin and the provision of counselling, vocational training, and case management to stabilise patient functioning
2. Long-term residential programmes: drug-free treatment in a community of counsellors and recovering addicts lasting to a year or more
3. Short-term inpatient programmes: medical stabilisation, abstinence, and lifestyle changes conducted by medical professionals and trained counsellors during a 30-day stay and
4. Outpatient drug-free programmes: problem-solving groups, community therapy, cognitive-behavioural therapy (CBT) and 12-step programmes.

Some elements of these four approaches have been adopted by rehabilitation programmes in Malaysia to provide a holistic approach to treatment by combining medical, social and spiritual components (Scorzelli, 2009).

Government-run rehabilitation centres practice three common treatment modalities in Malaysia, which is now classified as part of the old system (Vicknasingam & Mazlan, 2008). They consist of cold turkey detoxification, institutional rehabilitation for two years, and aftercare supervision for a period of one to two years (Vicknasingam & Mazlan, 2008). However, institutionalised treatment, which practiced total abstinence have been shown to be unsuccessful (Mazlan, Schottenfeld & Chawarski, 2006). Thus, most centres now adopt a multi-disciplinary approach that involve components such as spiritual, vocational, military physical training, psychosocial interventions and vocational training (Scorzelli, 2009). As such, it was of interest to gain insight into treatment components that were perceived as favourable and effective from the perspective of rehab patients and staff. The notable benefits of multi-disciplinary rehab programmes include restoring patients’ physical and spiritual health, providing access to counselling services and vocational skills as well as opening opportunities for job attachments, community integration and re-entry into society (Mazlan, Schottenfeld & Chawarski, 2006).

In 2010, NADA implemented an alternative system whereby drug users in Malaysia are able to register for treatment voluntarily without having to undergo legal judgment (NADA, 2012). The existing rehab centres were restructured into several types, which provide various treatment services: (a) Cure and Care 1Malaysia clinic, (b) Cure and Care Rehabilitation Centre (CCRC), and (c) Cure and Care Service Centres (CCSC) (NADA, 2012). Each centre has a different role. For example, the clinics enable drug users to obtain health services and methadone replacement therapy, while the CCRCs place drug users undergoing the standard 2-year treatment. Besides that, the CCSCs functions as an open institution for the community with drug issues. Services provided in the CCSC include guidance and counselling, treatment programmes, vocational training and job placements, as well as drug prevention and education. Moreover, it also functions as a drop-in centre for clients or a halfway house for rehabilitated patients with no home to go back to (NADA, 2012). These centres are attempting to change their approach by treating drug users as patients rather than criminals by ensuring all drug users receive proper medical treatment before focusing on the psychological and behavioural aspects of drug rehabilitation (Priya, 2013a).

Under the new system, medical professionals were more actively involved in drug abuse treatment with the use of medication to reduce illicit drug abuse (Nik Anis, 2007). The medications trialled include naltrexone (Navaratnam, Jamaludin, & Raman, 1994), buprenorphine (Mazlan, Schottenfeld & Chawarski, 2006) and methadone (Nik Anis, 2007).  Currently, methadone replacement therapy is commonly used to deal with patients’ withdrawal symptoms, and the results from trials on 5000 drug users in hospitals, health and private clinics across Malaysia had been positive (Priya, 2013a). The evidence further showed that 66% of those who underwent 12 months of therapy were able to function properly and maintain permanent employment while 24.9% were able to undertake odd jobs (Nik Anis, 2007). The positive impact of methadone maintenance therapy (MMT) was further supported by Baharom, Hassan, Ali, and Shah’s (2012) study, which found significant improvements in the psychological, physical and environmental domains of quality of life among government drug rehab patients in Malaysia after 6 months of enrolment in the MMT programme. The domain with the least improvement was social relationships.

Nevertheless, accounts of uncontrolled prescription of medication were reported, whereby the unsupervised use of buprenorphine has led to its use above the prescribed frequency and dosage (Vicknasingam, Kartigeyan & Navaratnam, 2007; Vicknasingam, Mazlan, Schottenfeld & Chawarski, 2010). Mintzer and Stitzer (2002) also showed that prolonged use of methadone in treatment could contribute to a decline in cognitive performance. Methadone-dependent patients exhibited some cognitive impairment related to working memory (two-back task), metamemory (recognition memory test), psychomotor speed (trail-making and digit symbol substitution tasks), and decision-making (gambling task), although no significant effects were found on long-term memory, time estimation, or conceptual flexibility (Mintzer & Stitzer, 2002).

Despite these risks, a combination of methadone maintenance, weekly counselling sessions, benzodiazepines and individual counselling under the supervision of a psychiatrist were found to reduce anxiety significantly, which was a common relapse factor for patients (Scorzelli, 2007). Thus, prescriptive medication may be beneficial to control anxiety symptoms during the withdrawal and treatment stages provided strict control of its dosage is practiced by treatment providers. Further exploration into CBT (i.e., progressive muscle relaxation and emotional imagery) and spiritual approaches (i.e., meditation, contemplative prayer and yoga) is recommended to complement current treatment approaches (Scorzelli, 2007).  Research on the effectiveness of treatment approaches found that outpatient treatment involving psychotherapy approaches such as problem-solving groups, community therapy or CBT were equally as beneficial as methadone replacement therapy and had superior benefits to detoxification or no treatment (Simpson & Sells, 1983). However, the positive effect of psychosocial treatment only became apparent after 3 months of treatment in comparison against detoxification (Simpson, 1981).

Despite a huge gap in the documentation of treatment approaches used in private drug rehabilitation centres in Malaysia, the Malaysian government acknowledged and welcomed the services provided by private centres set up by non-governmental organisations (NGOs) (Chan, 2010). Currently, there are no public records available on the types of private centres that were set up but it is known that they employ different methods like character-building, therapeutic community, religious approaches and the 12-step programme (Chan, 2010). Nevertheless, their aims are aligned with government centres, which are to rehabilitate drug users toward a better life, address social stigmas related to drug abuse, and initiate the re-integration of rehab patients into the community.

A major issue among drug rehab patients in Malaysia was the provision of suitable employment upon release from treatment centres. Securing employment will enhance self-efficacy and self-esteem, which helps former patients derive intrinsic satisfaction from work (Scorzelli, 2007). Subsequently, this reduces the risk of relapse (Scorzelli, 2007). However, there are difficulties for former patients to find or maintain employment because they often do not possess the basic behaviours needed for employment and thus, need to be provided with work adjustment training before being sent out for placement programmes (Scorzelli, 2007). Another problem faced by treatment providers is a shortage of trained and qualified vocational therapists in educating patients about work performance, quality of work, getting along with supervisors and employees, dress codes, time management and coping, which will help them not only in the workplace but also effectively re-integrate them into the community (Scorzelli, 2007).

As previously mentioned, there is still a high level of ambivalence among rehab patients in Malaysia about control over drug abuse behaviour and the uncertainty over readiness to change and recover (Fauziah et al., 2010). In researching deeper about the application of motivational interviewing (MI) towards initiating and maintaining behaviour change in drug abuse, it was found that MI has been widely applied to the treatment of drug dependency (Burke, Arkowitz & Menchola, 2003). Moreover, MI was used conjunctively within a well-known framework involving the Transtheoretical model of change (Prochaska, DiClemente & Norcross, 1992).

MI is a directive counselling style, which is patient-centred, and non-confrontational (Treasure, 2004). Both MI and the Transtheoretical model of change are often utilised as part of evidence-based practice in treating drug abuse across Australia, US and the UK (Mental Illness Fellowship Victoria, n.d.; Prochaska, DiClemente & Norcross, 1992). As seen in Figure 1 below, there are inherently six stages of change that drug rehab patients may experience and they may move back and forth between these six phases.

1. Pre-contemplation (Not ready): Patient is barely aware of that there is a problem with drug abuse and has no intention to change in the next six months.
2. Contemplation (Getting ready): The patient acknowledges drug abuse behaviour as a problem and is open to information and education. The patient is also increasingly aware of the pros and cons of changing, which also creates a state of ambivalence. There is intention to change in the next six months.
3. Determination/Preparation (Ready): There is intention to act within the next month. The patient would have begun to set goals, plans and strategies to change drug abuse behaviour such as consulting a counsellor, admission into a rehabilitation centre or buying and using self-help books to help manage drug addiction.
4. Action: Specific modifications are made in the patient’s lifestyle within the past six months. Examples include gradual reductions in dosage of drug abuse as well as engaging in pharmacological, cognitive and behavioural therapies to manage withdrawal symptoms and resolving thoughts and issues that led to drug abuse.
5. Maintenance: The patient continues to abstain from drug abuse and efforts are focused towards preventing relapse. The patient should be able to clearly identify situations and behaviours that could lead to a relapse and build up their self-confidence with every continuous positive change in behaviour.
6. Relapse: This can occur between the Action and Maintenance phase. A relapse in drug abuse should not be viewed as a failure but should be seen as a learning opportunity to learn which strategies and plans were effective and ineffective.

As seen in Figure 1, a patient may return to an earlier phase of the model such as pre-contemplation when a relapse occurs (Prochaska, DiClemente & Norcross, 1992). The benefit of this framework is that each action and strategy taken towards behaviour change is recorded in each step. Thus, patients who relapsed will be able to readily pick up behaviour change strategies used in the previous cycle and continue moving towards their treatment goal. The combination of MI and stages of change is good example of providing tailored and individualised treatment within a structured and patient-centred environment, which is important since drug abuse and relapse manifest differently for each individual (Winters, Botzet & Fahnhorst, 2011).

In most rehab centres, treatment approach and services vary according to staff expertise, resources and client groups although most adopt the eclectic approach, which combines multiple therapeutic frameworks in treatment delivery (Winters, Botzet & Fahnhorst, 2011). Thus, it is important that treatment providers identify the cause of initiation, maintenance and relapse in drug abuse, drug use history and patterns of use for each patient. Furthermore, patients should be referred to centres that meet their treatment needs rather than its occupancy rate.

In addition, it is timely to develop and implement more treatment interventions that move beyond the individual and encourage the participation of family members, spouses, partners and close social networks in a collaborative treatment framework (Copello & Walsh, 2016) since social and familial support are important inhibitors towards drug relapse. In addition, family members, partners and close friends are also negatively impacted when a member of their circle engages in drug abuse behaviour. Family members often have to cope with stressful and difficult situations that arise as a result of drug abuse within the family such as conflicts over financial issues and property, anxiety and depression, which could lead to the decline of family relationships, hostility and aggression (Orford, Velleman, Natera, Templeton & Copello, 2013). Examples of two such interventions that are currently practiced in the UK are the social behaviour and network therapy (SBNT) and the behavioural couples therapy (BCT).

There are three phases to the SBNT intervention. In the first phase, identification of the patient’s social network is done upon admission into treatment, and it usually involves a combination of family members, close friends and colleagues (Copello & Walsh, 2016). The second phase of SBNT involves having the therapist working together with the patient to establish individuals within the network that are perceived by the patient to be important, helpful and committed. Upon agreement from the patient, the network members are invited to future treatment sessions, in which a good level of positive social support needs to be established to support behaviour change in drug abuse (Copello & Walsh, 2016). In addition to this, a combination of core elements such as MI, coping mechanisms, communication training and social support building are utilised to help the patients explore and resolve ambivalence while developing skills to overcome addiction with the benefit of a good social support network. Need-specific components such as the development of positive group activities to replace drug abuse behaviour and the provision of education about drugs as well as relapse prevention management is also targeted in the second phase. Relapse prevention management includes establishing a network-based relapse prevention plan, which involves outlining strategies to support family members and the patient in the eventuality of drug relapse (Copello & Walsh, 2016). The third phase of SBNT focuses on planning for the future upon completion of the intervention as well as maintaining treatment goals (Williamson, Smith, Orford, Copello, & Day, 2007).

The feasibility of implementing SBNT within a drug treatment practice was tested in the UK, with a sample of 12 therapists who were trained and applied SBNT in their practice on 24 clients (Copello, Williamson, Orford & Day, 2006). Findings from Copello, Williamson, Orford and Day’s (2006) study demonstrated that SBNT is feasible for treating drug users and most of the trained therapists were able to apply the intervention in practice. The clients were also able to engage a supportive network among family members and friends, who were prepared to support their efforts towards behaviour change. Evaluation of the effect of SBNT on the clients’ treatment progress showed a significant reduction in drug abuse, especially heroin, as well as a reduction in level of dependence. Significant changes were also noted in the family environment after the implementation of SBNT, with increases in family cohesion, reductions in open conflict and increase in total family satisfaction. These changes in the family environment are subsequently, conducive towards supporting further change in the client’s drug abuse behaviour. Nevertheless, it was noted that there were a few challenges that required greater attention among therapists applying the SBNT, especially in the area of client confidentiality, communication, conflict resolution and control (Williamson et al., 2007).

BCT is a manual-based behavioural and psychological treatment that recently gained a comeback in the UK (Geel, 2016). It is an evidence-based couple therapy intervention for drug users and their spouse or partners and consists of four phases of treatment, which are divided into 12–20 weekly couple sessions (Geel, 2016; Ruff, McComb, Coker & Sprenkle, 2010). Fundamentally, BCT works best when only one partner has the drug abuse behaviour and both partners want to achieve abstinence but can be applied with more complex conditions such as both partners being involved in drug abuse as well as diagnosis of co-morbid psychological and psychiatric disorders. The first phase is engagement, whereby the therapist will obtain the client’s consent to contact their spouse or partner and invite them to attend a joint interview (Ruff, McComb, Coker & Sprenkle, 2010). An assessment of the couple’s suitability for BCT is then conducted in terms of motivation, commitment and goals (Geel, 2016). The second phase focuses on managing drug abuse, whereby the couple will be tasked with keeping a diary of daily drug abuse, urges and lapses, attendance in 12-step programmes or recovery meetings and methods to maintain abstinence (Geel, 2016). The third phase centres on improving the couple’s relationship through better communication as well as increasing positivity and commitment in the relationship (Ruff, McComb, Coker & Sprenkle, 2010). Communication skills, assertiveness, effective listening, conflict-resolution and problem solving techniques are instilled by the therapist to help couples manage stresses as a result of drug abuse while working on strengthening their relationship (Geel, 2016). In this phase, homework is assigned to help couples achieve set goals. The last phase is the continuing recovery stage, which focuses on developing a relapse prevention plan to maintain abstinence and recovery, with input from the couple (Ruff, McComb, Coker & Sprenkle, 2010). The role of the therapist is to help them foresee obstacles and practice strategies that should be acted on, in the event of a relapse.

The efficacy of BCT in treating drug or alcohol abuse was reviewed by Ruff, McComb, Coker and Sprenkle (2010) through a selection of 23 studies that have demonstrated its efficacy in primary (marital adjustment and drug use outcomes) and secondary outcomes (intimate partner violence and children’s psychosocial functioning). Based on past research evidences, it was concluded that couple-based interventions such as BCT are consistently more efficacious than individual-based interventions and BCT is able to create changes across a range of outcome measures. For instance, BCT consistently helped improve marital adjustment over time with the inclusion of relapse prevention and was more effective in improving drug use outcomes as compared to individual-based interventions. In addition, there was a significant decrease in male-to-female physical aggression couples who received BCT interventions as compared to individual-based interventions at the 12-month follow-up. In terms of the secondary effect of BCT on children’s psychosocial functioning, children of fathers who received BCT had higher levels of psychosocial functioning as compared to fathers who received intensive individual-based interventions or psychoeducation (Ruff, McComb, Coker & Sprenkle, 2010).

Due to the impact of drug abuse on drug users, their family and community, there is a growing need to shift the mindset and treatment approach from the traditional CBT and individual-based interventions to a more interpersonal and systemic approach (Geel, 2016). The growth and development of network-based or couple-oriented therapies would also provide service users (i.e., drug rehab patients, family members and close social networks) with a wider range of evidence-based methods to treat and cope with drug abuse and relapse.

8. Predictors of treatment outcomes

Past research investigating the predictors of rehab treatment outcomes in the UK and US found that longer treatment duration, treatment completion and proper aftercare services were key determinants of positive treatment outcomes (Gossop, Marsden, Stewart & Rolfe, 1999; Reno, Holder Jr., Marcus & Leary, 2000). Longer treatment duration was also predictive of better treatment outcomes. British patients who remained in treatment had five times greater odds of remaining abstinent from drugs such as opiates, psycho-stimulants and benzodiazepines (Gossop, Marsden, Stewart & Rolfe, 1999). Patients who completed treatment were more likely to remain drug free, have lower relapse rates, less unemployment, and decreased arrests as compared to patients who dropped out (Stark, 1992). A US study by Dasinger, Shane and Martinovich (2004) also found a strong association in reduction of drug intake (3-months post-intake versus intake levels pre-treatment) with treatment duration and type of rehabilitation. The greatest percentage of reduction in drug abuse was found in long-term residential centres (85%), followed by short-term residential centres (71%) and outpatient programmes (30%).

A qualitative study by Nyamathi et al (2007) further examined factors that facilitated or prevented 54 drug-using homeless youth from seeking or continuing drug treatment services in Los Angeles, US. This study confirmed that systematic or structural factors, such as mentoring, support groups and education on alternative choices to drug abuse, facilitated treatment and rehabilitation among drug-using youths. Other factors that facilitated treatment, which were captured through focus group interviews, include the personal decision to stop using drugs; experiencing the negative impact of drug abuse such as paranoia, hallucinations and skin abscesses; having a non-judgmental listener to help in resolving problems, and experiencing an epiphany about their life decisions. Engagement in creative or physical activity was also advocated among homeless youths who disliked having an authority figure dictating them to stop drug abuse, as it empowered them when they experienced emotional issues such as anxiety. Empowerment through creative or physical means was viewed as a healthier alternative to using drugs. In addition, personal shame and pain caused to family members and friends due to drug abuse helped strengthened the youths’ resolve to seek and complete drug rehab treatment (Nyamathi et al., 2007).

In Malaysia, low motivation to change drug abuse behaviour is a persistent barrier to successful drug abuse treatment since most drug users are often in rehab under court orders. International and local studies (Fauziah et al., 2010; Miller & Rollnick, 2013; SAMHSA, 2012; Thompson & Thompson, 1993) indicated that motivation is an important predictor of successful treatment. As such, the current study also examined factors that motivated rehab patients to change drug abuse behaviour. According to Thompson and Thompson (1993), motivation to change happens when an event transforms the emotional and cognitive component of the drug user’s attitude. This statement was supported by Miller and Rollnick (2013), who redefined motivation as a purposeful, intentional, and positive experience that is directed towards enhancing interests of the self by fully committing to a change strategy (Miller & Rollnick, 2013). Motivation is a complex and dynamic state that is influenced by the internal desire of the individual, external pressure and goals, the individual’s perceptions of benefits and risks of new behaviour, and cognitive evaluation of the situation (SAMHSA, 2012). There are five categories of life experiences that could increase or decrease an individual’s motivation to change: (a) distress levels (e.g., anxiety and depressive episodes); (b) critical life events (e.g., religious conversion and death of a loved one); (c) cognitive evaluation (i.e., impact of change); (d) recognising negative consequences (e.g., harm and hurt experienced by the self and others due to drug abuse), and (e) positive and negative external incentives (e.g., rewards, social support or stigmatisation). For instance, drug users may experience high motivation to change drug abuse behaviour when they have strong internal desire, strong support from family, friends, or the community; and acknowledged the impact of drug abuse towards the self and their family. However, drug users may experience low motivation to change drug abuse behaviour when there is a lack of community support, barriers to employment, and negative public perception of drug abuse (SAMHSA, 2012). From the research evidences above, it is clear that in-depth research on factors influencing rehab patients’ motivation to change, and treatment interventions that could improve motivation levels and treatment outcomes is much needed in Malaysia.

9. Evaluation of patient satisfaction

A review of available literature on patient satisfaction evaluation in Vietnam, UK and the US (Alden, Hoa, & Bhawuk, 2004; Ruggeri, 2001; Simpson, 2004) indicated that assessment of patient satisfaction with treatment is an essential element in evaluating healthcare quality across a wide span of health conditions and service provision. However, the use of patient satisfaction measures to assess the treatment process and outcome of drug rehab patients has been lagging behind within the behavioural health care field (Ruggeri, 2001). Limited research in this area could have stemmed from the belief that patient satisfaction was an independent factor towards rehab treatment outcomes, and was secondary to the counselling relationship (Simpson, 2004).

Available literature on patient satisfaction with drug rehab treatment in the US has largely yielded limited and inconsistent findings (Zhang, Gerstein & Friedmann, 2008). Past studies have generally found a weak relationship between patient satisfaction with treatment participation and outcomes (McLellan & Hunkeler, 1998). Matched service needs was found to associated with the perception that treatment was helpful but not associated with reduced drug abuse, in a survey conducted by Smith and Marsh (2002) on drug rehab treatment within an Illinois welfare system. A study of 36 community-based programmes in California by Hser, Evans, Huang and Anglin (2004) found positive relationships between service intensity and patient satisfaction with treatment, in which both variables were correlated with longer duration of treatment and the completion of planned treatment.

A research project by Zhang, Gerstein and Friedmann (2008), which was funded by the US Center for Substance Abuse Treatment, examined the clinical significance of patient satisfaction with treatment using a series of computer-assisted interviews. It involved a final sample of 3255 admitted patients from 62 community-based treatment delivery units. This study found that favourable evaluation of treatment at the time nearing discharge from treatment had a significant positive relationship with reduction in drug use outcomes one year post-treatment. This finding was independent of the measured effects of predictors like treatment duration, counselling hours and intensity, agreement and adherence to treatment goals, and baseline drug use.

In Malaysia, Ghani et al., (2015) conducted an explorative qualitative study of 20 drug rehab patients who underwent voluntary treatment. This study assessed patients’ satisfaction and obtained feedback on the Cure and Care treatment model, which was implemented in 2010. Positive treatment experiences were reported by patients when a holistic approach to treatment (i.e., an integration of religious teachings, psychosocial interventions, methadone maintenance treatment, healthcare provisions and recreational activities) was used. This study found that there was high satisfaction with the progress of recovery and services provided, such as an increase in accessibility to medical services. Furthermore, treatment adherence was fostered with the presence of an open environment that allowed the formation of close and trusting relationships among patients and staff. Despite being satisfied and optimistic about their progress, the patients expressed hesitation and uncertainty about their future. In general, there are limited studies providing an in-depth exploration of patient satisfaction with drug rehab treatment in Malaysia, with this study by Ghani et al., (2015) being the exception. The current study takes a step further by utilising a mixed method approach to patient satisfaction evaluation. Quantitative ratings were cross-checked against qualitative feedback about drug rehab programmes to establish validity in findings. Besides the patients’ perspective, the current study also acquired feedback from rehab staff to gain insight into the overlap and differences between patient and staff expectations.

10.   Reasons and predictors of drug relapse

Drug relapse was described by Ibrahim and Kumar (2009) as a psychologically and physically complex and volatile process, which involves the use and misuse of psychoactive drugs after receiving drug addiction treatment and rehabilitation. However, Shafiei, Hoseini, Bibak and Azmal (2014) viewed that the concept of relapse has changed over the years. It is more commonly viewed as a failure in the recovery process or as the result of prior detrimental actions that predisposes the individual to relapse (Shafiei, Hoseini, Bibak & Azmal, 2014). In Malaysia, high relapse rates in drug abuse continue to be an obstacle towards rehabilitative treatment. A study by Mohamad and Mustafa (2001) demonstrated that 90% of heroin addiction cases in Malaysia relapsed within six months after discharge from treatment. Moreover, patients who successfully completed rehabilitation also contributed to relapsed cases. This phenomenon was similarly observed by Habil (2001), who proposed that more than 70% of drug rehab patients would probably relapse. Despite the successful outcomes of some rehabilitation programmes in Malaysia, the overall rate of relapse within the first year of discharge was still at a high 70% to 90% (Reid, Kamarulzaman & Sran, 2007).

The current study explored students’ perceptions about factors that led to drug relapse. Students’ perceptions were compared against drug relapse factors obtained through semi-structured interviews with rehab patients and staff, to understand similarities and differences between perception and actual experience of drug abuse. A preliminary study by Ibrahim, Samah, Talib, and Sabran (2009) examined factors for relapse among rehabilitated drug users in Peninsular Malaysia and found that the three primary predictors of relapse were low levels of self-confidence (62.4%), limited social support (2.2%) and poor family support (0.7%). However, their study was criticised for potential bias or uncertainty due to the use of stepwise regression (Whittingham, Stephens, Bradbury, & Freckleton, 2006). The relationship between intrapersonal factors like low levels of self-confidence and the risk of drug relapse is closely associated with interpersonal factors such as familial and social support (El-Sheikh & Bashir, 2004). As the rehabilitated patient re-enter society and face social isolation from family members and their close social networks, the patient may experience a drop in self-confidence and relapse into drug abuse to seek comfort from feelings of frustration, desperation and stigmatisation (El-Sheikh & Bashir, 2004). The lack of social support as one of the catalyst to drug relapse was also reported in a qualitative study by Yang, Mamy, Gao and Xiao (2015). Their in-depth exploration of drug users’ experience during abstinence as well as the real-life catalysts to drug relapse in a sample of 20 drug rehab patients in Changsha, China revealed that the feelings of loneliness, emptiness, helplessness and hopelessness that were experienced due to social isolation and exclusion from family and friends, as well as the lack of social support were important predictors of subsequent drug relapse.

Besides lacking self-confidence and social support, a mixed methods research by Wang and Wang (2007) examined direct causes of drug relapse, in a broader range, among drug rehab patients who were admitted to a detoxification centre in Wuhan, China. Significant predictors of relapse found in this study comprised a variety of environmental factors and psychological factors, such as the urge to use drugs again on their own or via peer influence, family conflicts, unemployment, seeking pleasure and escape from reality through drug abuse, mental stress, feelings of irritation, lack of care, love and trust from the family, as well as perceived demoralisation and discrimination by the society. Out of these possible causes, environmental factors such as unemployment, lack of family care, love and trust, and discrimination by the society played a great part in influencing the psychological state of patients. The mental stress, feelings of irritation and depression that develop due to environmental factors, led to an increased urge to use drugs.

Lack of motivation and readiness to change are also key factors that contributed to drug relapse in Malaysia (Fauziah et al., 2010). According to the self-determination theory, (Deci, 1971; Deci & Ryan, 2011), behavioural changes which were formed naturally through intrinsic motivation were more lasting than changes which were influenced by external factors. Therefore, rehab patients who were coerced to receive treatment via court orders would have the tendency to reject treatment and experience difficulties in adopting positive behaviours to replace addictive behaviours, as compared to patients who voluntarily receive treatment due to awareness about their addiction problem. A research study by Fauziah et al., (2010) investigated the motivational readiness for change in a sample of 593 rehab patients from six drug rehab centres in Peninsular Malaysia. Their findings indicated that a majority of patients (82.8%) were aware that drug addiction was creating problems in their life and thus, wanted to make changes to their addictive behaviour. However, most patients (65.1%) still demonstrated high levels of ambivalence in regards to control over their drug behaviour and the uncertainty over whether they were really ready to change and recover from drug abuse. Additionally, 89.4% of patients reported making a few changes to their drug abuse behaviour but required additional help to avoid relapsing. Fauziah et al.’s (2010) study is pivotal in establishing the importance of employing other therapeutic methods such as motivational interviewing (MI), which would help drug rehab patients to explore the pros and cons of drug misuse to resolve ambivalence, initiate behaviour change when they are prepared to do so and help them deal with relapse when it occurs (Miller & Rollnick, 2013).

Scorzelli (2007) reviewed evidence about potential causes of relapse within the Malaysian context and suggested that the factors largely fall into personality correlates (i.e., depression and anti-social behaviour) and environmental factors (i.e., family dysfunctions and unemployment). Out of these, employment issues and the need for anxiety reduction were two constant factors that consistently led to relapse (Scorzelli, 2007). Additionally, Scorzelli (2009) proposed that the provision of low levels of vocational training in rehabilitative treatment services led to a higher risk of relapse as it significantly affects chances for employment. In turn, unemployment would increase the risk of drug relapse during and after rehabilitative treatment. This statement was supported by Zemlin and Henkel (2006), who found that 45% of rehab patients in Germany who were unemployed relapsed during the first 6 months after treatment as compared to 23% of employed patients who relapsed. Furthermore, the unemployed relapse more severely and significantly earlier than patients who were successfully employed. A meta-analysis by Brewer, Catalano, Haggerty, Gainey and Fleming (1998) identified patient-related factors that influence drug abuse during and after treatment. The factors identified include high levels of drug abuse at pre-treatment stage, prior treatment history, no previous abstinence from drugs, associations with drug-abusing peers, depression, high stress, short length of treatment or leaving treatment before completion and unemployment issues.

A recent study by Shafiei, Hoseini, Bibak and Azmal (2014) examined high-risk situations that predicted drug relapse among self-referred addicts in Iran. Their findings concurred with the view of Scorzelli (2007), in which both personality correlates and environmental factors played a role towards drug relapse. Among the Iranian rehab patients, unpleasant emotions (i.e., anger, frustration, boredom, sadness or anxiety) and physical discomfort (i.e., pain and illnesses) were the main triggers for relapse. In addition, interpersonal factors such as social conflict, social pressure and stressful times were also high-risk factors associated with resumed drug abuse.

Research has shown that counselors are poor predictors of their own patients’ relapse risk. Walton, Blow and Booth (2000) examined perceptions of drug relapse risk from the perspective of patients and counsellors in the US and found that in contrast to reports from the counsellors, patients reported greater confidence of not relapsing and requested greater needs for services (i.e., coping skills, social support, resources, and leisure activities). There were also major differences on views related to causes of relapse, with counsellors viewing level of income as a determinant, whereas patients rated multiple drug abuse as a major relapse factor. This study found that counsellors’ overall ratings were not predictive of drug relapse. However, one notable finding was that patients’ ratings of social support predicted drug relapse. This finding strongly supports the role of positive social networks in patients’ ability to recover from drug addiction.

11.  Drug prevention education in school

Although youths may be gaining awareness on drug risks, especially when a family member or friend is using drugs, they are less aware of other situations in which they could be in contact with drugs such as the school premises (Robers, Kemp & Truman, 2013) and during socialisation (Dishion & Owen, 2002). When youths enter college, they develop a more accepting attitude towards drug abuse and become more laid-back towards the risks and harm of drug abuse (Nebhinani, Nebhinani, Misra, & Grewal, 2013). This attitude change was supported by an Irish nation-wide survey on drug-related knowledge, beliefs and attitudes conducted by Bryan, Moran, Farrell and O’Brien (2000), which found that youths, higher educated individuals and people who had personal acquaintance with a drug user were found to have more positive attitudes towards drug abuse. To prevent the spread of normalisation, schools and college need to address the psychosocial and behavioural aspects of drug abuse through tailored prevention education (Lilja, Wilhelmsen, Larsson, & Hamilton, 2003). Furthermore, resources to disseminate accurate information about prevention strategies and contact information of treatment providers should be explored. Effective drug prevention programmes should be evidence-based, meet the needs of the community, and involve all relevant parties from grassroots to community leaders besides being monitored and evaluated consistently (UNODC, 2013).

Examination of literature related to knowledge and drug awareness among school children yielded a study by the Department for National Drug Control and Bermuda Ministry of Education. The study examined drug knowledge and awareness, reasons for drug abuse and accessibility among school children aged 8 to 14 years (Department for National Drug Control, 2013). The accuracy of drug perceptions as well as frequency and prevalence of drug abuse were also investigated. Most students believed that drug addiction would manifest only after using drugs multiple times. The students’ perception on drug abuse factors was that youth use drugs because their peers use it and due to parental influence. Only 1.3% felt that youth would use drugs because it makes them look cool. Patterns of lifetime use indicate that prevalence of drug abuse increases with advancement in school grades and 33.3% of students reported having used at least one drug in their lifetime. This was despite the fact that 70.1% of students were aware about the harm of drugs. The majority of the students (67.5%) were unsure about the accessibility of drugs. A higher proportion of boys (4.8%) indicated it was easy to obtain marijuana as compared to 3.6% of girls. The survey also investigated the age of initiation to drugs and found an early onset of exposure to drugs with an average age of 7.6 years for inhalants and 8.3 years for marijuana. Information on the age of initiation to drugs and the lack of knowledge among school children in differentiating drugs and its accessibility highlights the urgent need to educate youths from a young age to prevent them from unknowingly taking illicit drugs. As such, plans and implementation of drug education in Malaysian schools was initiated in 1998 under the National Anti-Drug Policy (Tay, 1999).

In 1995, a survey was conducted by the Malaysian Anti-Narcotics Task Force to obtain feedback from students, youths, parents and educators about relevant topics that should be included into drug prevention programmes (Tay, 1996). The topics outlined risk factors, the effect of drugs on the individual, consequences of drug abuse on family relationships, friendships, religion, race and country and ways to refuse drugs. Besides this, participants were asked to consider the importance of school counselling and parenting skills as part of prevention education. More than 80% agreed to all the topics listed but only 60% of the total participants reported that it was important to know about the classification of drugs. Most educators (83.8%) considered counselling skills to be very important and this attitude resulted in the installation of a counselling unit in every school within the country as seen today.

With the co-operation of the Malaysian Education Ministry, teachers were provided training related to drug education and managing student-related drug cases (Tay, 1999). Plans were also made to integrate drug prevention education into the national curriculum through subjects such as art, sciences, physical and health education, mathematics, moral education, history, living skills and languages (Tay, 1999). The Education Ministry also collaborated with NADA, Institute for Medical Research and the Anti-Narcotics Unit under the Royal Malaysian Police in adopting and implementing a drug prevention education programme from the US, known as STRIDE, at the primary education level (Hanjeet, Wan Rozita, How, Raj & Omar, 2007). This intervention aimed to build and enhance interpersonal skills among primary school children from an early age and develop their resilience towards drugs through a series of physical and health education curriculums (Hanjeet et al., 2007). The programme was run for three months in nine schools from three states in Malaysia and commenced with a camp to instil leadership skills and build mental, physical and spiritual resilience. This was followed by a structured programme in school whereby activities such as lectures, dialogues, question and answer sessions, role playing and physical activities were organised.

A pre-and-post evaluation of students’ drug knowledge, attitude and practices was conducted and positive improvements were found in knowledge about drug trafficking laws, risk factors, drug users’ behaviour, and health risks due to drug abuse (Tay, 1999). However, this research discovered some unexpected outcomes of the programme in regards to students’ attitude towards drug abuse and drug users. At post-evaluation, a higher percentage of students viewed that it was safe to have drug traffickers in their peer network and thought that occasional use of drugs will not be harmful as compared to pre-evaluation. This finding highlights the importance of content evaluation in which field experts should be brought in to evaluate the contents of prevention programmes to ensure that the right message is being presented to school children.

In Malaysia, NADA has played an active role in educating the young about drug abuse through drug prevention programmes conducted at all levels encompassing pre-school (TUNAS), primary school (CEGAH, INTEM camp and PEDAS) as well as colleges and universities (NADA, 2010; 2012). Although drug prevention education at tertiary education level are mostly carried out at will of the institution in most countries, NADA developed and implemented two drug prevention programmes for public and private universities (NADA, 2012). In 2012, 5867 youths attended the SHIELDS programme while 22,243 youths and adults participated in the Tomorrow’s Leader programme. Until now, there has been limited supportive literature on the appropriate age to initiate drug prevention education among young children. Thus, most government agencies and NGOs involved in drug prevention efforts design programmes to suit a variety of age groups. With the huge amount of money that goes into financing drug prevention programmes, a core question that arises is whether this approach is sufficiently cost-effective and evidence-based to conduct drug prevention education? A report by Miller and Hendrie (2008) states that school-based prevention in the US costs 220 dollars per student including teacher training. Although 80% of American youths reported having participated in prevention programmes in 2005, only 20% of students were exposed to effective prevention education (Miller & Hendrie, 2008). Subsequently, the Global Commission on Drugs Policy (2011) proposed that successful prevention programmes are those targeted towards specific at-risk groups. Simplistic ‘just say no’ messages or ‘zero tolerance’ policies should be avoided in favour of educational programmes grounded with credible information, and prevention efforts focused on building social skills and resisting negative peer influence (Miller & Hendrie, 2008).

As shown in the research evidences above, most local and international studies provided recommendations and implemented policies for drug prevention education solely based on expert opinion. The current study took a step further by having students evaluate the strengths and limitations of past drug prevention programmes in school. In addition, feedback on methods to improve drug education programmes was sought from the perspective of students.

12.        Drug prevention interventions at tertiary level

There is growing evidence of a normalisation phenomenon in the area of youth experimentation with drugs. It was to the extent that law-abiding individuals socially-reconstruct the act of using and supplying recreational drugs as a normal lifestyle event, despite the act being illegal and carrying severe punishment (Bryan, Moran, Farrell & O’Brien, 2000; Parker, Williams & Aldridge, 2002; Larimer, Kilmer & Lee, 2005). The socio-cultural accommodation of drug abuse by the society partly contributes to the continuous phenomenon of drug abuse (Parker, Williams & Aldridge, 2002). Besides schools, colleges and universities also have vital roles to play to ensure adolescents, young adults and the general public view illicit drug abuse and relapse as a serious public health issue (Polymerou, 2007). They have the responsibility to keep youths and parents updated with information about the harms and legal consequences of drug abuse. To regulate prevention at the tertiary level, a leading UK charity support group and resource on drugs and drug-related issues called DrugScope, developed guidelines to aid colleges and universities in developing drug education practices in 2004 (Polymerou, 2007).

A study across college campuses in the US found that students have the tendency to overestimate the frequency and quantity of drug abuse by peers (Perkins, Haines & Rice, 2005). Thus, most drug prevention programmes focus on trying to change these misconceptions. There is substantial evidence indicating social norms interventions as an effective strategy in preventing cannabis use among young people (Zhao et al., 2006). This intervention involves targeting misconceptions about the social norms of drug use and providing students with personalised normative feedback (i.e., information about actual drug use norms). A brief version of MI was developed with the aim of prevention for young people at the early stage by helping them make informed decisions, facilitate reduction in drug intake and prevent further involvement in drugs. The effect of MI on reducing drug intake and drug-related risks was examined by McCambridge and Strang (2004) in 10 colleges within London, UK. It was shown that students who received MI interventions reduced their intake of cannabis, other drugs and drugs such as alcohol and nicotine at 3-months follow-up in comparison with students who received the usual prevention education syllabus. Moreover, there were positive changes in students’ perceptions of risk and harm.

A recent study by Heckman, Dykstra and Collins (2011) examined the impact of a drugs and behaviour course on drug-related knowledge, attitude and behaviour of college students from a Midwestern university in the US. The course, which was not part of a drug prevention programme, was conducted twice a week in 1.25-hour sessions for 16 weeks. Content of the drugs and behaviour course covered the major classes of recreational drugs such as opioids, alcohol, marijuana, stimulants, hallucinogens, inhalants and club drugs. The college students were provided exposure to the drug history and nature, pharmacology, the positive and negative effects (psychotropic and health), addiction issues, prevention, treatment approaches, drug regulation and enforcement as well as current issues such as the legalisation of marijuana. The course was conducted in lecture format via PowerPoint slides, videos and guest panels. The pre-and post-test showed that while the drugs and behaviour course students had similar levels of knowledge about drugs as students from other courses at the start, their level of knowledge increased over the duration of the course. Heckman, Dykstra and Collins’ (2011) study also indicated that students who have prior exposure to drug abuse during college were more aware of the negative impact of drug abuse. Further measurements of physical and mental health indicated that there was a decrease in affective well-being among students during the semester due to stress from academic pressures. Gender-wise, male college students were more at-risk of drug abuse as a stress-coping measure as compared to female college students. Comparatively, the positive expectancies for marijuana decreased among male students from other courses, but remained constant for male students in the drugs and behaviour course. A possible explanation for this was that male students in the drugs and behaviour course received in-depth exposure to various types of drugs that were viewed as more harmful than marijuana as compared to students in other classes.

As mentioned earlier, NADA implemented two drug prevention programmes (i.e., SHIELDS and Tomorrow’s Leader) for public and private universities in Malaysia (NADA, 2012). Additional drug awareness and prevention campaigns are often conducted at the will of counselling units in colleges and universities. Unfortunately, there is limited research studies or reports on the impact of drug prevention education conducted in higher education institutions in Malaysia. Thus, comparisons between drug prevention education conducted in colleges and universities in Malaysia and other countries like the US and UK were not feasible.

13.        Bridging the literature to the current study: Exploring the research issues

From the literature, eight research issues in drug abuse and relapse were identified within the Malaysian context. The current study explores these issues through a mixed methods approach, with attempts to validate findings across multiple sources. Firstly, most statistics report on drug types are based on drug users who were admitted into rehab due to severe addiction. This could have resulted in a general misconception that only physically addictive drugs (e.g., heroin, amphetamine, methamphetamine and cocaine) are commonly abused within the community. There is an evident lack of information about drug trends (i.e., drug types that are commonly used and easily available) from the community perspective. Yet, greater insight about drug trends could be better gauged from the personal observations of the community and at-risk groups such as university students.

Secondly, there is limited literature examining factors for drug abuse, drug relapse and relapse prevention strategies across multiple perspectives (i.e., the experiences of drug rehab patients as well as perceptions of students with no drug abuse experience and treatment providers), which is a prudent point for exploration in this study. A review of literature in the US revealed a bulk of literature involving drug user populations, and research studies that involved treatment providers were mostly focused on drug abuse problems within prisons, psychiatric settings and the community (Cantwell & Harrison, 1996). Literature focusing on staff perceptions and attitudes towards patients’ drug abuse in primary treatment settings, such as clinics, hospitals and rehab centres are rather scant in number (Barry, Tudway & Blissett, 2002). A similar situation is found in Malaysia. In addition, there has been limited research exploring drug abuse, drug relapse and relapse prevention from the perception of university students who had no prior experience with illicit drug abuse. Past research involving normal populations focused on their reasons for not using illicit drugs (Sanchez, Oliveira & Nappo, 2005) as well as perception of risk, which are considered key factors in the decision of whether or not to use a drug (Bejarano et al., 2011). It would be of interest to investigate whether university students in the current study indeed had a lesser sense of drug availability than drug users like Bejarano et al.’s (2011) study.

Most literature in both Western and Asian settings focused on descriptions of lived experiences from recovered patients or drug users under rehab, which provided a good grasp of the reality of illicit drug abuse. However, the huge gap in literature involving perceptions of treatment providers and populations with no drug abuse experience has led to difficulties in comparing the differences between perception and reality. Nevertheless, it is imperative to accurately understand public perception about illicit drug abuse since public opinion has the ability to influence decision-making and health policies (Matthew-Simmons, Love and Ritter, 2008). As such, the current study will compare findings from the university student sample with accounts from drug rehab patients and staff to establish similarities and differences in perception and real-life experiences with drug abuse. Findings related to the first and second research issue have important implications towards public education. It can help re-emphasise the important role of parents and family bonds in drug abuse prevention and provide direction in tailoring prevention messages. Increasing the level of awareness among university students on the easy availability of illegal drugs and potentially dangerous situations when socialising, could help reduce their susceptibility to drug abuse and dependency.

Thirdly, the lack of more recent studies on drug relapse in a Malaysian context (e.g., Habil, 2001; Reid, Kamarulzaman & Sran, 2007; Scorzelli, 2009) has also made it essential to examine the issue of drug relapse across multiple perspectives. Fourthly, there are limited behavioural research on information searching and sharing in the area of drug abuse and prevention. To promote effective ways of spreading drug prevention messages and public education, it is important to understand the habits of information users in Malaysia such as the frequency of searching and sharing information, the preferred medium, and its reasons.

Fifthly, the issue of limited documentation related to drug prevention activities in schools, colleges and universities needs to be addressed. It is generally understood that school and university students are most at-risk for drug abuse. This was by virtue of neurodevelopmental factors that could heighten the risk of behavioural problems, and having to cope with individual, interpersonal, academic and societal demands. These demands include leaving home, becoming independent and responsible, building a new network of friends, peer pressure for undergraduate students as well as juggling work, studies and family commitments for mature students (Larimer, Kilmer & Lee, 2005). For this reason, proper evaluation of prevention programmes with a focus on the quality of content, effectiveness and efficacy, is essential towards ensuring that college and university students are adequately equipped against high-risk behaviours. This study attempts to explore this issue by getting qualitative feedback from undergraduate and postgraduate university students about their experiences with drug education and prevention programmes. This is done while acknowledging recent improvements made in the content of drug education programmes.

The sixth issue was limited information about the prevalence of drug abuse progression in Malaysia, which this study is exploring through records of patients’ drug use history. Through interviews with patients, this study also endeavours to establish the relevance of family factors and peer influence as factors for drug abuse and drug relapse in the presence of new social contexts, resulting from technological growth and the growing detachment in human relationships. The presence of less publicised factors for drug abuse is explored thematically through patients’ responses and cross-referenced against the perspective of drug rehab staff.

The seventh issue was limited research about drug rehab patients’ motivation and readiness to change in the Malaysian setting, despite wide publication in Western literature as important influencers of treatment outcomes. Thus, this study attempts to explore patients’ motivation to change and the reasons that prompt patients to enter treatment through a qualitative approach. The findings are cross-referenced with findings from drug rehab staff.

Lastly, the practice of evaluating patient satisfaction with drug rehab treatment is still under-utilised in Malaysia. This study attempts to evaluate patient satisfaction through the collection of feedback from drug rehab patients via assessments of clinical sessions, patient satisfaction scores, and qualitative responses on the strengths, limitations and suggestions for improving treatment components and the overall system. Feedback from patients are then cross-referenced with findings from drug rehab staff, in their role as treatment providers. Quantitative measures of the patients’ level of assertiveness against drugs and opinions about the perceived probability of relapse are also collected to ascertain the impact of drug rehab treatment on patients.

14.        Research aims and objectives

The aims of the current study are as follows:

1. To obtain insights into issues related to drug abuse and relapse in Malaysia from different perspectives (i.e., university students who do not use drugs, drug users and rehab staff);
2. To understand knowledge gaps in drug prevention education; and
3. To evaluate patient satisfaction with treatment in a government and private drug rehab centre.

These aims were fulfilled by achieving the following objectives:

1. To investigate the presence of gender differences in university students’ perceptions about factors for drug abuse and relapse, as well as relapse prevention strategies.
2. To examine awareness and beliefs about treatment services in government and private rehab centres among university students.
3. To examine university students’ perceptions about commonly abused and easily accessible drug types.
4. To investigate university students’ preferred information resources for searching and sharing information about drug prevention and treatment.
5. To explore students’ perceptions about drug prevention education in school and their experiences with past prevention programmes.
6. To gain a deeper understanding of drug abuse patterns, treatment history, and family and peer relationships among drug rehab patients.
7. To examine rehab patients’ perceptions of their ability to decline drug offers.
8. To examine similarities and differences between drug rehab patients and rehab staff on issues related to drug abuse and drug relapse factors, motivation to change drug abuse behaviour and reasons for seeking treatment.
9. To explore multi-perspective ratings (rehab patients versus staff) of satisfaction and compare it against patients’ evaluation of treatment sessions using a Session Evaluation Questionnaire.
10. To analyse qualitative feedback from rehab patients and staff on the useful components, limitations and areas for improving existing drug rehab programmes.
    15.        Research questions and predictions

A set of research questions, in line with the research aim and objectives, was generated according to the sample groups investigated, namely university students, rehab patients and rehab staff. As mentioned earlier, no specific hypotheses or predictions were formed at the start of research in line with the principle of grounded theory (Glaser & Strauss, 1967). This measure ensured that the researcher remains sensitive to the data, by detecting and recording events without filtering them through pre-existing hypotheses and biases (Glaser, 1978). However, a set of predictions were formed in response to the research questions after analysing data from the pilot survey and focus group interviews.

1. University students

Research Question 1: What is the difference in perception of drug abuse and relapse factors, and effective relapse prevention strategies between male and female university students? (Quantitative)

Prediction 1: It was predicted that female students were significantly more likely to perceive factors related to problem and coping, sensation-seeking, and the social environment as reasons for drug abuse. However, male students were more likely to perceive disposition and social environment factors as reasons for drug abuse. Additionally, it was expected that there would be no significant differences in perception of drug relapse factors. In terms of relapse prevention strategies, it was predicted that female students were significantly more likely to perceive social activity, change and help-seeking strategies as effective. In contrast, male students were more likely to perceive change and avoidance strategies as effective methods of preventing drug relapse.

Research Question 2: What proportion of university students have knowledge about drug rehabilitation and believe private rehab centres are more effective? (Quantitative)

Prediction 2: It was predicted that a higher percentage of university students would report having knowledge about drug rehabilitation and believe that services at private rehab centres were more effective.

Research Question 3: Which drugs are rated as the most commonly abused and easily available by university students? (Quantitative)

Prediction 3: It was expected that university students would perceive ecstasy and cannabis as drugs which were most commonly abused and easily available.

Research Question 4: Which information resource is most favoured by university students to learn and share information about drug abuse? (Mixed method)

Prediction 4: It was predicted that internet resources such as websites and blogs would be most favoured by university students to learn about drug abuse, drug prevention and rehab treatment. In addition, it was expected that social media networks such as Facebook and Twitter would be favoured by university students for sharing information.

Research Question 5: What is the difference in university students’ actual and perceived age and school grade of exposure to drug prevention education and their perceptions on past prevention programmes? (Mixed method)

Prediction 5: It was predicted that there would be no significant difference in university students’ actual and perceived age and school grade of exposure to drug prevention education. In addition, it was expected that students would perceive drug prevention education as useful in spreading awareness about drug abuse, building resilience against drug offers, and moulding attitudes towards drug users through documentaries and various drug prevention activities.

2. Rehab patients and staff

Research Question 6: What user patterns would emerge in regards to drug abuse progression, and conditions of family and peer relationships? (Mixed method)

Prediction 6: It was predicted that drug rehab patients would demonstrate a pattern of drug abuse progression (from soft to hard drugs). In addition, it was expected that patients and their peers would have poor relationships with their family.

 

Research Question 7: What are the levels of assertiveness against drugs exhibited by rehab patients at the point of treatment? (Quantitative)

Prediction 7: It was predicted that a majority of drug rehab patients would report feeling assertive against drug offers; followed by patients who reported feeling extremely non-assertive. Only a minority of patients would report feeling extremely assertive against drug offers.

Research Question 8: To what extent are rehab patients’ responses about factors for drug abuse, drug relapse, and entering treatment similar and different to responses from the rehab staff, and what factors would motivate patients to change drug abuse behaviour? (Qualitative)

Prediction 8: It was expected that there would be large similarities and moderate differences in patients’ and staff’s responses about factors for drug abuse, drug relapse and entering treatment. It was predicted that most patients would have no motivation to change at the start of treatment because they were admitted through court orders. For patients who had motivation, it was predicted that the impact of drug abuse, religion and personal wishes would be important factors for change.

Research Question 9: What is the difference in treatment satisfaction scores between patients and rehab staff and patients’ perception of their level of satisfaction? (Mixed method)

Prediction 9: It was expected that there would be no significant difference in treatment satisfaction scores between rehab patients and staff. Nevertheless, patients’ mean score would be consistently lower than the staff. It was also predicted that most patients would report being feeling satisfied with the treatment across the four dimensions of depth (value of content), smoothness (well-conducted, pleasant and ease of understanding), positivity (providing positive messages and encouragement), and arousal (empowerment, focus and confidence). However, it was also expected that there would be issues leading to dissatisfaction among patients, such as inconsistent depth of content during group counselling sessions, unexpected changes or cancellation of treatment sessions, and non-arrival of counsellors for unspecified reasons.

Research Question 10: To what extent are rehab patients’ responses about favourable treatment components, treatment limitations and suggestions for improvements similar and different to responses from the rehab staff? (Qualitative)

Prediction 10: It is predicted that there would be major similarities in themes between patients’ and staff’s responses on favourable treatment components. However, it is expected that there would be major differences in themes related to treatment limitations and suggestions for improvement as the experience with treatment would differ according to the perspective of patients or staff.

16.   Chapter summary

To recap, Chapter 1 provided an introduction to the trends and current situation of drug abuse and relapse in Malaysia as well as justifications for continuous research in the field of drug abuse. In Chapter 2, past studies across twelve research areas were reviewed: (a) type of drugs commonly used and easily accessible; (b) progression of drug abuse; (c) contributory factors of drug abuse; (d) choices of drug information resources; (e) perception, knowledge and attitudes towards drug use; (f) knowledge about drug rehabilitation services; (g) treatment approaches in drug abuse; (h) predictors of treatment outcomes; (i) evaluation of patient satisfaction; (j) reasons and predictors of drug relapse; (k) drug prevention education in school; and (l) drug prevention interventions at tertiary level. In addition, eight research problems were identified and discussed in conjunction with the research aim and objectives of this study. The research questions for the university student, drug rehab patient and rehab staff samples were subsequently outlined.

In a preview of the upcoming chapters, Chapter 3 will outline the conceptual framework and methodology of this research study in detail while Chapter 4 will encompass statistical analyses and thematic analysis findings from the university student sample. In Chapter 5, mixed method findings related to factors for drug abuse and relapse, relapse prevention strategies, motivation to change and treatment admission factors from the perspective of drug rehab patients and staff is laid out. Chapter 6 will feature feedback from rehab patients and staff on patient satisfaction and drug rehab treatment evaluation. Chapter 7 comprises an integration of findings across three sample groups and the overall framework depicting how the research areas in this study fit within the drug rehab and drug prevention education systems. In Chapter 8, findings in response to the research questions, strengths and limitations of the study, future research directions and important research implications are discussed.

Chapter 3: Framework and Methodology

The current study was conducted using a mixed method approach, which involved collecting, analysing, and integrating quantitative and qualitative components in a single study. The combination of both quantitative and qualitative components provides a better understanding of research problems than either approach alone (Creswell & Plano Clark, 2011). For instance, in understanding drug abuse patterns, qualitative data is able to clearly capture the fact that poly-drug users frequently prefer particular types of drugs more than others and their preferences shift over time (Sterk & Elifson, 2005). This pattern cannot be captured by quantitative data, which focuses on measures of drug consumption such as the number of drugs used and the frequency of abuse. Quantitative data is able to identify drug types that are preferred by drug users but qualitative data is able to supplement this finding by providing a deeper understanding of the criteria that determine drug users’ choices (Sterk & Elifson, 2005). These criteria include the most frequently used drug at the point of the interview, their perception of which drug is most easily accessible, the reputation of the drug in society and the legal consequences of its use (Sterk & Elifson, 2005). The examples above clearly illustrate the benefits of conducting mixed methods studies. Thus, the mixed method approach was applied in the current study.

This study was conducted according to the following steps for mixed methods research (Collins, Onwuegbuzie, & Sutton, 2006): (a) determining the aim of the study; (b) developing the research objectives; (c) determining the research rationale and purpose; (d) determining the research questions; (e) selecting the sampling design; (f) selecting the mixed methods research design; (g) collecting quantitative and qualitative data; (h) analysing quantitative and qualitative data; (i) validating quantitative and qualitative data; (j) interpreting data; (k) writing the mixed methods findings; and (l) integrating quantitative and qualitative outcomes into a viable guideline.

The research aims and objectives, its rationale, research questions and predictions were laid out in the previous chapter. The following items are discussed in this section:

• mixed method design and grounded theory framework,
• sampling design and recruitment procedures,
• research respondents,
• research materials,
• data collection procedures,
• analytical techniques to analyse quantitative and qualitative data, and
• strategies to determine reliability and validity of quantitative and qualitative data.
  1. Mixed methods design and grounded theory framework

This study utilised a concurrent, exploratory mixed method design using purposive, multi-level sampling. A concurrent design refers to a study which collects quantitative and qualitative data within the same time frame from group samples (Onwuegbuzie & Collins, 2007). For instance, the college and university students sample were administered a survey which consists of close and open-ended items, while rehab patients and staff were asked a series of questions involving open-ended and closed-ended items (i.e., rating and ranking) in the semi-structured interviews. Besides the efficiency of collecting quantitative and qualitative data at the same time, the concurrent design was chosen due to several external conditions. Firstly, data collection involving university students had to be conducted anonymously as part of the conditions set by the Monash University Human Research Ethics Committee (MUHREC) to protect the rights of adolescents and young adults who were participating in a drug abuse research, which was categorised as a high risk research. Secondly, the qualitative component of the interview was emotionally exhausting for both rehab patients and staff. Rehab patients often had to deeply reflect on their experiences with drug abuse and treatment whereas the staff had to reflect on their working experience with rehab and honestly evaluate the strengths and failure of their treatment methods. Thus, the quantitative component of the interview (e.g., rating scales) provided a mix to the interview programme. Furthermore, each interview session had to properly fit into a fixed time frame to avoid disrupting treatment and work schedules for patients and staff. Thus, the concurrent mixed method design was deemed most appropriate.

In terms of research framework, this study applied principles from the constructivist grounded theory in its approach to the research procedure and data analysis (Charmaz, 2006). From the constructivist paradigm, there is no single underlying truth to the issue of drug abuse and relapse (Charmaz, 2006). Rather, the experience of drug abuse and relapse are as varied as the individuals who perceive or experience them. During the research process, this study adhered to three grounded theory principles: (a) to adopt an interpretative approach with flexible guidelines; (b) to emphasise understanding of values, views, beliefs, feelings and assumptions of individuals rather than methods of research; and (c) to acknowledge the role of the researcher during the process of collecting rich data, coding and developing analytical notes for analysis (Charmaz, 2006). This means that the researcher does not only play the role of an objective observer. Instead, their values, which are influenced by their personal history and culture, must be acknowledged by themselves and their readers as an imminent part of the research outcome. In addition, the researcher will actively make decisions about the data categories generated besides including questions, personal values, beliefs and experiences to data interpretation (Charmaz, 2006).

As mentioned earlier, grounded theory research investigates research problems as experienced by respondents and how they would resolve it in the real world (Glaser & Strauss, 1967). The current study applies the principle of grounded theory to investigate how drug abuse and drug relapse issues are experienced by drug users and treatment providers, and the methods used to resolve drug dependency through treatment. In addition, this study also examines how drug abuse and drug relapse is perceived by university students (without drug abuse experience) and their suggestions to overcome knowledge gaps in drug prevention education. With the collection of comprehensive data, it is important to ensure that the researcher remains sensitive to the data and do not filter information through pre-existing hypotheses and biases, which are often formed from past research (Glaser, 1978). In grounded theory research, data should be analysed without preconceived ideas or hypothesis to ensure that potentially novel themes are not unconsciously dismissed. As mentioned in Chapters 1 and 2, no specific hypotheses were formed at the start of research. However, predictions of expected findings were made after conducting the pilot survey and focus group study to provide a sense of research direction.

Complete immersion in the emerging data also enabled the construction of an explanatory scheme that integrates the various research areas explored (Glaser, 1978). For instance, findings related to knowledge gaps in drug prevention education, patient satisfaction with the drug rehab system, and suggested improvements were integrated with feedback and observations from the sample groups to form a guideline that may improve public education. This guideline could be a starting point for stakeholders within the drug education and treatment systems to work collaboratively in developing up-to-date education materials and help resources.

As mentioned earlier, the experience of drug abuse and relapse are as varied as the individuals who perceive or experience them. Thus, the current study attempted to gain insight of this issue from the view of university students without drug abuse experience, drug rehab patients and the rehab staff. Data from the three sample groups (university students, rehab patients and staff) were coded and analysed using the constant comparison method, in which data was compared against each other (Bitsch, 2005). This progressed to comparisons between their interpretations, which were translated into codes and categories. A noted code and category was then compared with others, in terms of its differences and commonalities. This process helped to unearth and explain particular patterns and its variation (Bitsch, 2005). Additionally, the research concepts in this study were progressively developed since grounded theory is a complex iterative process. As such, findings from the pilot survey and focus group interviews were noted and constantly re-evaluated with progressive findings involving larger samples.

The principles of constructivist grounded theory was also reflected in its efforts to triangulate data from university students, rehab patients and staff to develop a conceptual understanding of drug abuse, drug relapse, knowledge gaps in drug prevention education and treatment evaluation. Observation notes and findings across the three sample groups were integrated to construct a guideline that could encourage stakeholders in the field of drug education and drug rehabilitation to collaborate and improve public education. This was in contrast with the quantitative research approach, which would have tested the research findings against a pre-selected drug abuse model.

2. Ethics, sampling design and recruitment procedures

Ethics approval. Before the commencement of data collection, ethics approval to conduct this research was received from the Monash University Human Research Ethics Committee (MUHREC) on 3^rd June 2013 (CF13/511 – 2013000227). Subsequently, permission to conduct research on the grounds of Monash University Malaysia campus was also received from the Monash Campus Research Office.

Sampling design. A non-random purposive sampling involving a multilevel relationship was used to recruit respondents. A multi-level relationship refers to the use of two or more samples that are extracted from different populations (Onwuegbuzie & Collins, 2007).  This sampling design was appropriate for the current study because its aim was to obtain insights into drug abuse and relapse from different perspectives (i.e., university students without drug abuse experience, drug users and rehab staff).

Recruitment of university students. University students had to first indicate their interest in participating after reading the explanatory statement. In the online survey, students had to click on the interest button while verbal interest was noted during the recruitment process for paper questionnaires. In the explanatory statement, the criteria for inclusion are clearly stated as follows:

• Respondents should be at least 18 years of age.
• Respondents should have no prior history of drug abuse but have undergone drug prevention education in school or college/university.

Students who met the criteria would then indicate their agreement to participate by clicking a consent button, which would lead them to the online survey. In the paper survey, students had to tick a box indicating their consent to participate in the study. The purpose of recruiting university students based on the above criteria was because it was of interest to examine the gaps in perception and real experiences of drug abuse and relapse. Findings from the university student sample were compared against findings from the rehab patients and staff samples to determine overlap and differences in perception and real experiences. The age criterion was set to recruit respondents who are within the at-risk age group but not excluding mature age students so that the findings would be more representative of the general population.

Fifty university students from Monash University Malaysia were recruited for the pilot survey. In the actual study, respondents were recruited from Monash University Malaysia and other higher learning institutions within Selangor, Kuala Lumpur, Penang, Sabah and Sarawak. This includes Sunway University, Sime Darby Nursing and Health Sciences College, Alfa College, SeGi University, and University Selangor (UNISEL) in the state of Selangor, Management and Science University (MSU) in Kuala Lumpur, Universiti Sains Malaysia (USM) and SeGi College in Penang, Gaya Teachers Education Institute (IPG) in Sabah and Universiti Malaysia Sarawak (UNIMAS) in Sarawak. In terms of exposure to drug prevention education, university students who underwent schooling in Malaysian schools had exposure to talks, exhibitions and various drug awareness activities during the Anti-Drug Week programme, either during primary or secondary schooling. These programmes were often organised by their respective school counselling units with the collaboration of NADA and the Anti-Narcotics unit of the Royal Malaysian Police.

Students from college and universities were recruited through social media networks, word-of-mouth and through written permission from their respective lecturers via email and face-to-face communication. A short description of the research and link to the online questionnaire was circulated through university websites and the social media (i.e., Facebook, Google+, LinkedIn) to increase sample coverage to various states in Malaysia. In addition, 300 paper questionnaires were distributed in university premises in the states of Selangor and Penang. The data collection period was from July 2013 to July 2014. The targeted response was 400 complete responses. However, 500 responses were collected (both online and paper questionnaires). Nevertheless, 40 responses had to be excluded due to incomplete data or incorrect response. Thus, 460 complete responses were recorded and used in this study.

Recruitment of rehab patients and staff. An official letter seeking permission to conduct semi-structured interviews with drug rehab patients and staff was submitted to the Policy, Planning and Research Department in the Malaysian National Anti-Drug Agency (NADA) and the administrator of Christian Care Centre (CCC). Permission to conduct interviews at the government-run Bukit Kuda Cure and Care Service Centre (CCSC) in the Klang district, Selangor was granted on 31^st October 2012 [Ref No: ADK 60/1/7, Vol. 12(81)].  Permission to conduct interviews at the private-run CCC in Hulu Langat, Selangor, was granted via email in January 2013. The inclusion criteria for interview respondents were as follows:

• Respondents had to be above 18 years.
• Drug rehab patients should have stayed at the rehab centre for at least 3 months.
• Patients should not be medically ill, suffering from withdrawal symptoms or physically injured at point of interview.
• Rehab staff should have at least 6 months of working experience.

With permission from the centre administrators, posters were put up on notice boards at the centres and flyers were placed at their respective administrative offices. Patients and staff who were interested could register their names in a form. Subsequently, interested respondents were gathered for a group briefing about the research. The centre administrators played an important role in helping to screen patients who met the selection criteria and were medically fit to participate. Patients who were medically ill, suffering from withdrawal or severe side effects of drug abuse; or physically injured were excluded, as they would be unable to provide their consent to participate. In addition, the 3-month rehab experience criterion for the patients sample was set because this duration would allow patients to have a good grasp of the treatment programme. Nevertheless, there were concerns that this criterion could exclude drop-outs and less successful patients from this sample. However, not all patients were in rehab for the first time. The experiences of rehab patients who dropped out in the past, or relapsed and were readmitted into treatment provide useful insights into the limitations of treatment programmes. During the interviews, it was constantly emphasised to the administrators and respondents that participation from patients and staff was voluntary. Moreover, participation in this research should not affect future treatment or job benefits received at the centre. There would be no consequences to the respondents should they decide to withdraw from the study.

Before conducting the actual study, a focus group involving five drug rehab patients and five rehab staff was carried out. Its purpose was to examine the relevance of content for the semi-structured interviews and clarify details about the eventual interview protocol, with feedback from both patients and staff. In determining the appropriate sample size for the interview sessions, there were two conditions considered: (a) For studies utilising grounded theory, an adequate sample size for detecting moderate effect sizes with .80 statistical power at the 5% level of significance was between 20-30 respondents (Creswell, 2007); and (b) In grounded theory, data is collected until a saturation point is reached, in which no new or relevant data emerges regarding a category. A sample of thirty drug rehab patients (i.e., 15 from CCSC and 15 from CCC) and ten rehab staff (i.e., 5 from CCSC and 5 from CCC) who met the selection criteria were involved in the final interview sessions. As the interview data was analysed iteratively, it was found that saturation point was gradually achieved starting from the 13^th patient in the government rehab centre, the 10^th patient in the private rehab centre and the 8^th staff.

Background of target rehab centres.The CCSC is a government rehabilitation service that utilises a multi-disciplinary approach to rehabilitate drug users through group counselling, community projects, vocational and skills training, and employment opportunities (NADA, 2012). Group counselling helps rehab patients work together to find a solution in resolving personal problems, which may impede treatment and recovery. Vocational and skills training provides patients with basic training and resources for future employment or starting their own business ventures. Involvement in community projects helps patients interact and re-integrate with society while giving them the opportunity to contribute to the community.

The CCC, which is a private rehabilitation centre, places more emphasis on spiritual studies and improving patients’ mental well-being. However, CCC patients also learn vocational skills aimed at post-treatment employment and participate in recreational activities to help rebuild their physical vitality.

3. Profile of respondents
   1. University students sample

Pilot survey. As mentioned earlier, fifty university students from Monash University Malaysia were involved in the pilot study of the Student Perception Questionnaire (SPQ). They consisted of 46 females (92.0%) and 4 males (8.0%). Only 43 students provided information regarding age. The age range was from 18 to 44 years while the mean age was 21.84 years (SD=3.786). The sample consisted of 42 (84.0%) students of Malaysian nationality and 8 (16.0%) students of other nationalities. The Malaysian students comprised of 30 (60.0%) Chinese, 7 (14.0%) Malays and 5 (10.0%) Indians. A majority of the sample embraced the Buddhist religion (38.0%). This was followed by Christianity (30.0%) and Islam (18.0%). Three students (6.0%) were Hindus, one student (2.0%) was Sikh and three other students embraced Agnostic beliefs, Taoism and Scientology respectively. The majority of the students (90.0%) were pursuing a Bachelor degree while 10.0% of students were pursuing a Masters or PhD.

Actual survey. In total, 460 university students from public and private colleges and universities within Selangor, Kuala Lumpur, Penang, Sabah and Sarawak responded to the SPQ. As shown in Table 1, the respondents’ age ranged from 18 to 56 years and the mean age was 21.60 years (SD = 3.547). There were more female respondents (74.3%) than males (25.7%). A majority of them were Malaysians (97.0%) while 3.0% were of other nationalities. Among Malaysians, a higher proportion of sample respondents were Chinese (40.9%), followed by Malays (37.2%), Indians (13.5%) and other ethnic groups from East Malaysia (5.4%). A majority of the respondents were Muslims (41.5%), followed by Buddhists (26.3%), Christians (17.0%), and Hindus (10.9%). In regards to educational status, most of the respondents were pursuing a Bachelor degree (74.3%), followed by 12.0% of respondents who were studying for a Diploma or equivalent.

1.      Drug rehab patients

In total, there were 30 drug rehab patients involved in the actual interviews. Fifteen patients were from a government rehab centre (CCSC) while another fifteen were from a private rehab centre (CCC).

Age group. The age group comparison showed that most patients in the private centre were between 30 – 39 years old (n=7, 46.7%) while a majority of patients in the government centre were from the younger population, between the ages of 20-29 years old (n=4, 26.7%). This was followed by the 50-59 year olds (n=3, 20.0%) in the government centre and the 40-49 year olds (n=5, 33.3%) in the private centre. Patients under the age of 20 years were the youngest age group in the government centre (n=2, 13.33%) while the oldest age group was 60-69 years old (n=2, 13.3%). The youngest age group in the private centre was 20-29 years (n=2, 13.3%) while the oldest age group was 50-59 years (n=1, 6.7%). The remaining patients from the government centre were in the 30-39 years (n=2, 13.3%) and 40-49 years (n=2, 13.3%) age groups.

Age of initiation. The mean age of initiating drug abuse among government centre patients was 18.87 years (SD = 4.340) while the mean age for private centre patients was slightly lower at 18.60 years (SD = 4.356).

Ethnic composition. There were differences in the ethnic composition of patients with Malays (n=12) comprising the majority in the government centre. This was followed by patients of Indian ethnicity (n=2) and one Chinese rehab patient. In contrast, the Chinese (n=9) made up the highest proportion of patients in the private centre. This was followed by patients of Indian ethnicity (n=5) and one rehab patient from the ethnic Lun Bawang in Sarawak.

Marital status. Eleven patients (73.3%) each in the government and private centre were single. Four patients (26.7%) in the government centre were married. Additionally, there were equal proportions of private patients who were married (n=2, 13.3%) and divorced (n=2, 13.3%).

Educational status. Most patients in the government centre (n=8, 53.3%) and private centre (n=10, 66.7%) were educated, as they had completed at least an upper secondary level of education. In fact, one government patient had a graduate diploma while a private patient underwent pre-university education. Three out of fifteen government centre patients (20.0%) and two out of fifteen private centre patients (13.3%) had at least a lower secondary level education. In both patient groups, two patients (13.3%) respectively had obtained at least a primary school level education although there was one patient from the private centre who had never undergone formal schooling at all.

Past rehabilitation experience. Nine government rehab patients (60.0%) and eight private rehab patients (53.3%) had never been admitted or received treatment for drug abuse before entering their current rehabilitation. In contrast, six government patients (40.0%) and seven private patients (46.7%) reported having relapsed after receiving treatment in the past.

Parents’ occupation. As shown in Table 2, patients in both rehab centres came from middle-class working families. Most of the patients in the government and private centres have mothers who were housewives or homemakers (66.7% respectively). However, 13.3% of mothers of private centre patients worked as business assistants. On the other hand, a higher proportion of fathers belonging to patients in the government centre were lorry drivers (13.3%) and government servants (13.3%). One patient in the private centre was unable to provide this information as his father had left the family when he was a child. Among private centre patients, most fathers were businessmen (26.7%) and government servants (13.3%).

1.      Drug rehab staff

Age group. The age group distribution reveals that three out of five staff in the government centre were between 30-39 years. The remaining two government staff were each in the 40-49 years and 50-59 years age group. Comparatively, four out of five staff from the private centre were in the senior age group of 40 – 49 years and one staff was in the 70-79 years age group.

Educational status. Rehab staff from the government centre had higher learning qualifications with four out of five staff having a graduate diploma and one staff with graduate degree studies. In contrast, the highest level of education that staff in the private centre had was lower secondary schooling (n=3), followed by primary level education (n=2).

Work experience. The job scopes for staff in these two rehabilitative centres involved administrative work and direct-contact work with rehabilitative patients. As shown in Table 3, private rehab staff had longer ranges of total work and rehab experiences as compared to government rehab staff. Staff in the private centre had a total average of 12.8 years (SD = 7.328) of working experience and 11.4 years (SD = 6.878) of direct-contact experience. In contrast, staff in the government centre had an average of 4.9 years (SD = 3.170) in both total working experience and direct-contact experience.

4. Research materials

Student Perception Questionnaire (SPQ). There are 26 items in the SPQ. It took most students approximately 30 minutes to complete in a single sitting. The SPQ was mostly self-developed although the five-point Likert scales for Causes of Drug Abuse Scale (CADAS) and Cures for Drug Abuse Scale (CUDAS) were adapted from Cirakoglu and Isin (2005). Other questionnaire items were presented as ranking items, checklists, yes/no responses, contingency questions and open-ended responses. The SPQ was developed with the purpose of understanding university students’ perception on:

1. drug types that are commonly used and easily available
2. factors for initiating drug abuse and drug relapse
3. strategies to overcome drug addiction and prevent relapse
4. prior knowledge about rehab treatment services and beliefs about treatment effectiveness
5. seeking and sharing information resource on drug prevention and treatment
6. appropriate age and school grade for initiating drug prevention education

The full example of the SPQ can be found in Appendix A. The online version of SPQ can be accessed through the following links: http://tinyurl.com/l6bgxkq or https://qtrial.qualtrics.com/SE/?SID=SV_1Y9HQx0j9gAl9Dn.

The reliability of the SPQ was tested in a pilot study and obtained a Cronbach’s Alpha of .69 (see section 3.7). As the SPQ also collects qualitative data, the content validity of its items was examined by a panel of two experts. Both experts were trained in the field of clinical psychology as well as social, developmental and cultural psychology respectively and have done substantial work using the qualitative or mixed methods research methodology.  They have past research experience in handling projects related to drug abuse and relapse, coupled with substantial clinical work and training experience with diverse patients.

The field experts evaluated the clarity and representativeness of the SPQ items. Several items related to drug rehab programmes were rephrased and open-ended questions regarding prevention education and preferred mediums for sharing information on drug abuse were extended.

Finalising the interview checklists. Focus group interviews were conducted with five rehab patients and five rehab staff before finalising the list of questions that were included in the actual interview checklists. A warm-up session was initiated, in which broad topics such as the general reasons for drug abuse and relapse and current drug trends were discussed. The focus group respondents were then posed some specific questions from the interview checklists and their responses were discussed. Examples of the questions include:

1. Rating scale of patients’ and peers’ relationship with their parents (Rehab patients)
2. What caused the patients to have thoughts of stopping or changing drug abuse behaviour? (Rehab Patients)
3. Session Evaluation Questionnaire (Rehab patients)
4. Job satisfaction at the rehab centre (Rehab staff)
5. What were the effective and/or ineffective components of rehab programmes? (Rehab staff)
6. How can rehab programmes be further improved from a rehab and/or management perspective? (Rehab staff)

The points and further elaboration generated from the discussion was noted down quickly by the student researcher. Besides re-examining the relevance of content within the interview checklist, the focus group also helped finalise the actual interview protocol.

Patient interview checklist. The items in the patient interview checklist were adapted through works from several resources (Callner & Ross, 1976; Coombs & Landsverk, 1988; Jurich, Polson, Jurich & Bates, 1985; Melby, Conger, Conger & Lorenz, 1993; Stiles & Snow, 1984). There were 8 demographic items, 4 scaled items and 17 open-ended items that encompassed the following topics:

1. demographics such as family background, age group, gender, ethnicity and educational status
2. drug use history
3. contributory factors of drug abuse and relapse
4. admission to centre history
5. evaluation of treatment
6. suggestions for improving treatment

Six items from the Assertion Questionnaire in Drug Use (AQ-D) by Callner and Ross (1976) that focused particularly on assertion in male heavy drug users was extracted. The participants’ answers were rated on a four-point scale (i.e., – 2 = Never descriptive of me to + 2 = Always descriptive of me). The AQ-D was found in past research to have good reliability with a test-retest correlation of .86 and excellent concurrent validity with correlations ranging from .71 to .95 (Callner & Ross, 1976).

Besides that, two scales that were developed for use in a research study by Foo, Tam and Lee (2012) to examine the influence of family factors and peer influence on drug abuse among Malaysian patients in a Christian-based rehab centre, were included. The first scale consists of 20 items that rates patients’ relationship with their parents while the second scale comprises 10 items rates peers’ relationships with their family. These items were adopted from past research by Coombs and Landsverk (1988), Jurich, Polson, Jurich and Bates (1985) and Melby, Conger, Conger, and Lorenz (1993). In both scales, participants had to rate their responses on a four-point scale (i.e., 1 = Not at all true to 4 = Very true). The minimum score for the patient-parents relationship scale was 20 while the maximum score was 80. Higher scores indicate problematic relationship with parents. On the other hand, the minimum score for the peer-family relationship scale was 10 whilst the maximum score was 40. Higher scores indicate more behaviour problems among peers (Foo, Tam & Lee, 2012). The mean and standard deviation (SD) for the patient-parents relationship scale was 29.43 and 7.58 respectively while the mean and SD for the peer-family relationship scale was 21.63 and 5.03 respectively. By summing the two, (29.43+7.58; 21.63+5.03), the cut-off score for patient-parent relationship was 37.01 and peer-family relationship was 26.66. This means that scores above 37.01 was coded as clinical (indicating problematic relationship with parents) while scores below 37.01 was coded as normal (indicating good relationships with parents) for the patient-parents relationship scale. Similarly, scores above 26.66 was coded as clinical (indicating problematic relationship with peers) while scores below 26.66 was coded as normal (indicating good relationships with peers) for the peer-family relationship.

A Session Evaluation Questionnaire (SEQ), which was designed by Stiles and Snow (1984) to measure the impact of clinical sessions, was included at the end of the checklist to assess patients’ feelings about their most recent treatment session and their current emotions at the point of interview. In this study, the SEQ was used as a quantitative measure of patients’ satisfaction with drug rehab sessions. The SEQ has 24 bipolar adjective scales presented in a seven-point semantic differential format. Patients’ perception of the clinical sessions was measured using two dimensions: Depth and Smoothness. The post-session mood was measured using the two dimensions: Positivity and Arousal. Depth refers to the perceived power and value of a session while Smoothness refers to the comfort, relaxation and pleasantness felt during the session. Positivity refers to feelings of confidence, clarity and happiness while Arousal refers to active and excited feelings as opposed to calm and quiet. The four dimensions were scored separately. Scores were the sum of item ratings. The SEQ has good internal consistency with alphas ranging from .78 to .91 (Stiles & Snow, 1984). Test-retest reliability estimates of .80 were reported for the SEQ over a 6-week period. Construct validity for the SEQ was based on a confirmatory factor analysis of all four dimensions: depth (α = .87), smoothness (α = .93), positivity (α = .89), and arousal (α =.78) (Stiles & Snow, 1984). A view of the full patient interview checklist can be seen in Appendix B.

Staff interview checklist. There were 9 demographic items and 10 open-ended items that encompassed the following topics:

1. demographics such as family background, age group, gender, ethnicity and educational status
2. working experience
3. perceptions of reasons for drug abuse and relapse
4. perspective on reasons for drug users entering rehab
5. satisfaction with work and the rehab programme

A view of the full staff interview checklist can be seen in Appendix C.

5. Data collection procedures

Survey study. Recruitment posters were displayed on notice boards and flyers were handed out in areas such as the cafeteria and foyer areas of colleges and universities. The posters contained information on the research study and the web link to the online questionnaire. An online research advertisement was also posted on the my.monash portal and social sites such as Facebook, Google+ and LinkedIn to circulate information on this study. Contacts were also established with academic staff from Monash University Malaysia and other institutions from Penang, Kuala Lumpur, Selangor, Sabah, and Sarawak. Paper questionnaires were left in a box in their respective course offices for students who were interested to participate. The students were allowed to respond to the questionnaires in their own time and completed paper questionnaires were returned to the course office. In addition, permission was received from Universiti Sains Malaysia (USM) in Penang to set up a booth for active recruitment of student respondents. Flyers and posters with the link to the online questionnaire were handed out. Students who expressed interest to participate were briefed about the research background and purpose, criteria to participate and the rights to withdraw from the study without consequences. Students who agreed to fill in the survey on the spot were handed out paper questionnaires. The questionnaires took 30 minutes to complete and were immediately returned to the researcher. No names were stated on the paper questionnaires to protect the anonymity of student respondents. Data collection for the survey took place from June 2013 to June 2014.

Semi-structured interviews. With permission from the centre administrators, recruitment posters were put up on notice boards at the government and private rehab centre. Research flyers were also placed in the administrative offices of both centres. Potential respondents were invited to register their names in a form, which indicated the patient’s expression of interest. The forms were taken back to the centre administrators to clarify that the rehab patients were physically and mentally fit to participate. Interested respondents were gathered in a group for a research briefing about the objectives of the research, the interview scope and research contributions. The interviews were conducted individually by the student researcher without the aid of audio recording. The protocol for semi-structured interviews was designed according to Taylor and Bogdan’s (1998) guidelines. The patient and staff interview checklist was prepared as aguide to ensure that key research questions were asked during the interview session. However, the semi-structured format of the checklists also allowed the researcher to probe with additional questions where appropriate. The flow of the interview was determined by the interview respondents, and they were asked to talk openly about whatever was viewed as important about the discussed topic. Respondents were also encouraged to elaborate and take the topic of conversation into an unforeseen direction. To avoid disrupting the treatment and work schedule of the respondents, each interview session were scheduled for completion within a single session, which was expected to take between 1 hour to 1 ½ hours. Upon completion of the interview, respondents were given an additional one month time frame to submit requests to withdraw their data from the study. The interview sessions were conducted on a one-to-one basis from June 2013 to August 2013.

6. Analytical procedures

In line with iterative inquiry, preliminary analyses were conducted between surveys and interviews to obtain a grasp of emerging patterns and themes. After completing the actual survey and interviews, a formal analysis was initiated. Quantitative data from the SPQ and interview checklists were analysed using IBM SPSS 20 while qualitative data were managed, organised and analysed using NVivo 10.

Analysis of quantitative data. Demographic details of respondents across three sample groups (university students, rehab patients and staff) were analysed using descriptive statistics. The estimate of reliability for the SPQ was obtained through Cronbach’s Alpha. In this study, quantitative data was collected with the purpose of gaining insight into university students’ perceptions on the following topics: (a) factors for drug abuse and drug relapse; (b) effective relapse prevention strategies; (c) drug information seeking behaviour and the preferred medium; and (d) beliefs about drug rehab services in government and private centres. Within the patient sample, quantitative data helps: (a) examine the prevalence of good or problematic family relationships among patients and their peers; (b) assess the patient’s assertiveness against drug offers; and (c) obtain a measure of patient’s satisfaction with drug abuse treatment using the SEQ. Furthermore, quantitative ratings of treatment satisfaction by rehab patients and staff helped determine the presence of statistical differences between perceptions of both sample groups. This study does not examine relationships between two factors nor determine predictors or mediating factors between dependent and independent variables. Rather, its purpose was to gain and compare insights on drug abuse and drug relapse issues across multiple perspectives. This was achieved through the collection and exploratory analysis of quantitative and qualitative data, whereby a major proportion of the research data comprised of qualitative data. Therefore, besides descriptive statistics and the Cronbach’s Alpha, simple inferential statistics such as independent t-test, paired sample t-test and Pearson’s chi-square were used. For instance, independent sample t-test was used to determine if there were: (a) differences in perception of drug abuse factors and effective relapse prevention strategies between male and female university students; and (b) differences in perceived satisfaction with drug rehab treatment between patients and staff. Pearson’s chi-square was also conducted to determine the differences in perception of drug relapse factors between male and female university students. Additionally, paired sample t-test was used to determine differences in actual and perceived age of first exposure to drug prevention education.

Analysis of qualitative data. From the patient sample, qualitative data was collected to identify patients’ motivation to change and track the prevalence of drug abuse progression. From the patient and staff samples, qualitative data helped examine factors for drug abuse, drug relapse, and treatment admission factors, besides evaluating patient satisfaction with existing drug rehab services. Qualitative responses from the staff also helped determine effective methods to prevent drug relapse, assess staff’s satisfaction with rehab work, and identify recent adaptations to the rehab programme. Qualitative data collected from the university students’ sample was useful in identifying the preferred medium for sharing drug information and the rationale behind their choice; besides evaluating the strengths and limitations of past drug prevention programmes. Qualitative data was iteratively analysed using thematic analysis. Braun and Clarke’s (2006) six phases of thematic analysis and Thomas and Harden’s (2008) methods of thematic synthesis were used to identify, explore and report themes within the qualitative data:

1. familiarising with data by reading data repeatedly and generating initial ideas,
2. systematically generating initial codes by coding text responses line-by-line
3. searching for themes by collating potential codes across several sources into general themes
4. reviewing the descriptive themes,
5. redefining the themes by generating lucid definitions and thematic names, and
6. producing a report with selected extract examples and relating themes with the research question.

Coding and making memos. Grounded theory methodology advocates using several coding techniques. There are two types of coding techniques used in this study: (a) open coding; and (b) selective coding. As mentioned above, initial codes were generated by coding text responses line-by-line. This process is known as open coding and it helps identify initial phenomena (event, object, action or idea) and produce a list of potentially important themes (Strauss & Corbin, 1998). For example:

Interviewer: Could you tell me about the reason(s) for drug abuse?

Respondent [PP02]: I sought the use of drugs as a form of tension release [relaxation] because I was under stress [distress] and diagnosed as having depression [mental health issues]

During the process of coding, memos, which are kept separately from the data, were also added to make notes of identified concepts (Strauss & Corbin, 1998). The initial thoughts that recorded in memos can be revisited and reflected upon during the overall data analysis. For the example above, the following memo was recorded:

Memo: The word ‘use’ in the answer implies that for this particular respondent, drugs were wilfully employed for a purpose.

From the initial codes generated, codes that share similar properties are then grouped together into categories. This process is known as selective coding. The categories generated will be tested on other interview responses between and across the three sample groups through constant comparison (Strauss & Corbin, 1998). The abstract categories developed will then form the basis for the overall theory/guideline.

7. Reliability and validation of data

Reliability of SPQ. Quantitative items in all five constructs of the SPQ were analysed and the results are as shown in Table 4. Four out of five constructs were within an acceptable to good reliability range (0.6 ≤ α < 0.9). Only one construct evaluating students’ knowledge and perception about drug rehab programmes had poor internal consistency (α = 0.22). However, it was decided upon further examination that the items under this construct could not be removed as most questions in this section were contingency response items (i.e., items were only answerable if respondents answer accordingly in the previous construct). The overall internal consistency of the SPQ (α = 0.69) was found to be within acceptable levels of reliability (0.6 ≤ α < 0.7).

Triangulation was also performed as a method to establish the validity of quantitative and qualitative data collected from the three sample groups (Guion, Diehl & McDonald, 2002). Yeasmin and Rahman (2012) defined triangulation as a process in which combinations of two or more theories, data sources, methods or researchers are used to provide deeper insight into a single phenomenon. As mentioned earlier, the current study investigated the issue of drug abuse and relapse across multiple perspectives using the principles of constructivist grounded theory, which acknowledges the experiences and values of the researcher during the research process. Triangulation has the capability to capture the multiple realities of drug abuse through the use of multiple methods, including the researcher’s experiences (Denzin, 1970). According to Denzin (1970), there are four forms of triangulation: (a) theoretical triangulation: the use of multiple theories to interpret data; (b) data triangulation: comparing data across multiple sources; (c) methodological triangulation: the use of multiple research methods or data collection techniques); and (d) investigator triangulation: the use of multiple observers in gathering and interpreting data. There were three forms of triangulation used in the current study, which are data, methodological and investigator triangulation.

Data triangulation involves comparing research results across two or three data sources, which are the rehab patients, staff and university students (undergraduate and postgraduate). For example, satisfaction with drug rehab treatment was evaluated using overall ratings in the Session Evaluation Questionnaire (SEQ) for the rehab patient group and responses from an open-ended question to the rehab staff. Methodological triangulation involved comparing quantitative and qualitative data from the survey and semi-structured interview. If the conclusions derived from both sources are consistent, then research validity is established (Guion, Diehl & McDonald, 2002). Investigator triangulation was employed in the stage of data coding and interpretation. The codes and themes generated by the researcher were checked against those, which were independently generated by two field experts. Both field experts were also involved in examining the content validity of the SPQ. The codes across all three raters were collated and an agreement of codes was indicated in each column (1=Yes, 0 = No). The percentage of agreement was calculated using inter-rater differences. A score of 0 indicates agreement. As shown in Table 5, the mean level of agreement on the generated codes and themes was 89.8%, across all three raters.

The large size of qualitative data yielded a wide range of codes and themes in each research area. These themes were eventually reviewed and narrowed by all three raters to a manageable size as shown in Table 6.

Chapter 4: Understanding drug abuse perception among the university student sample

As mentioned earlier, a purpose of this study was to gain insights on drug abuse, drug relapse and drug prevention education from the perspective of university students without drug abuse experience. This chapter presents findings related to the first to fifth research questions, which encompassed the perceptions of university students on:

1. factors contributing to drug abuse and drug relapse,
2. standards of treatment provided by government and private rehabilitation programmes,
3. drugs that are commonly abused and easily accessible,
4. common resources used to seek and share information about rehab services and drug prevention,
5. prior exposure to prevention education,
6. age and school grade appropriate for initiating drug prevention education, and
7. the evaluation of past drug prevention education.

Besides frequency and descriptive analyses of demographic information, inferential statistics such as independent sample t-test was used to examine differences in perception about drug abuse and drug relapse factors, and relapse prevention strategies between male and female university students. Chi-square analysis was also used to examine gender differences in perception of drug relapse factors. Qualitative data on the preferred medium for sharing information, the usefulness of prevention education activities in school, its limitations and suggestions for improvement were categorised and analysed through thematic analysis procedures and techniques using the NVivo 10 software.

1. Research Question 1: What is the difference in perception of drug abuse and relapse factors, and effective relapse prevention strategies between male and female university students?
   1. Perceived drug abuse factors

The students rated the degree in which they agree or disagree with the given statements on reasons for drug abuse, on a five-point Likert scale. As shown in Table 7, it was found that university students on average, agreed that life stresses (M = 4.16, SD = .814) and the social environment (M = 4.12, SD = .831) were factors for drug abuse. However, they disagreed that being uneducated (M=2.91, SD = 1.125) could lead to drug abuse. The students indicated that they neither agreed nor disagreed with the role of the remaining factors as reasons for drug abuse.

An independent sample t-test was further conducted to determine differences in perceptions of drug abuse factors between male and female university students. As shown in Table 7, significant gender differences were found for the factor ‘unemployment’ [t(458) = -2.236, p<.05]. This means that female students were significantly more likely to view unemployment (dispositional factor) as a reason for drug abuse, in contrast to male students. However, male students were more likely to view two dispositional factors as reasons for drug abuse, which were ‘being uneducated’ [t (458) = 1.833, p>.05] and ‘is weak-willed’ [t (458) = .295, p>.05]. Nevertheless, the gender difference was not significant.

1.      Perceived drug relapse factors

The students could select as many relapse factors as they felt applicable. As shown in Table 8, lack of family support (n = 397) was perceived as the major reason for relapse, followed by lack of self-efficacy (n = 377) and peer influence (n = 357). However, the Pearson’s chi-square test demonstrated that there were no significant differences in perceptions of drug relapse factors between male and female university students.

2. Relapse prevention: Strategies perceived as effective

The students rated the extent in which they agree or disagree with statements on effective relapse prevention strategies on a five-point Likert scale. As shown in Table 9, it was found that university students on average, agreed that breaking unhealthy relationships (M = 4.43, SD = .734), keeping busy with healthy activities (M = 4.46, SD = .712), building supportive social networks (M = 4.23, SD = .798), practicing caution with medication (M= 4.01, SD = .812), believing in overcoming problems (M = 4.19, SD = .896), being active in skilful areas (M = 4.34, SD = .740), learning stress management (M = 4.10, SD = .812), maintaining communication with recovery doctors (M = 4.27, SD = .773) and having constant consultation with rehab centres (M = 4.17, SD = .775) were effective strategies to prevent drug relapse among rehabilitated patients. However, they perceived that limiting places to visit (M = 2.98, SD = 1.062) and not carrying too much money (M = 2.73, SD = 1.110) were ineffective in preventing drug relapse. The students also neither agreed nor disagreed that listening to music or forgetting the past and making new life changes were effective methods of preventing relapse.

An independent sample t-test was also conducted to determine differences in perceptions of effective relapse prevention strategies between male and female university students. As shown in Table 9, significant gender differences were found for six relapse prevention strategies. In contrast to male students, the female students were more likely to view three help-seeking strategies: ‘learning stress management’ [t(458) = -2.990, p<.01], ‘maintaining constant communication with recovery doctors’ [t(458) = -3.120, p<.01] and ‘consulting rehabilitation centres’ [t(458) = -2.846, p<.01]; two change strategies: ‘caution with medication’ [t(458) = -2.080, p<.05] and ‘believe in overcoming problems’ [t(458) = -2.001, p<.05]; as well as one social activity strategy: ‘building supportive social networks’ [t(458) = -3.615, p<.01] as effective.

2. Research Question 2: What proportion of university students have knowledge about drug rehabilitation and believe private rehab centres are more effective?

It was reported that 293 (63.7%) students had knowledge about drug rehab services, in contrast with 167 (36.3%) students who did not. In addition, 211 (45.8%) perceived that there was a difference in treatment provided by government and private rehab centres while 193 (42.0%) students perceived that treatment was equally good in government and private rehab centres. Fifty-six students (12.2%) chose not to answer this item.

Furthermore, 225 (48.9%) students perceived that private rehab centres provided better treatment services than government rehab centres (n=45, 9.8%). However, one student (0.2%) viewed that semi-government or semi-private centres provided better treatment services. Many students (n=189, 41.1%) did not respond to this item by choice.

3. Research Question 3: Which drugs are rated as the most commonly abused and easily available by university students?

In this study, ‘commonly used drugs’ referred to drugs that were perceived by university students as highly used by drug users. ‘Easily accessible drugs’ referred to drugs that were perceived as easily available within the Malaysian drug market. Ten drug types were listed for students to rank in terms of commonality (1 = most commonly used to 10 = least commonly used) and availability (1 = most easily available to 10 = least easily available). Mode values were obtained to establish the highest proportion of rankings for each drug type, as shown in Table 10.

Ecstasy and cannabis were highly ranked as the two drugs which were most commonly used and easily available (score of 1). Heroin was also rated as most commonly used and second most easily available drug. Ketum leaves, a traditional herbal drug that is more customary in Southeast Asian countries, was ranked as most easily available but the least commonly used. Methamphetamines was rated third in terms of commonality but only ranked a 6 in availability. Morphine was mid-rank (score of 5) in both commonality and availability. Opiate derivatives (excluding heroin and morphine) were ranked 7 in commonality and availability while psychoactive drugs and ketamine were viewed as the most difficult drugs to obtain (score of 10). In addition, ketamine was also ranked as the least commonly used drug, together with ketum leaves.

4. Research Question 4: Which information resource is most favoured by university students to learn and share information about drug abuse?
   1. Medium to search for information

It was found that 267 students (58.0%) searched for information on drug abuse and prevention on their own initiative whereas 192 (41.7%) students did not. One student did not provide a response to this item. To obtain insight into the preferred resource for information on drug abuse, the students had to select the resources they would use to seek information on as drug rehab programmes and drug prevention. The students were encouraged to select as many resources as applicable to them.

Drug rehabilitation information resources. Television or radio came in first place, with 226 (49.1%) students reporting both conventional mass media as their preferred resource. Newspaper and magazines were the second most preferred information medium among 225 (48.9%) students. Internet resources such as blogs and websites were in third place, with 199 (43.3%) students reportedly using it to learn about rehab services whilst brochures, pamphlets and posters were the fourth most preferred resource among 147 (32.0%) students.

Family members were the least preferred source for information about drug rehab among 104 (22.6%) students. Peers were the second least preferred resource among 105 (22.8%) students, followed by social sites (n=114, 24.8%) and books (n=139, 30.2%) in third and fourth place respectively.

Drug prevention information resources. The students ranked the resources they would use to research about drug prevention on a five-point scale (1= most preferred resources to 5 = least preferred resource). Mode values were used to establish the highest proportion of rankings for each resource. As shown in Table 11, internet resources (websites and blogs) were ranked in first place by 41.7% of students as the most preferred medium. This was followed by newspaper and magazine articles (20.9%) and brochures, pamphlets or posters (15.9%). Social sites (24.8%) and books (18.9%) were both rated as the least preferred resources.

2. Medium for sharing information

The students were encouraged to provide views on the best medium to share information on drug abuse, relapse and prevention. Most students provided at least one preferable medium although there were two students who were unsure about which medium they would choose to share such information. In this section, a brief description of the themes and its key concepts are outlined. Representative quotes were also presented to better illustrate the concept of each theme and sub-theme. A detailed outline of the themes and the representative quotes can be seen in Table 12.

Online media. As shown in Table 12, the thematic analysis indicated that the most popular online medium for sharing information was social media, which was cited by 155 university students. Among the reasons mentioned by students for the wide usage of social media was the simplicity of sharing information to a wider audience and the broad accessibility of social network services, with mobile internet access and technology advances. A student (US040) commented that since younger generation have at least one Facebook, Twitter, Instagram or Tumblr account, information is easily shared through this medium with a click of the mouse. Another student (US004) viewed that information about drug abuse and other social issues can be easily searched and shared through newsfeeds in social media.

A student (US097) also felt that there is increased accessibility to information on drug abuse with the development of advanced gadgets such as the iPad, smartphones and laptops. Moreover, ideas and perspective could be exchanged with friends from anywhere easily. Another student (US032) viewed that the learnt habit of sharing information on their social media profile pages among the younger generation have also benefited other people by greatly improving their knowledge just by following these pages or sites. The student also commented that with more people in society becoming increasingly attached to their mobile gadgets and social networking sites, more people are able to capture bits of information on drug abuse and prevention at a glance.

The second most popular online medium was internet websites, which was cited by 117 students. The ease of searching for information from unlimited sources without much physical and mental effort, coupled with the anonymity accorded when discussing drug abuse issues in support group forums were some of the reasons for the widespread use of internet resources. The internet provides many avenues for searching information through search engines (e.g., Google, Yahoo!, Bing, WebCrawler) as well as for information sharing, through blogs, forums, health videos and YouTube message videos. In being able to access not only written information but also visual and auditory information easily, the younger population and the public in general are able to select the resources that best capture their attention or best fit their learning styles. Besides, the anonymity accorded when serious topics such as drug abuse is being discussed in internet forums would encourage these individuals to open up on their issues to others who may have undergone the same situation and seek the necessary help to overcome drug abuse.

Conventional mass media. The third most popular medium was radio and television, as cited by 51 students. Since most households have at least a radio or television, these medium were perceived by students as important methods to educate the public about drug abuse issues and prevention. A student (US007) proposed that infomercials and documentaries were good ways to provide information on causes and effects of drug abuse as well as the ways in which university students could accidentally engage in drug abuse. Another student (US002) also felt that movies and television dramas were good avenues to disseminate important messages as the character roles make it more relatable to the audience, which leads to a deeper understanding of dealing with drug abuse.

These students also felt that radio programmes play an essential role in increasing awareness among the public. For instance, student US032 felt that public awareness could be increased by getting field experts to share their expertise on rehabilitating drug users and provide information on available treatment or counselling services through the radio. In addition, rehabilitated drug users should be invited to share their personal experience to provide a relatable human connection to the public.

Paper-based media. Newspaper, books and magazines were among the resources cited by 21 students as their preferred medium for sharing information. Since newspapers and magazines were read daily, a student (US010) viewed that having a committed column towards drug abuse topics would increase public awareness about the severity of this social issue. Moreover, this option provides a choice to the public to read and having an electronic version would enable the public to read when convenient. Another student (US160) viewed that newspaper and magazine articles by established columnists and field experts were more influential and easily accepted by the public, in addition to its wide and quick accessibility through these medium. However, a student (US114) highlighted a need for greater access to books on psychiatry and drug abuse in libraries and bookstores.

Other paper-based media that were cited by24 students as the preferred medium for sharing drug information were brochures, pamphlets and posters. According to a student (US014), brochures, pamphlets and posters are easily read because brief summaries of important facts are presented creatively. In addition, they are small enough to be carried around and shared with others. Another student (US302) also preferred using brochures and pamphlets to share information because they are light and can be mass distributed to a large number of people within a short time. A student (US156) suggested that brochures, pamphlets and posters can be distributed during drug prevention seminars, to strengthen the audience’s knowledge of presented information.

Face-to-face communication. Although information on drug abuse, relapse and prevention is quite easily obtained through the internet, six students felt there is still an existent need for face-to-face interaction to get drug messages across. Two students (US300 and US328) cited that the personal approach, such as personal communication with officials from various NGOs and health professionals as well as the distribution of additional information through flyers and campaigns from site-to-site, were still preferable to some individuals. A student (US394) explained that this was because face-to-face interaction is able to provide some assurance on the reliability of the information received. One student (US153) also reported preferring the use of word-of-mouth because personal discussions with peers or trusted members of the community are able to increase awareness and disseminate useful information about drug abuse and prevention more persuasively.

Forty-eight students also reported preferred sharing information using face-to-face communication via prevention education to provide students with awareness and early exposure to avoid drug abuse. A student (US063) asserted that public road shows in urban and rural schools by the NGOs were able to reach out to troubled children and teenagers. Moreover, it was suggested by another student (US168) that this method would be more effective among heavy drug users as well as students who lack the initiative to search and learn about drug abuse and its consequences. This student also believed that the educational system has been less effective in instilling the desire to read, learn and investigate. Thus, conducting compulsory programmes were beneficial towards this group of students.

Based on the experience of 27 students, face-to-face communication of drug prevention was also carried out through organised public events. According to a student (US439), poster exhibitions, health talks and forums conducted in public places such as shopping complexes, hospitals and community centres were viable modes to increase awareness on drug abuse. Moreover, a student (US297) suggested that the public are more likely to attend these events if a field expert is involved, as information on drug prevention strategies are more likely to be perceived as credible and reliable. Road shows and drug-free pledges in colleges and universities across various geographical locations were also viewed as useful by a student (US228), in ensuring that at-risk groups and the public are educated on this topic and increase their commitment towards leading a healthy and drug-free life.

However, three students felt that youths would only learn to avoid drugs through action and consequences. A student (US034) suggested that youths would truly understand that using drugs is wrong only by experiencing the bad effects of drug abuse. In addition, a student (US158) felt that serious legal consequences should be meted out towards drug offenders to prevent others from following the footsteps of drug users. Another student (US100) was of the opinion that having strong self-control is important in avoiding drug abuse.

Community roles. In the opinion of five students, having access to support networks were also good methods to gain realistic knowledge and share information to the public. A student (US155) felt that direct contact to treatment services that provide individual counselling and group therapy would help youths gain a better idea of therapies used in drug abuse treatment, and this experience could be subsequently shared with their peers. Another student (US169) suggested that the opportunity for former drug users to share their experience, such as the difficulties faced when under the influence of drugs, during the treatment process and their progress post-treatment, should be made available to students. Besides educating the public, it is an avenue for drug users to come to terms with their past and aid their healing process. It was also suggested by the student that more group therapy facilities which are similar to the structured groups for Alcoholics Anonymous, should be made available to youths in need.

Fifteen students also suggested that college and university should play a more proactive role in providing and sharing information about drug abuse since college and university students were most vulnerable towards drug abuse. Besides campaigns and road shows, three students felt that college and university peers play an important role in educating each other about drug abuse. According to a student (US049), peer group discussions based on a movie or television drama is a good way for youths to exchange ideas about drug prevention as well as correcting misconceptions between the realities of drug abuse versus the image depicted in the media. It was suggested by another student (US184) that students and their peers should be encouraged to participate actively in programmes conducted by the Ministry of Health (MoH) and NADA. A student (US106) also suggested that social work experiences would provide students with the opportunity to learn about the treatment admission procedures, treatment approach and its processes as well as job training skills that are provided to rehab patients. This information could be shared to their friends, family and community. Including drug abuse, relapse and prevention as part of classroom presentations was viewed by a student (US108) as a good way of instilling interest among students to learn more about this topic on their own initiative. This student related his experience in which the lecturer made drug abuse as the topic of an assignment that contributed towards his final examinations. The student felt that in addition to sparking an interest in the topic, the fact that this assignment was evaluated made him devote more attention to this topic.

Two students also re-emphasised the importance of family roles in educating, sharing and discussing information on drug abuse. According to a student (US456), open communication between family members about drug abuse topics was important towards curbing curiosity about drugs among the young. Moreover, another student (US209) asserted that family members have the responsibility to educate the young about the consequences of drug abuse from an early age, which could be achieved through informal family discussions.

From the mixed method findings, it appears that conventional mass media, online media and paper-based media were favoured by university students to search for information on drug prevention and rehab services. Similar findings were found from qualitative themes, in which more university students perceived online media (internet websites and social media), conventional mass media (radio and television) and paper-based media (magazines, newspaper, brochures and pamphlets) as effective mediums to share information about drug abuse and prevention. Factors that influenced their choices include the ease and convenience of sharing information, the ability to share information creatively through text and audiovisual methods and wide accessibility to expert opinions. Only a minority of university students perceived the role of the community (family roles, support networks, college and university) and face-to-face communication (prevention education and organised public events) as effective means of sharing information. This finding highlights two important issues: (a) greater involvement from the local community in educating and raising awareness about drug abuse and how to protect young people from potential risk factors; and (b) greater promotion of events that involve face-to-face communication of drug abuse and prevention issues such as drug awareness and prevention campaigns in public venues that feature field experts, and drug abuse and prevention activities that are conducted in urban and rural areas.

5. Research Question 5: What is the difference in university students’ actual and perceived age and school grade of exposure to drug prevention education and their perceptions on past prevention programmes?
   1. Actual and perceived age and school grade of exposure to drug prevention education

Actual and perceived age. As shown in Table 13, the average age of exposure to drug prevention education was 10.57 years (SD = 5.704). This age was younger than the age which was perceived as optimum for conducting prevention education at 11.68 years (SD = 3.226). A paired-sample t-test further showed that the difference between age of actual exposure and perceived age was significant [t (412) = -2.896, p<.01]. The minimum age of first exposure to drug prevention education was at the age of 6. However, the students viewed that the basics of prevention education should be initiated at an early age of 4 years (pre-school level).

Actual and perceived school grade. As shown in Table 14, the highest proportion of students received their first exposure to drug education in Form 1 (Malaysian schools). Correspondingly, most students (25.2%) perceived drug prevention should be initiated in Form 1. Some students chose to provide general answers and did not specify the school grade in which they received prevention education such as pre-school (0.2%), primary school (0.4%), secondary school (0.4%), diploma/foundation/pre-university courses (1.1%) and degree/first-year of university (0.4%). Comparatively, more students (2.2%) perceived that prevention education should start in pre-school as compared to the current education system, which mostly initiated prevention education in primary school. Additionally, one student felt that prevention education should be conducted at every school grade.

2. Perceived usefulness of prevention education in school

The students were also invited to voice their opinions on the usefulness of drug prevention education in school, based on their personal experience. Most of the students felt that activities ranging from drug prevention campaigns to talks and exhibitions were quite useful. Five students reported that the prevention programmes were only moderately useful for them whilst 19 students felt that the prevention activities were not useful at all. Seven students did not provide any opinions, as they were unsure of how drug education could be further improved at the school level. A summary of the themes and representative quotes generated can be seen in Table 15.

In-depth drug information.As shown in Table 15, 315 students reported that in-depth information involving the consequences and negative effects of drugs were most useful. A student (US055) reported that drug prevention education satisfied their curiosity about drugs and equipped them with the knowledge to avoid drug abuse. Another student (US099) also provided feedback on how some prevention programmes are able to prevent drug abuse among the young through deeper understanding of the impact drug abuse to the self, family members, the community and society in general. An increased awareness on drug abuse as a result of the in-depth information provided in drug prevention education was also reported by 119 students. A student (US064) reported that school students were educated on various drugs that were easily accessible in the market, how to identify them and what they should do to avoid it. In addition, another student (US007) reported an increased awareness of the situations that should be avoided, as well as what should or should not be done in dangerous conditions. Besides this, 56 students reported that they were able to gain a deeper understanding of the risk and causative factors of drug abuse through the in-depth information provided in school. A student (US030) claimed that such information would act as preventative measures and increase students’ exposure to healthier, alternative coping strategies. Twenty students reported that they were able to relate better to drug prevention information with real-life elements. Two students (US046 and US089) commented that examples taken from the shared experience of former drug users on the consequences of drug abuse and the difficulties during recovery was particularly informative. Eight students particularly felt that information about strategies to overcome addiction were useful. A student (US051) reported that the in-depth information provided a clearer picture of treatment pathways that would help break drug dependency. In addition, knowledge on alternative treatment strategies was also useful towards improving physical and mental health.

Six students reported that information which helped debunk drug myths were useful. A student (US001) noted that such information have helped correct misconceptions about drug abuse, AIDS and drug users. Another student (US198) felt that such information is particularly useful to the younger population, who lacked proper education on the dangers of drugs and the proper use of some drugs like morphine and marijuana, which were originally developed for medicinal purposes. Moreover, the young are also easily influenced and misdirected by movies and television dramas that show drugs being used recklessly for fun and recreation. In the case of four students, scary drug abuse images in exhibitions were useful ways to educate and prevent drug abuse. According to a student (US268), horrible pictures showing the consequences of years of drug misuse on the human body was informational. In addition, another student (US164) noted that the association between drug abuse and the image of death was a useful deterrent towards drug abuse among the young.

Change in dissemination methods. Fifty-one students noted that changes in drug prevention activities conducted by NADA and various non-governmental organisations were useful towards providing a more beneficial and interesting learning process to students. For instance, a student (US307) disclosed that interactive talks and discussions with doctors, pharmacists and other health professionals enabled the students to assimilate accurate information about drugs and drug prevention strategies.  According to 21 students, activities and information presented using visual and interactive methods were much more useful and interesting. A student (US010) remarked that although any sort of information would be useful, information presented using visual images such as posters, slide shows, documentaries and films would be more beneficial as it would be able to create a greater impact on students as compared to written words. Two students (US379 and US389) viewed documentaries, which depict how an individual could get addicted to drugs and subsequently becomes motivated to recover, as an inspirational message to students. Another student (US396) also noted that films were particularly effective in demonstrating the consequences of drug abuse to students. On another note, three students observed that efforts to incorporate drug education into the national curriculum to be useful. A student (US357) commented that information about drugs should be integrated more frequently in the science syllabus such as biology and chemistry, as well as moral and civic education subjects. Another student (US393) noted that conducting these classes using a workshop format would be more enlightening. Two students also called for more opportunities to conduct student dialogues with youth leaders and field experts. A student (US011) stated that dialogues could encourage students to openly discuss drug abuse topics, which may be considered taboo in some communities. Another student (US410) suggested that student dialogues would also increase interaction and provide students with time for proper discourse on drug abuse and its effect on society and the economy.

Help resources. Seven students reported that information which helped identify help resources to seek professional assistance and develop resilience was a useful aspect of drug prevention programmes. A student (US011) viewed that information on resources for help would ensure faster and safer action to aid peers who exhibited symptoms of drug abuse while another student (US412) noted that such information was beneficial in circumstances when an individual has accidentally consumed an illicit drug. Eight students viewed that prevention programmes in school were able to help students build resilience against drug abuse. Two students (US311 and US448) noted that this could be achieved through sufficient exposure to information about various drugs; treatment approach and help resources, which would increase their level of knowledge, curb curiosity and instil resilience against drug abuse. Additionally, four students reported that an exposure to good coping skills was among the help resources provided to them through drug prevention education in school. A student (US238) disclosed that students were taught methods to manage stress levels and problem-solving pathways that could be used as an alternative to drug abuse. Another student (US352) affirmed the importance of having health professionals conduct clinics to educate the public about methods of identifying drug users and motivational strategies to encourage young drug users to seek treatment. Motivational talks by school counsellors were also viewed as equally essential and beneficial.

Five students perceived good social support as important components towards drug prevention and helping peers who were involved in drug abuse. A student (US304) asserted on the importance of unconditional love and support from family members in helping drug users overcome their drug dependency. Good social support is also important in drug prevention as choosing peers who live positively and healthily will influence the young to maintain a healthy and drug-free lifestyle.

Prevention. Thirty-nine students reported that early prevention was extremely beneficial to them. Two students (US161 and US428) recommended early exposure to information such as circumstances that led to drug abuse, the consequences of drug abuse and prevention strategies from a young age (i.e., primary school) as it could curb curiosity about drugs, which is a main driving force towards drug experimentation. Four students also reported that students were only briefly introduced to the concept of moulding the right attitude towards drugs despite its importance. According to a student (US099), students would be more likely to avoid misusing drugs with a thorough understanding of the dangers of drugs and positive attitudes towards drug users who are recovering could be formed with a deeper understanding of societal perceptions about drug users. It was suggested that recovering drug users should not be viewed as criminals indiscriminately without understanding the reasons for involvement in drug abuse and equal opportunities for education and work should be given, regardless of their background.

Having a wide exposure to a wide variety of knowledge on drug abuse and prevention was important to three students in terms of making informed decisions. Two students (US159 and US285) noted that learning about drug abuse and its consequences from different perspectives would empower students with the required knowledge to avoid drug abuse and motivate them towards making the decision to live healthily. Lastly, fourteen students viewed that the introduction to a variety of mentally and physically healthy activities was a good method to prevent students from getting involved in drug abuse. A student (US017) suggested that fun and useful activities such as sports, regular exercise, cooking healthy meals, learning of a musical instrument, self-defence techniques, dance and fitness training should be promoted to encourage a healthy lifestyle among the young and increase the repertoire of positive activities that they could engage in their pastime, instead of experimenting with drugs.

From the qualitative themes above, it was found that most university students perceived drug prevention programmes as useful because of: (a) the provision of in-depth information about the consequences of drug abuse, drug myths, and shared experiences of drug users who have recovered from drug abuse; (b) its role in spreading awareness about various drug types in the market and potentially dangerous situations that could lead to drug abuse; (c) the use of interactive and visual methods to present important information; and (d) early exposure to drug prevention. Only a minority of students perceived that information on help resources were useful because it identified accessible resources and helped build resilience against drug offers. This finding highlighted the need to increase accessibility to information on help resources (assertion and coping skills, rehab services, and contacts of health professionals specialising in drug addiction cases) in drug prevention education so that students are able to seek appropriate help for themselves, a peer or family member who may be involved in drug abuse.

1.      Prevention programme limitations

The students reported eight primary limitations in past drug prevention education or activities. Seven students did not respond to this survey item, as they were unsure about the weakness of prevention activities they had experienced.  A summary of the themes, sub-themes and representative quotes can be seen in Table 16.

Dry talks and exhibitions. Sixteen students reported that the talks and exhibitions conducted in drug prevention programmes were unexciting. A student (US004) noted that some programme facilitators delivered talks in a monotonous manner, resulting in a drop of interest from the students despite the good intentions of drug prevention activities. Another student (US418) did not find the exhibitions useful and was doubtful whether students would take the time to go through the exhibition items. Moreover, this student felt that drug prevention information was often dispensed from a general perspective using uninteresting videos and lectures.

Lack of hands-on activities.This second limitation was reported by 13 students. A student (US002) disclosed that some activities in the drug prevention programme did not involve active participation from the students, which was unfortunate, since hands-on activities have a greater impact. This opinion was supported another student (US452) who recommended that students be encouraged to participate actively as the knowledge gained by students involve input from facilitators, their peers and themselves.

Generic information. The third limitation was reported by 10 students, based on their experience. A student (US074) disclosed that the messages sent out during drug prevention activities were often vague such as not mixing with the wrong crowd and calls for strong family support. However, methods to identify whether their peers were mixing with the wrong group and how to provide strong family support were not discussed. Another student (US245) also felt that the precautions and advice which were given from a normative perspective did not sufficiently cover all aspect of drug prevention.

Lack of drug information. Four students reported the fourth limitation. A student (US173) disclosed that past drug prevention programmes in school did not provide students with the exposure to information on various types of drugs, its origins and side effects of drug misuse. This student also cited that drugs were often grouped together without clear distinction of the different classes of drugs and its medicinal uses. Another student (US405) added that there was also insufficient guidance provided on methods to identify an individual who was high on drugs or experiencing drug withdrawals.

Lacking of support services. The fifth limitation as suggested by 3 students was a severe lacking of support services. A student (US048) remarked that despite the usefulness of counselling programmes, there were no counsellors available in school to explain about drug abuse and methods of overcoming drug addiction. Another student (US201) felt that there was insufficient support and motivation from the government in regards to the organisation of drug prevention education and activities in schools.

Use of unsuitable language. Three students also reported the use of unsuitable language by the programme facilitators as the sixth limitation. A student (US133) revealed that the language used for communication with students and the public was full of jargons, which made it difficult to comprehend. Consequently, another student (US152) reported that the inability to understand contents of the talk have resulted in inattention and disinterest from students.

Ineffective knowledge environment. Eighteen students highlighted a need to modify the content and context in which knowledge was disseminated. Two students (US163 and US341) particularly felt that the information were presented in an unclear manner and suggested the use of interactive teaching and learning styles. Four students felt that suitable timing of prevention programmes should be set. A student (US039) felt that drug prevention programmes should be conducted more frequently within the year instead of once annually. This student viewed that frequent reinforcement of knowledge is necessary for prevention programmes to be effective. Another student (US062) supported this view and observed that drug prevention programmes in school are not effective as it was held infrequently. Furthermore, two students felt that it was important to reform educators’ mind-set about drug abuse issues. A student (US140) viewed that educators are having problems teaching and explaining concepts on drug abuse due to societal and personal inhibitions against drug abuse issues. Another student (US407) felt that the school authorities were not committed towards the drug prevention cause, resulting in ineffective transfer of information. One student (US020) also cited an increasing need to widen target groups of prevention programmes to include working adults in addition to teenagers, in line with current changes in user demographics. Another student (US087) re-emphasised the need to tailor age-appropriate drug prevention information to increase the effectiveness of campaign messages.

Narrow impact. There a few reasons given by the students in explanation for the narrow impact of past drug prevention activities and programmes in schools. Firstly, a student (US244) reported that student inattention was a problem as it was difficult to get students to pay attention to serious public health topics like drug abuse. Secondly, a reverse effect could occur in some minor cases. For instance, it was reported by a student (US408) that exposure to certain drug information could create more curiosity and encourage school students to misuse drugs as a way to rebel against school rules. Thirdly, a student (US050) noted that the presentation of information about drug users in a particular way could further instil stigma and reinforce societal prejudices against drug users. Fourthly, a student (US434) viewed that despite being educated on drug prevention, strong peer influence has a bigger impact on school students and they are more likely to use drugs if their peers do. Finally, a student (US313) reported that no strict action from authorities in school and the community against students who were caught using drugs provided the message that drug abuse is acceptable and not as serious an issue as illustrated by drug prevention programmes.

From the qualitative themes showed above, there were four limitations that were most evident in past drug prevention education programmes: (a) the presence of an ineffective knowledge environment (unclear presentation of information, infrequent timing of programme, narrow target groups, use of unsuitable language and reform of educators’ mind-set about drug abuse and drug users); (b) the common format of dry talks and exhibitions; (c) limited hands-on activities that could retain students’ interest; and (d) the dissemination of generic information on drugs and methods of prevention. This finding highlights a need to further improve the content and format of presenting updated and in-depth drug education and prevention information to students. Furthermore, drug prevention education should be carried out in approaches that are relevant and interesting.

1.      Suggestions for improving drug prevention education

The students were also provided the opportunity to suggest improvements that could be made to drug education and prevention programmes at the school level (see Table 17) and college or university level (see Table 18). The students were asked to provide suggestions for improvements at the college or university level with the purpose of determining whether issues that undermined the effectiveness of drug education and prevention programmes at the school level still exists at the tertiary education level. Moreover, it could be investigated whether students had similar or different educational needs in relation to social health issues such as drug abuse at the school versus college and university level. Eight students did not provide any suggestions for improvement at the school level while thirteen students did not provide suggestions at the tertiary level because it was felt that drug prevention activities were adequate or the students did not know how it could be further improved. One student highlighted the fact that she could not provide any suggestions for improvement at the university level because her university did not conduct any form of drug prevention education.

Nevertheless, thematic analysis of student responses across both education levels indicated that there were six areas of improvement that could increase the effectiveness of drug education and prevention programmes which are change in dissemination method, coping skills, knowledge intensity, help resources, phenomenological experience and stricter action. Additionally, the students perceived that at the school level, there should be a greater focus on prevention efforts.

Change in dissemination method.Thirty-two studentsfelt that there should be a change in methods of disseminating drug prevention information at the school level while twenty-four students felt this change is still needed in drug prevention programmes at college and university level. At school level, 94 students cited that it was imperative that interactive learning styles be used to instill an interest among school children about drug abuse topics. According to two students (US039 and US054), this interest could be initiated through academic subjects such as Science and Chemistry and workshops, with the opportunity to conduct interesting experiments on chemical reactions of various drugs found in drugs and its subsequent consequences to the body in addition to analysing case studies. Social and cultural programmes with drug prevention themes was also suggested by the students as an interactive way of learning through theatre and music. This suggestion was similarly found at college and university level, in which 28 students viewed that students should be educated on drug abuse and relapse topics using visual and interactive learning styles. Two students (US324 and US404) proposed organising video and filmmaking competitions to showcase the impact of drug abuse and present drug prevention messages using creative concepts. Fourteen students viewed debates and student dialogues as a form of discourse that would allow an exchange of insightful ideas between fellow students in secondary schools, public and private universities. Two students (US313 and US323) particularly felt that university students should lead by organising dialogues and forums during drug prevention campaigns because they are educated and should be sufficiently matured to do so.

Forty-two students also suggested introducing school children to healthy activities. Two students (US024 and US104) in particular, proposed that fun activities that encourage interaction and hands-on games and activities should be organised in drug prevention programmes to teach school children about the effects of drug abuse and healthy methods of managing life stresses lifestyles. Another student (US263) emphasised that school children should be taught healthy living skills such as fun exercise routines, healthy and balanced eating habits and resilience against unhealthy social influences by health and fitness professionals, from an early age. Similarly, 22 students viewed that knowledge and practice of healthy habits should be reinforced at college and university level through exposure to more healthy activities. A student (US055) recommended encouraging college and university students to exercise within a stimulating and secure environment. Another student (US347) proposed that college and university students should actively involve themselves in green events, which would raise awareness about healthy living. A student (US278) also recommended participation in extra-curricular activities such as outdoor and indoor activities that would encourage positive socialisation and living healthily without drugs.

Although learning through research is less commonly practiced at school level, two students recommended that this learning strategy be introduced to school children. A student (US389) felt that the process of doing an assignment that requires them to learn about various drugs and its effects on the brain and human body as a whole could ultimately increase awareness and understanding about drug abuse among school children. Another student (US460) noted that the use of self-research as part of class assignments could inculcate the initiative to seek and share useful information about social health issues like drug abuse and drug prevention. However, six students viewed that there are greater opportunities for learning through research at college and university level. For instance, a student (US383) reported that college and university students are given more autonomy in research assignments by designing their own study, collecting data through interviews with young drug users and analysing statistical data annual drug usage. Another student (US397) noted that including drug abuse as an assignment research topic could increase interest among youths to learn and investigate current issues surrounding drug abuse. In addition, a student (US333) viewed that hands-on approaches like lab experiments should also be encouraged and conducted in college and universities to allow youths to see the effect of drugs on mice samples and subsequently, relate it to humans.

In addition to this, three students (US055, US064 and US459) suggested creating opportunities for mentorship at school and university levels. Despite the fact that mentorship is an opportunity for youths to receive good coaching as stated by a student (US055), another student (US064) highlighted the issue of having limited experts in the field of drug abuse treatment to teach and guide interested youths. A student (US459) also proposed that it would be useful to have recovered rehab patients participate in a mentor-mentee programme to share their past experience and educate school children and university students on avoiding drug abuse. A student also suggested organising short-term social work at school level while 10 students proposed conducting voluntary work with health professionals at college and university level. The student (US205) urged local schools to make arrangements which would allow school children to work voluntarily at rehab centres during weekends and school holidays. At college and university level, a student (US199) suggested that community reach-out programmes be organised, in addition to voluntary work in rehab centres, as a way of educating the public and students about drug abuse as well as treatment and recovery issues.

Additionally, another student (US355) felt that college and university students should be more proactive in raising public awareness about drug abuse and treatment issues. Thirty-two students were in accord that college and university students could do more to increase public awareness. For instance, a student (US201) proposedsetting-up a society which conducts campaigns and seminars to educate the public about drug abuse, its consequences and prevention strategies. Besides this, a student (US060) also recommended that websites by organisations involved in drug abuse treatment and prevention should be publicised so that reliable and credible information are able to reach wider audiences. As part of drug prevention campaigns in tertiary education institutions, it was suggested by a student (US329) that information booths with useful information on drug abuse, treatment services and facilities as well as prevention methods be set up and made open to the public.

Coping skills. Ten students perceived that more efforts towards strengthening coping skills among school children was needed. In the view of nine students, resisting peer pressure is the primary coping skill that should be taught to school children. A student (US020) felt that school children should have higher self-confidence rather than being easily influenced by their peers and the social environment. Two students (US033 and US075) also noted that school children needed to be resilient against peer pressure to use drugs and achieve awareness that using drug is not right nor a norm for every teenager and young adult. Additionally, five students felt that stress management was another aspect that should be targeted at school level. These students recommended equipping school children with skills such as problem-solving techniques, healthy lifestyle habits and alternative methods to deal with stress.

Five students also felt that it was imperative that school children be guided on positive socialisation such as choosing their friends wisely and taking precautions against negative influences. Three students once again stressed the importance of teaching school children about assertiveness. For instance, a student (US033) suggested that school children could be taught simple but courteous methods of saying no when being offered and pressured to use drugs by their peers. In addition to this, two students perceived that there should be more efforts to instil self-confidence among school children.  For example, the students (US020 and US371) noted that children should learn how to maintain their confidence and decisiveness when handling peer pressure as well as a sense of independence. Two students also felt that responsibility towards actions and religious guidance should also be emphasised from an early age. The student (US020) felt that school children should be taught the principle of bearing responsibility for the choices that were personally made. Another student (US206) viewed that early exposure to religious teachings through interactive medium like videos would help strengthen the moral development of school children. In addition, it was recommended that the religious perspective on drug abuse should be discussed at length when school students are able to comprehend the significance of such social issues.

At college and university level, 45 students were in consensus that there should be reinforcement of basic coping skills and expansion of new coping techniques. While the basics in stress management such as simple exercises, breathing techniques, meditation, eating a balanced diet and managing time properly have been taught at school level, 18 students reported the need to reinforce stress management techniques at college and university level. Three students (US021, US063 and US112) noted that it was increasingly important to learn and apply stress management techniques to deal with life stresses and the complexities of university social life, without having to rely on drugs such as anti-depressants (psychoactive pills). As noted by 8 students, positive socialisation was evermore important at college and university level. Two students (US248 and US365) cited that college and university students should practice healthy lifestyles and socialisation by participating in beneficial activities like motivational programmes, club and societies as well as increasing their circle of like-minded friends who practice healthy lifestyles. Seven students observed that assertiveness training was also important in college and universities because youths were increasingly vulnerable towards pressure from peers to engage in risky behaviours as part of the process of socialisation. Seven students also recommended that college and university students be given more guidance on increasing and maintaining student motivation. Two students (US338 and US367) suggested that an elevated motivational programme and clinical sessions be conducted in college and university to help those who are at-risk of drug abuse besides guidance to resolve personal issues using healthier methods.

To five students, responsibility for actions are as important in college and university as in school. A student (US011) cited that it was essential for college and university students to learn and explore more about the self and making decisions upon assessing the consequences of their actions. Another student (US162) felt that the individual has to take responsibility for their own actions if they insist on engaging in drug abuse because it was the outcome of their own will. Spiritual guidance was viewed by four students to be equally important at college and university level. A student (US146) perceived that youths should have greater exposure to the spiritual guidance offered by various religious teachings to strengthen self-confidence. Another student (US316) also noted the importance of youths understanding where their beliefs stand in relation to drug abuse. A student (US382) further highlighted the need for youths to know about karma and religious consequences, through educational films, as this could help deter college and university students who are most at-risk from drug abuse.

A student (US021) also perceived the need for more exposure on drug-related pregnancy, which is considered a drug-related social issue. In the student’s opinion, college and university students should be made aware of available support and educated on necessary coping skills since drug abuse increases the tendency of risky behaviours such as early sexual activity.

Improving knowledge intensity. At school level, 187 students perceived that there should be an emphasis on providing school children with in-depth drug abuse information. According to a student (US006), school children should be provided greater exposure to drug knowledge, method of drug production and its effect on the body system through academic subjects such as science, chemistry and biology. Two students (US011 and US190)  further recommended that visiting sessions at the drug rehab centre would be useful as interactions with a patient in recovery could help provide school children with a realistic perspective of different drug types that were commonly used, potential dangerous situations leading to drug abuse, the real consequences of drug abuse to health, and the beauty of having a normal, healthy life. According to 151 students, exposure to in-depth drug abuse information was still important to college and university students but should be provided in greater depth and range. A student (US060) commented that as university students become more proactive in their learning approach, updated links to credible and reliable information from organisations and official websites should be made easily accessible. Another student (US213) suggested that increased exposure to case studies that would enable college and university students to understand various causes of drug abuse, progression of drug abuse, related symptoms, impact on life and the possible treatment solutions was needed. Besides the health consequences of drug abuse, a student (US013) felt that college and university students should also be made aware of its legal consequences.

This sentiment was agreed by 152 students, who felt that awareness of consequences from drug abuse should be inculcate at school levels. A student (US023) proposed that school children be given access to clear and honest assessments about the attractions which are associated with drug abuse and the long-term health complications that result from recreational drug abuse. Furthermore, a student (US195) commented that drug abuse was often associated with communicable diseases like AIDS and hepatitis C. Thus, it was suggested that it would be beneficial for school children to be educated on the causes of such diseases and how it spreads. According to a student (US042), school students must be made to fully comprehend the effects of drug abuse on their lifestyle, health, family, and friends in addition to the legal ramifications so that the younger population can make rational decisions to avoid drug misuse. At college and university level, 103 students proposed that a more comprehensive awareness of risk and consequences from drug misuse was greatly needed. A student (US056) suggested that since college and university students find stories to be more relatable, drug prevention programmes should include real-life stories that would educate them about the outcome or harm derived from drug abuse. Another student (US067) commented that it was also important to remind college and university students that the impact of drug abuse goes beyond the individual and often impacted families and the community. Moreover, youths should be reminded that there are multiple risk factors of drug abuse such as biological, social and environmental causes and it was not acceptable to use drugs for social purposes due to the associated high risks. Additionally, a student (US303) also cited that it was essential that college and universities increase the coverage of drug prevention programmes beyond prevention. It was suggested that awareness and knowledge on detecting drug abuse within the neighbourhood be included as part of drug prevention components.

Besides in-depth knowledge about drug abuse issues and their risk factors, 38  students felt that being educated on various drug prevention strategies was important at school level. A student (US397) felt that school students should be made aware of potentially dangerous situations that are conducive for accidental drug use as well as identify addiction symptoms and resources to help friends or family members who misuse drugs. Another student (US239) also recommended publicising information on healthy lifestyle habits to provide school children with some idea of ways to avoid drug abuse. According to 30 students,  learning prevention strategies was still important at college and university level. A student (US238) recommended implementing prevention strategies that would prevent college and university students from getting involved with illicit drugs such as providing them with the means and knowledge about drug-conducive situations and modus operandi that could increase the risk of unintentional drug use. Another student (US230) adviced that guidance on financial management should also be considered a drug prevention strategy as college and university students should be provided the skill set to avoid mismanagement of monetary resources, which could lead to involvement in drug abuse and drug selling. A student (US336) also suggested that drug prevention activities conducted in college and universities should include frequent talks, debates or student dialogues as one of the compulsory components to increase public awareness about public health issues like drug abuse and to stimulate critical thinking.

In addition to this, there were four areas that required further emphasis in drug prevention education at college and university levels.

Better publication of help resources. Twenty-five students cited a need for wider access to information on treatment solutions. A student (US064) particularly highlighted a need for more circulation of information on credible rehabilitation centres through social media and internet websites. Besides this, a student (US052) reported a need for greater presence from counselling units in colleges and universities. According to the student, the presence of counsellors during drug prevention activities would be useful as college and university students who realised that they may have a drug abuse problem after attending talks on drug awareness would know whom they could refer to for help. Another student (US190) also requested that clearer guidelines be provided on how to help drug users such as methods of establishing trust with peers who are abusing drugs and ways to encourage them to seek treatment.

Regularity of drug prevention programme.Three students raised the need to increase the regularity ofprogramme timing. Two students (US235 and US448) agreed that drug prevention programmes should be adequately paced throughout the year to reinforce knowledge on drug misuse and coping skills among college and university students. Another student (US321) recommended conducting brief drug prevention activities weekly with compulsory attendance to ensure that all college and university students received the drug campaign messages and the basic coping skills needed to avoid drug abuse.

Correcting public misconceptions. Two students noted the need to correct existing misconceptions about drug abuse and relapse. A student (US190) observed that more efforts in understanding drug users is needed in society. Moreover, this student felt that negative assumptions about drug users should be clarified and societal mind-set should be shifted, such that drug users who were previously treated as criminals should be viewed as patients requiring treatment as part of efforts to stop discrimination of drug users. Another student suggested that private agencies can do their part to raise awareness, dispel drug myths and helping the public to understand the true nature of drug abuse by organising or actively participating in drug prevention programmes in college and universities.

Awareness of health and legal policies. A student (US424) viewed that college and university students should be constantly made aware on the latest updates to health and legal policies involving drug misuse such as new drugs classified under the Dangerous Drug Act and drug penalties.

Help resources. Twenty-two students reported that there was a need to increase dissemination of help resources at school level. Three students (US007, US234 and US397) suggested that school children should be provided adequate information about telephone help lines, help resources for drug-related issues such as the person and location that they could refer to for treatment services in addition to how to how and where to report drug abuse especially when it involves a friend. Another student (US127) also recommended that contact details of social support groups should be better publicised as it would be useful to young people who are at high tendency of relapse. Thirteen students also felt the formation of a supportive treatment network is increasingly important towards encouraging young drug users to seek treatment. A student (US023) perceived that treatment providers involved in treating drug abuse should be trained in treatment pathways and demonstrate non-judgemental support to their patients or clients. Another student (US061) felt that the presence of counsellors in school should be increased to raise accessibility to counselling services among school children who are at-risk of drug abuse. A student (US235) also felt that the drug rehab system should provide more emphasis to family support and care as part of relapse prevention interventions. Furthermore, nine students viewed that the scope of information on rehabilitative treatment provided at the school level should be expanded. A student recommended drug prevention programmes to provide updated contact information of rehab services within the local vicinity. In addition, another student (US051) suggested that treatment strategies to overcome drug addiction and the roles in which family members and peers could play in recovery should be clearly outlined. A student (US060) also would like to see future drug rehab programmes providing these information in a simple and easily comprehended format.

At college and university level, increasing dissemination of help resources was similarly viewed as an important part of prevention education by 29 students. A student (US001) reported that since college and university students are within the most at-risk group, more detailed information about help resources like counsellors, hotlines and government agencies whom could provide assistance with problems which could lead to drug abuse should be made easily accessible. Moreover, the student felt that college and university students should be made aware of the confidentiality of counselling sessions to encourage them to seek help. This sentiment was similarly found at school level, in which two students (US401 and US418) suggested establishing confidential one-to-one counselling sessions to help school children resolve the root problems to stress issues and understand the reasons why drugs should never be considered an option towards managing stress.

In addition to increasing accessibility to clear treatment pathways and non-judgemental support from treatment providers, a student (US014) felt that young drug users should also be provided access to youth workers and mentors, whom they could relate well with, while working on building resilience against drugs. Additionally, 12 students recommended the provision of easy access to free health support services to college and university students. Two students (US071 and US072) proposed conducting free health checks including urine tests, to encourage college and university students to be more aware of their physical health, and workshops that provide guidance on living healthily without drug abuse. Another student (US086) also suggested that the university collaborate with health professionals to conduct counselling and mental health workshops as well as additional private sessions for students with serious issues.

Four students highlighted the need to establish more peer support groups in college and universities. Two students (US190 and US395) proposed that peers should be trained to understand problems from the young drug user’s perspective. In addition, both students felt that peer support groups can be mobilised as part of the counselling unit or involved in organising student camps, which would allow them to share their problems freely with similar-aged peers. Besides that, a student (US200) suggested that peer groups could also extend their roles in raising awareness and appreciation for what they have by organising meaningful events such as charity projects within the community.

Phenomenological experience. Experiencing drug abuse issues from the perspective of drug users and treatment providers was viewed as an important element of drug prevention education by 92 students at school level and 101 students at university level. In order to introduce this element, 32 students suggested that the school organise field visits to drug rehab centres. Three students (US004, US032 and US322) explained that the field visit to government and private rehab centres would create more awareness about drug abuse issues, allow school children to speak and listen to the experiences of former drug users as well as personally view the effects of drug abuse. Another student (US138) proposed that school children should be given the opportunity to shadow rehab staff in-charge of help lines during field visits to experience how difficult it is to convince individuals with drug addiction problems to seek proper treatment. This student further noted that the real-life perspective of dealing with drug abuse from the patient and treatment providers’ view would have more impact as compared to countless motivational speeches. Fifty-eight students felt that college and university students would also benefit from field visits to drug rehab centres. Four students (US015, US023, US032 and US050) reported that field visits to rehab centres were an eye-opening experience as it allowed them to understand the reasons why some individuals got involved in drug abuse and what motivated them to deal with the addiction. Besides this, the students reported that they were able to witness the sad side-effects of drug abuse and their rehabilitative progress after treatment admission. A student (US103) also suggested letting college and university students participate in sharing sessions and talks with former drug users while another student (US151) suggested that they should be given the opportunity to do volunteer work at rehab centres to help and provide a support network to recovering rehab patients.

Stricter action. Stricter consequences towards school and university students who were caught with drug abuse was viewed by the students as necessary towards understanding the consequences of their own actions. At school level, 10 students proposed that the school authorities and police officers who were assigned to monitor schools should carry out appropriate punishments. A student (US099) suggested that hard punishment should be carried out as drug abuse is a serious offence while another student (US270) believed that school children should understand the effects and detection methods of drug abuse before relating it to the designated punishment. A student (US232) also proposed that school children be made aware of the legal punishment for drug distributors besides the legal consequences of drug abuse.

Additionally, seven students felt that school authorities should conduct regular monitoring to deter school students from getting further involved in drug misuse and dealing. Two students (US237 and US252) suggested that blood and urine tests should be conducted annually to detect drug misuse. Another student (US399) would  also like to have stricter government and enforcement policies implemented in circumstances involving underage children who were found to be involved in any form of drug activity.

At college and university level, stricter rules and action against drug abuse were merited more than ever. Fourteen students were in agreement that regular monitoring would serve as a deterrent to college and university students. Two students (US231 and US409) recommended that colleges and universities conduct routine or annual urine and blood tests as part of university regulations and establish a punishment or demerit system for students who were caught for drug abuse. Another student (US180) also proposed that a reward system be established to provide educational incentives to college and university students who obtained clean and negative drug test results.

Prevention efforts.As stated earlier, there were also calls from students for greater emphasis on prevention efforts at school level. Twenty-two students felt that public health programmes organised by NADA, PEMADAM and other non-govermental organisations (NGOs) in schools could be further improved. A student (US111) suggested that the organisers of public health programmes should take the opportunity to widen their educational span to include other social and health issues that are correlated with drug abuse such as domestic violence, sex education, and AIDS/HIV. Moreover, another student (US334) felt that public health programmes should be tailored to address current drug abuse trends and prevention strategies such as how to avoid being duped into drug use. A student (US160) further highlighted a need for public health programmes to progress in content and style of presentation, in line with the advancement in virtual technology. For instance, it was suggested that attractive display exhibits could be created using graphic design softwares public presentations and talks could be made interesting with the use of visual and interactive aids like PowerPoint and videos. Additionally, the student also proposed that videos and visuals of talks and displays could be uploaded and made accessible to the public through social media (e.g., Facebook, Twitter, Instagram) and YouTube to increase the impact of its health messages. To increase public awareness and generate more interest in drug abuse issues, the student also suggested that public health programmes feature field experts, with access to on-site counselling or voice and video calls with health professionals.

Additionally, seven students respondents felt that early intervention practice is more effective in dealing with drug abuse and prevention among school children. Two students (US062 and US119) recommended that school children be educated about drug abuse and dangerous circumstances that they should avoid from an early age, since prevention was better than cure. Another student (US133) also viewed that school children should be made to understand the dangers of drugs to the self and how  involvement in drug abuse could cause anxiety to their parents.

Besides this, the students felt drug abuse prevention should involve the co-operative effort of all parties involved in a child’s development. Five students felt that teacher roles in drug prevention should be more clearly defined and prominent. A student (US175) clarified that since teachers were familiar to school children and often viewed as role models, they were better placed to facilitate drug prevention education and make an impact. This suggestion was made based on the student’s past observation of some secondary school peers who tended to assume knowing everything about drugs and did not pay full attention towards programmes conducted by external facilitators. Another student (US295) viewed that teachers could play a more prominent role by mediating talks or forums about drug abuse and prevention as well as actively feedback on how schools should address drug abuse when it involves their students. A student (US405) also felt that it was the teacher’s responsibility to teach school children useful skills such as identifying different types of drugs and its dangerous consequences and techniques to resolve personal problems using non-harmful ways.

Four students also viewed that parental roles were equally important in preventing drug abuse among school children. A student (US180) felt that some parents should be more invested in their children’s social and emotional development, and allocate time for parent-child counselling sessions when problems such as drug abuse and general misbehaviour is detected. Another student (US413) also felt that parents have the responsibility to learn more about drug abuse issues and explain to their children about the dangers of drugs. Furthermore, a student (US267) proposed that guidelines and strategies to address drug abuse and prevention should be a topic of importance in Parents and Teachers Association meetings as well as school assemblies.

Two students also highlighted the issue of limited societal roles in drug prevention up till now. A student (US137) emphasised that it is the citizen’s role to prevent drug abuse within their community and thus, influential members of the society need to step-up to educate their community about drug misuse and drug prevention. Moreover, a student (US147) viewed that every member of society should be well-educated about how to prevent oneself from getting involved in drug abuse and should advice those who are less knowledgeable.

From the qualitative feedback above, it can be concluded that there are much improvement needed for drug prevention education at school and tertiary education levels to create an impact on students. In particular, students perceived that there were six areas in drug prevention education that could be improved: (a) change in dissemination method (e.g., the use of interactive learning styles such as learning through research, and the introduction of healthy activities); (b) expanding the range of coping skills taught to students; (c) increasing knowledge intensity of drug prevention education (e.g., updated information about new drug types, consequences of drug abuse and life experiences as shared by former drug users); (d) increasing dissemination of help resources (e.g., pathways to accessing support networks, treatment services and counselling sessions); (e) phenomenological experience (e.g., field visits to personally view treatment process and sharing of patients’ experiences through stories); and (f) stricter action (e.g., enforcing harsh punishment for drug distributors, and regular monitoring of school and university students via urine testing). At the school level, the students perceived a need for more focus on prevention efforts. This means that parents, teachers and society through participation in public health programmes and engage actively in early prevention interventions. At college and university levels, the students perceived that improvements were needed in four areas: (a) better publication of help resources (e.g., providing in-depth information on credible hotlines, professional counsellors, rehab centres, health support services and clear guidelines on procedures to help drug users); (b) regularity of drug prevention programmes (e.g., conducting weekly activities or pacing drug prevention programmes throughout the year); (c) correcting public misconceptions (e.g., correcting negative assumptions about drug users and stopping discrimination by treating drug users as patients instead of criminals); and (d) awareness of health and legal policies (e.g., increasing awareness about updates on classification of new drugs or new drug penalities under the Dangerous Drugs Act).

6. Summary

In summary, significant gender differences was prevalent in university students’ perceptions of drug abuse factors and effective relapse prevention strategies. Female students were significantly more likely to view unemployment (dispositional factor) as a reason for drug abuse. Furthermore, female students were more likely to perceive that multiple strategies (help-seeking, change and social activities) were effective in preventing drug relapse. Although no significant gender differences were found in students’ perceptions of drug relapse factors, lack of family support, lack of self-efficacy and peer influence were viewed as major factors of drug relapse.

Most students had basic knowledge about drug rehab services through drug prevention education. Nevertheless, there is a persistent belief that private rehab centres provide higher quality treatment services. In assessing students’ perceptions of drug types that are commonly abused and easily available, it was found that ecstasy and cannabis were perceived as most commonly abused and easily available, followed by heroin. Additionally, conventional mass media, online media and paper-based media were favoured by university students to search and share information on drug abuse, prevention and rehab services. Factors that influenced their choices include the ease and convenience of seeking and sharing information in creative forms and the wide accessibility to expert opinions. The fact that only a minority of students viewed the role of the community and face-to-face communication as effective means of sharing information highlights the need for: (a) greater involvement from the local community in educating and raising awareness about drug abuse and prevention; and (b) greater promotion of face-to-face events in urban and rural areas.

From the students’ evaluation of past drug prevention programmes, it can be concluded that past programmes were beneficial towards: (a) providing in-depth information about the consequences of drug abuse, drug myths, and shared experiences of recovered drug rehab patients; (b) spreading awareness about illicit drugs available in the market and psychosocial factors of drug abuse; and (c) early exposure to drug prevention. Only a minority of students viewed that the help resources were useful in identifying accessible resources and building resilience. This finding highlighted the need to increase public accessibility to a wider range of help resources (assertion and coping skills, and contacts of health professionals specialising in drug addiction cases). There were four major limitations identified in past drug prevention programmes: (a) the presence of an ineffective knowledge environment; (b) the common format of talks and exhibitions; (c) limited hands-on activities to retain students’ interest; and (d) the dissemination of generic information. These findings suggest a need for further improvement in the content and format of presenting information to students through interactive learning approaches that are relevant. In order to create meaningful impact to students, improvements in six areas were suggested for drug prevention education at school and tertiary education levels: (a) change in dissemination method (e.g., using interactive learning styles and introducing healthy activities); (b) expanding the range of coping skills; (c) increasing knowledge intensity in content; (d) increasing access to help resources; (e) providing phenomenological experience (e.g., field visits and sharing of patients’ experiences); and (f) stricter action from local authorities, school and universities. Additionally, the findings suggest a need for more involvement from parents, school teachers and society in public health programmes and early prevention interventions. Furthermore, the findings also suggest a need to: (a) increase regularity of drug prevention programmes; (b) correct public misconceptions and stop discrimination; and (c) increase awareness of health and legal policies at college and university levels.

Chapter 5: Investigating experiences with using and treating drug abuse from the perspective of the rehab patient and staff sample

Mixed method analysis was conducted in response to the sixth, seventh and eighth research questions. Quantitative data such as patients’ drug history, patients’ assertiveness against drug offers, as well as patients’ and peers’ relationship with their families were analysed using IBM SPSS 20. Qualitative data such as drug abuse progression trend, factors for drug abuse and relapse, motivation to change drug abuse behaviour, and reasons for entering drug rehab treatment were categorised and analysed through thematic analysis procedures and techniques using the NVivo 10 software.

To compare the extent in which patients’ responses were similar or differed from interviews with the government and private rehab staff, qualitative data such as factors for drug abuse and relapse, and reasons for entering drug rehab treatment were categorised and analysed through thematic analysis procedures and techniques before conducting constant comparisons.

1. Research Question 6:What user patterns would emerge in regards to drug abuse progression, and conditions of family and peer relationships?
   1. Patients’ drug use history

As shown in Table 19, marijuana/cannabis was the drug with the highest record of usage among 19 patients in private and government rehab centres. The second, third and fourth highest recorded drugs used were heroin (n=18), methamphetamines (n=14) and ketamine (n=7). Six patients also reported the use of psychoactive pills. Based on the record of use, ecstasy, morphine and erimin-5 were less commonly reported among the rehab patients.

2.     Drug progression trend

During the interview sessions, data on patients’ drug abuse patterns and type was collected and examined to determine the prevalence of a progression pattern of drug abuse (i.e., from soft to hard). Out of 30 patients, a slightly higher proportion of rehab patients (n = 15) did not demonstrate the progression trend as compared to those who did (n = 13).

Out of 15 private rehab patients, seven patients demonstrated a drug progression pattern from soft to hard drugs while another seven patients did not. Among the seven patients who did not follow the progression trend, three patients used only hard drugs and three patients demonstrated atypical patterns: hard-soft-hard, hard-soft-intermediate (i.e., contains both hard and soft properties), and hard-intermediate-soft. One private patient started with soft drugs, experimented with an intermediate, before going back to a soft drug. In addition to this, one private patient demonstrated a partial progression pattern of drug abuse, with oscillations from soft to hard, and subsequently to an intermediate drug.

Out of 15 government rehab patients, eight patients did not demonstrate the drug progression trend while six patients did. Among the eight patients who did not follow the progression trend, six patients used hard drugs only, one patient demonstrated an atypical hard-intermediate-soft drug pattern while another patient used soft drugs only. Similarly, one government patient demonstrated a partial progression trend (i.e., oscillating from soft to hard drugs, and subsequently using an intermediate drug).

It was also noted that drug abuse patterns involved either poly-drug (i.e., several drugs used in rotation) or mono-drug use (i.e., one drug throughout their entire history). Further examination of the data revealed that a majority of government rehab patients were poly-drug users (n = 12) with the remaining three patients being mono-drug users. In the private rehab centre, there were eight poly-drug users and seven mono-drug users. An examination of the period of addiction revealed a wider addiction range for government rehab patients, between 3 months to 40 years. The addiction range for private rehab patients was between 5 to 33 years.

3. Patients and peer relationships with the family

Most patients and their peers (n=25, 83.3%) reported having normal relationships with their parents and family. This means that the patients had a close relationship with their parents and reported receiving parental love and support. The family environment was also reported as harmonious, with constant communication between family members. A higher proportion of patients was from families with stable incomes and had parents with no history of drug abuse or behaviour problems. Besides this, most patients had friends from normal backgrounds in which they were not isolated or suffered rejection or hostility from their parents. Moreover, most of their peers did not demonstrate clinical levels of rebelliousness and problem behaviours such as getting involved in fights, stealing and robbery. Only five patients and their peers (16.7%) reported experiencing poor relationships with their parents and family members.

2. Research Question 7:What are the levels of assertiveness against drugs exhibited by rehab patients at the point of treatment?

The analysis of assertion scores showed that out of 30 patients, 14 patients (46.7%) reported themselves as assertive in resisting drugs when offered by their friends or strangers in a social party. This was followed by 10 patients (33.3%) who reported being extremely non-assertive when faced with drug offers. Only six patients (20.0%) felt extremely assertive in resisting drugs offered by strangers or preventing friends from bringing drugs to their house. All patients revealed that they would only use drugs outside the house, as they did not want their family to know about their drug abuse.

3. Research Question 8:To what extent are rehab patients’ responses about factors for drug abuse, drug relapse, and entering treatment similar and different to responses from the rehab staff, and what factors would motivate patients to change drug abuse behaviour?

The thematic findings indicate that there were major similarities between patients’ and staff’s responses about factors for drug abuse and entering treatment. Major similarities were also found in responses about drug relapse factors but there was greater range of themes found in patients’ responses. In addition, factors that motivate patients to change drug abuse behaviour could be divided into three categories: (a) intrinsic factors; (b) extrinsic factors; and (c) religion: extrinsic-intrinsic spectrum.

1. Contributory factors of drug abuse

Within the patient group responses (i.e., government versus private patients), six dominant themes were found: (1) peer influence (n = 29); (2) curiosity (n = 25); (3) tension release (n = 11); (4) enjoyment (n = 6); (5) family conflict (n = 6); and (6) personal problems (n = 6). Comparisons between the themes generated from patients and staff responses revealed that in addition to the six themes that were previously mentioned, unemployment also emergedas a factor for drug abuse.

Peer influence. Most patients had their first attempt with drugs when they were knowingly given a drug to try for fun and subsequently, became addicted to it. The drug pushers earned a lucrative income by selling drugs using the peer system. However, one patient (GP11) was reportedly caught for a drug offense after being given an illegal drug unknowingly by a peer during a group gathering.

‘…my friends were a primary factor for my involvement in drugs. They were drug pushers and often came to find me when they wanted to sell drug. It was a lucrative job for them as they sell the drugs for RM 100 when the base price is actually RM 50.’ [PP12]

‘I was at a gathering with my group of friends. My friend gave me a cigarette. At that time, I didn’t know it was laced with the drug.’ [GP11]

‘The first reason was my friends’ influence. They let me taste it and when I found that I like it, I started to search for more on my own.’ [GP15]

Staff from the private rehab centre (PS01 and PS04) concurred with patients’ responses, in which peer influence was a primary contributory factor to drug abuse, especially for social entertainment purposes in night outlets.

‘Probably influence from peers’ [PS01]

‘…it was mostly peer influence especially when entertaining their friends at the nightclubs.’ [PS04]

Curiosity. As their group of friends were mostly using drugs, patients like PP02, PP05 and GP14 were curious about how drugs would make them feel. A private patient (PP02) also admitted that he was too immature to think of the consequences of his actions at that point in life.

‘It was also about satisfying my curiosity about drugs. At that time, everyone around me was doing drugs.’ [PP02]

‘I was curious about what would happen when I take drugs.’ [PP05]

‘I was with the marines in my younger days. I saw the women I met in the disco in the 80s bringing some stuff with them. I was curious and tried some of it when they were not looking. It was drugs and soon after, I became hooked.’ [GP14]

The role of the media like the internet and television was perceived by staff as a major factor in raising curiosity among the younger generation about drug abuse. According to a private staff (PS04), some films or television dramas that portray drug abuse in a positive light (i.e., being a cool way of life) would lead the young to experiment with drugs to find out what drug abuse actually feels like.

‘The younger batch gets involved when trying to satisfy their curiosity of drugs based on what they see on the internet and TV.’ [PS04]

Tension release or coping mechanism. The use of drugs as a method to manage tension, stress and anxiety was more often cited among patients from the private rehab centre compared to the government rehab centre. For patients like PP02, drug abuse happen when psychoactive drugs are misused under stressful circumstances related to depression and anxiety. In addition, some patients like PP03 and GP12 used drugs to cope with academic pressure, which may have resulted from high parental and teacher expectations. For one private rehab patient (PP09), tension release was a side effect of drug abuse, which eventually became a motivating factor for subsequent drug abuse.

‘…I sought the use of drugs as a form of tension release because I was under stress and diagnosed as having depression.’ [PP02]

‘I often felt anxious and also took drugs as part of my method of dealing with all the tension.’ [PP03]

‘Seeking release from tension was not exactly a contributing reason to me, rather it was a side effect experienced from taking drugs.’ [PP09]

‘I was using it to release some tension from the academic stress I was feeling.’ [GP12]

The phenomenon of using drugs as a method to release tension was similarly observed by drug rehab staff and was viewed to be more prominent recently with the change in user demographics. Although tension release only featured in only about 5% of admitted cases as noted by a government rehab staff (GS04), another rehab staff (GS01) acknowledged that it was becoming common among professional and highly educated groups. A private rehab staff (PS05) also reported that drugs were used for various motives such as escaping from academic and social stress, or lowering inhibitions that may have affected the ability to socialise appropriately. It was observed by the same staff that drugs such as stimulants were used as an energy booster. The recent trend among students was to use drugs to increase mental alertness, to improve study rate and performance.

‘Using drugs as a way to release tension is skewed towards the highly educated group.’ [GS01]

‘Using drugs as a tension release component only features in less than 5% of the cases.’ [GS04]

‘They also use it as a way to cope with academic and social stress. But I noticed a new trend among the younger generation. More of them are using stimulant drugs to boost their energy for studying several days without sleep.’ [PS05]

Enjoyment. Enjoyment was solely cited by private rehab patients as a factor for drug abuse. For some patients like PP02, enjoying their youth involves experimenting and seeking new experiences. This often includes engaging in risk-taking behaviour such as drug abuse, for the purpose of fun and enjoyment. In addition, another patient (PP06) reported that drugs were also used to heighten enjoyment when socialising with their friends at nightspots.

‘It was something to do with age and for the enjoyment of it.’ [PP02]

‘My friends and I started taking drugs for the enjoyment during happy hour at the pub.’ [PP06]

The patients’ sentiment of drug abuse for enjoyment and for getting ‘high’ was similarly observed by a private rehab staff (PS02).

‘…quite many also take drugs just for the enjoyment and the feeling of getting ‘high’…’ [PS02]

Family conflicts.Family conflict was also reported as a drug abuse factor by three government rehab patients and three private rehab patients. Broken families, due to divorce or the death of a parent was cited as causes for conflicts as well as feelings of being unloved and neglect. The situation was often made worse when the remaining parent remarries, resulting in issues between the child and step-parent. Even within intact families, small conflicts occurred due to various reasons such as different parenting styles, financial issues, sibling rivalry as well as familial expectations and responsibilities. The patients reported that the pressure and tension from such family encounters often led them, who were in their teens or young adulthood, to resort to unhealthy methods of coping (i.e., drug abuse). Moreover, the frequent conflicts led to a lack of parental guidance on how to resolve problems.

‘There were also a lot of family issues and conflicts. At that time, my mother had passed away and I felt that there was no one around to love and care for me. Even my siblings did not want to talk to me.’ [PP03]

‘There were also issues with my family as my parents often had small fights.’ [PP13]

‘Family conflicts with my step-mother also sort of contributed to my habit though I have a good relationship with my father.’ [GP01]

A staff from the private rehab centre (PS01) concurred with findings from the rehab patients’ sample. The role of family conflicts as a contributory factor of drug abuse was acknowledged, although it was observed that there had been less drug abuse cases which stemmed solely from family conflicts.

‘Some family issues or conflict…could also contribute but there are less of these.’ [PS01]

Personal problems. Personal problems were reported as a drug abuse factor in higher frequency by five patients in the private rehab centre as compared to one patient in the government rehab centre. The government rehab patient (GP01) attributed his broken engagement with a loved one as the reason leading to drug abuse. A private rehab patient (PP06) reported experiencing health issues and was often in pain. Drugs which were firstly used as medical painkillers were eventually misused as the pain became worse. To some patients, personal problems were not only a contributory factor but also a side effect of drug abuse. For instance, a private rehab patient (PP12) started using drugs due to work and relationship issues. Subsequently, his drug habit resulted in more problems such as broken relationship, family conflicts, and bouts of aggression.

‘I was experiencing personal problems. I met a girl I liked while I was working and we got engaged. But not long after, the engagement was broken off.’ [GP01]

‘I was also having lots of personal problems.  I was sick and experiencing a lot of physical pain. I was using drugs as a painkiller but it didn’t work. Instead, it made the pain worse.’ [PP06]

‘…more personal problems came. My girlfriend broke off with me because of my drug habit. When I was under drugs, I never thought about my family or their feelings. Even though my brother and sister-in-law continuously advised me to stop, I was stubborn and refused to listen. I became quite aggressive and often fought back with my siblings when they commented about my habit. It was to the extent in which my parents preferred to give me money to buy drugs rather than have me resort to stealing.’ [PP12]

Only three staff from the private rehab centre cited personal problems as a contributory factor whilst all staff from the government rehab centre viewed that drug abuse occurs due to a variety of other factors besides personal problems.

‘…Others might have some personal problems in life that caused them to resort to drugs to cope and live day by day.’ [PS02]

Unemployment. Four patients from the private rehab centre also made reference to the dual role of unemployment as a predictor and outcome of drug abuse as shown in the quotes below. It was reported that when patients found themselves unemployed between inconstant jobs, they engaged in drug abuse to fill time. For others, unemployment was an outcome of drug abuse as they were unable to concentrate on their jobs when they were ‘high’ on drugs. This resulted in a decline in their job performance, which made it difficult for them to maintain a steady occupation.

‘In between jobs, I sometimes find myself unemployed and I took drugs to fill time.’ [PP01]

‘Unemployment was not a contributing factor to drug abuse but rather an effect of taking drugs. When I was under the influence of drugs, it was hard to concentrate on finding and maintaining a job.’ [PP03]

From the perspective of a government rehab staff (GS01), unemployment was a primary cause for drug distribution rather than drug abuse. Drug distribution was considered a lucrative method of earning money despite the risks.

‘Unemployment does not often lead to drug abuse but rather to the distribution of drugs.’ [GS01]

2. Drug relapse factors

The analysis of patients’ responses found that relapse factors were categorised into three main themes: (1) environmental factors, (2) personal problems and (3) methadone replacement therapy.

Environmental factors. There were four sub-themes present within environmental factors: (1) societal pressure, (2) life pressures, (3) neighbourhood factors and (4) family conflicts.

Societal pressure. Two private rehab patients (PP02 and PP13) reported resorting to drug abuse again because they were unable to deal with societal pressure. After leaving the rehab centre, patients have to re-integrate themselves with society, find employment and establish a new life routine. However, their peers have moved on to achieve success in their career, personal relationships and family life in the time whereby patients were involved with drug abuse and rehabilitative treatment. Constant comparisons with their peers by the patients themselves or their family led to feelings of guilt, stress, anxiety and depression. Thus, the only option in which they could escape from these emotions was to use drugs, which provides them with a happy and spacey feeling. Furthermore, both patients reported that upon recovery, they faced uncertainties about potential job opportunities and their capabilities to perform well in such jobs despite being taught vocational skills at the centre.

‘…was constantly comparing myself with friends who by then were working, married and have kids.’ [PP02]

‘I was under a lot of pressure from society and was unsure about the type of work I can do.’ [PP13]

The process of re-integrating patients into society was difficult because non-acceptance of drug users was still high among various communities, as reported by a private rehab patient (PP02). The situation was made worse when their own family did not accept them and they were left without the familial support needed to start over. Rejection from their family could lead them to associate with the only group that was perceived to accept them unconditionally, which were their drug user friends. This would increase the risk of relapse.

‘I expected my parents to understand me and immediately accept me back when I was out of the centre. But the reality was they didn’t really accept me.’ [PP02]

Life pressures. Upon establishing their new life routines, two government rehab patients (GP01 and GP02) reported facing life pressures such as inadequate work performance, working relationship conflicts as well as problems with personal relationships, friends and family. Such pressures were often overwhelming and the inability to deal with issues from multiple sources while trying to maintain a drug-free life has led patients to relapse.

‘I was also facing lots of life pressures at that time, be it work, relationships or friendships.’ [GP01]

‘There were constant family conflicts and work wasn’t going on as well as I hoped.’ [GP02]

Neighbourhood factors. This was reported by a government rehab patient (GP07) as a drug relapse factor. Staying in a location with high concentration of drug users and drug pushers eventually led the patient to engage in drug abuse again and subsequently, sell and distribute drugs as a form of livelihood.

‘…drug addicts staying in the same housing area.’ [GP07]

Family conflicts. According to a private rehab patient (PP06), family conflicts produced a tense and unstable environment for rehabilitated patients. The patient reported that the unhappy and stressful situations at home caused a relapse as he attempted to cope with fights and disagreements while trying to establish a stable lifestyle with a proper job. He was tempted to use drugs to escape and experienced temporary relief and happy feelings.

‘I was really unhappy and stressed at that time due to many family conflicts occurring.’ [PP06]

Personal problems. There were five sub-themes categorised under personal problems: (1) depression, (2) drug urges, (3) unemployment, (4) coping with work stress, and (5) energy boost.

Depression. A private rehab patient (PP03), who was diagnosed with depression by a psychiatrist, attributed this condition as one of the factors that led to a relapse episode. In this patient’s circumstances, his bouts of depression were instigated by distress due to broken relationships and non-acceptance from his family. Although anti-depressants were prescribed to elevate depressive mood, the patient reported a high risk for misuse of prescription medication without proper supervision.

‘I had depression due to broken relationships with my uncle and family.’ [PP03]

Drug urges. Nine patients reported that drug urges constantly occur during drug abuse, treatment and even post-treatment. A government rehab patient (GP06) reported being particularly susceptible to relapse when he was unable to stand the physical pain and mental suffering during drug withdrawals. For another patient (GP15), the urge and positive memories of taking drugs overshadowed the negative side effects of drug abuse during difficult circumstances. The pattern of drug abuse was also not constant as it depended on whether the drug user has the financial resources to obtain drug supplies. A private rehab patient (PP14) reported experiencing strong drug urges after a certain period of not using drugs and when he had sufficient money, it was used to satisfy the drug cravings.

‘I couldn’t stand the urge to take drugs, especially the pain and suffering from withdrawals.’ [GP06]

‘I couldn’t stand the urge and memories of taking drugs.’ [GP15]

‘…could not withstand the urge to take drugs. This was especially so when I had enough money to get a supply.’ [PP14]

Submission to drug urges was associated with two sub-factors, which are lack of willpower and drug accessibility. Seven patients perceived that the loss of willpower and subsequent submission to the strong urge to relapse was due to a variety of reasons such as missing the happy and spacey feeling from using drugs, the need to fit in with their friends (who are drug users), as well as to cope with the rejection or negative feelings received from the workplace or community. Although the contributory factors of relapse involve both external and internal influences, the patients in this sample were more likely to attribute their relapse episodes to the self (i.e., lack of willpower) as shown in the quotes below.

‘I was not strong enough and I fooled myself in believing that I could overcome it.’ [PP02]

‘I just wasn’t strong-willed enough to stand the urge of taking the drugs.’ [PP07]

‘…it was mostly due to my own lack of willpower.’ [GP08]

As mentioned earlier, the risk of relapse increases with greater drug accessibility. A government rehab patient (GP08) reported that he relapsed because he knew the source of illegal drugs very well (i.e., often a close family member or friend), which made it much easier for him to obtain drugs whenever there was an urge.

‘I knew the source of drugs very well.’ [GP08]

Unemployment. A private rehab patient (PP08) reported that unemployment at post-treatment was also a relapse factor as he had too much free time after failing to obtain employment. Other rehabilitated patients with prior record of relapse also reported that employers remained sceptical of their capabilities and would only offer low-paying jobs or odd jobs.

‘This was partly because I was unemployed after coming out from CCC, so I had too much free time.’ [PP08]

Thus, rehabilitated patients had to look for other means to earn a living. At post-treatment, there were patients who were still attracted to illicit drugs. A private rehab patient (PP03) admitted that upon release from past rehab centres, he sought employment for money to buy drugs but was subsequently lured into drug pushing, which ensured easy drug accessibility and lucrative profits from buying and selling drugs.

‘I was really looking for work to get more money to get drugs. Then I was introduced to pushing drugs as a job to get money and drugs supply.’ [PP03]

Coping with work stress. Among patients who were previously able to gain employment after treatment, two patients reported relapsing due to work stresses. For instance, a private rehab patient (PP15) admitted that the inability to meet personal expectations or lacking the necessary work skills have resulted in fatigue and frustration. These negative emotions triggered the urge to use drugs. Another private rehab patient (PP13) also reported that drugs were used for the purpose of releasing tension by escaping from reality for a short time. Three patients also reportedly relapsed from using drugs as a coping mechanism. A patient (PP01) admitted using drugs as a way of coping when he was unable to resolve work issues.

‘I was using drugs to cope when I couldn’t solve problems.’ [PP01]

‘…I relapsed into the habit to escape reality.’ [PP13]

‘When I am tired and have problems, I feel the frustration and then I end up taking drugs.’ [PP15]

Energy boost. Some patients who were employed as hard labourers relapsed simply due to the nature of their jobs. For instance, a government rehab patient (GP14) disclosed that he used amphetamines and cocaine for the energy boost because he was working a job that required the expansion of great physical energy in long shifts. It was reported that the drugs were able to help reduce fatigue, leading to increased energy, improved reflexes and higher levels of mental alertness.

‘…the drugs made me feel more energetic for a short period of time because my job required me to lift heavy things.’ [GP14]

Methadone replacement therapy. There were mixed reactions towards methadone replacement therapy as a treatment method to reduce drug abuse. A government rehab patient (GP04) found that the therapy was useful in reducing his addiction towards hard drugs such as heroin, but another patient (GP03) claimed that the administration of methadone triggered episodes of relapse. The patient was reportedly able to gradually reduce and stop dependency on the drug he was admitted for. However, the cravings for higher doses of methadone developed.

‘My relapse was actually triggered by the methadone replacement therapy. Instead of the normal drug I used, I started craving for higher dosage of methadone.’ [GP03]

‘…the current methadone replacement therapy that I am undergoing has helped reduce my addiction towards heroin and hopefully this will remain until the time I am released from rehab.’ [GP04]

1.      Relapse prevention strategies

A government rehab staff (GS05) provided additional insight into three strategies that he viewed would be able to help rehab patients avoid relapsing. The strategies recommended were job selection, maintaining self-confidence and relocation.

Job selection. As seen in the quote below, the staff suggested that patients select jobs that would keep them physically active to avoid boredom, which was viewed as a reason for drug relapse.

‘A personal suggestion from me is also that clients should choose jobs that require them to move around actively. For example, working as a security guard in condominium units which involves a lot of seating within the booth is not recommended as they may become bored easily and they can easily be influenced by the urge to take drugs again.’[GS05] 

Maintaining self confidence. In addition, the staff proposed that patients should feel confident about their capabilities since they have learnt a variety of coping, vocational and social skills as well as the ability to be self-sufficient at the rehab centre. Starting a new lifestyle post-treatment with a good level of self-confidence was viewed as a beneficial method towards reducing the risk of relapse.

‘Clients also need to be confident about the self and start a new life.’ [GS05]

Relocation. Lastly, the staff also suggested that patients, who are at risk of relapsing due to neighbourhood factors, relocate to a new place to start their new life.

‘If possible, they should relocate as they may fall back with the old group of friends if they still continue to stay at their previous place.’[GS05]

 

 

2. Motivation to change

From the patients’ responses, there were three themes identified as motivational factors for a change in drug abuse behaviour: (1) impact of drug abuse: the self, health, family and work; (2) personal wishes and (3) religious guidance.

Impact of drug abuse. The impact of drug abuse to the self, health, family and work was found to be a primary factor that motivated rehab patients to change drug abuse behaviour.

Impact to the self. Three government rehab patients (GP04, GP07 and GP14) reported that they were motivated to change due to the impact of drug abuse to the self. A patient (GP04) reported that due to his drug habit, he experienced financial constraints and his physical and mental state was greatly affected. Additionally, the patient stated that his increasing age made it difficult to withstand the long-term effects of drugs due to the weakening state of his body. Another patient (GP07) also reported being unable to cope with the constant need to raise sufficient money to obtain a regular supply of drugs. This was made more difficult as the patient only earned enough for his daily expenses. The constant mental torture experienced during drug abuse and in between usage, also became an unbearable vicious cycle for a patient (GP14).

‘I could not stand it physically, emotionally and financially anymore. I had to find enough money to get my supply. Moreover, I am getting older.’ [GP04]

‘I was financially unable to support my drug habit anymore. My money was only sufficient to live day by day.’ [GP07]

‘…the difficulties of undergoing the constant mental torture.’ [GP14]

Impact on health. Three patients from the government and private rehab centre reported that the effect of drugs on their health was also a factor that motivated them to change their drug abuse behaviour. Two private rehab patients (PP05 and PP09) experienced health complications associated with drug abuse, as they age. The inability to withstand the myriad of health problems motivated them to seek treatment to eliminate the core issue, which was drug abuse. A government rehab patient (GP10) who was younger in age realised the tangible side effects of prolonged drug abuse through interaction with senior patients. This strengthened the patient’s resolve to complete rehab treatment.

‘My family encouraged me to stop as my health was not so good. I also wanted to change for the future and myself.’ [PP05]

‘My health was getting bad as I got older. I couldn’t stand it anymore.’ [PP09]

‘I realised that if I had continued to use syabu for a long time, my health would have deteriorated because it is bad for the body.’ [GP10]

Impact on family.Four patients attributed theeffect of drug abuse towards their family as another reason that motivated behaviour change. All four patients had families with young children or elderly parents and they admitted that their drug abuse habit have led them to neglect their responsibilities such as to love, care and support them emotionally and financially. In addition, three patients (GP08, GP09 and GP15) also cited the concern of family members for the patient’s future and their unconditional support, despite their shortcomings as instrumental towards the patient’s motivation and determination to live a better life without drugs.

‘My family was the primary motivation. My habit was causing me to neglect them.’ [PP06]

‘My family was the main factor for change and my thoughts for stopping my habit.’ [GP08]

‘My family was the main reason for thinking of stopping drug abuse as they didn’t want me to mess up my future more than necessary.’ [GP09]

‘The thing that drives me to stop is that I am unable to take care and support my aging parents. Money that should be contributed to the family was being used to buy drugs instead. So this cannot go on.’ [GP15]

Impact on work. A government rehab patient (GP02) reported that his work performance and attendance was impacted due to the physical and mental effects of drugs. The patient further elaborated that the use of drugs like opioids resulted in drowsiness and clouded mental functioning, which led to declining work performance and attendance. However, there were times when stimulants were taken to increase work performance, resulting in a temporary surge of energy. However, the downside of using stimulants was that extreme exhaustion would set in when its effect subsides and repeated use could lead to feelings of hostility and paranoia. These unhealthy emotions have affected his family life by causing conflicts with his family.

‘…drugs was affecting my work and was causing family conflicts.’ [GP02]

Personal wishes. The concept of changing drug abuse behaviour due to personal wishes was coded and categorised when it was identified that the primary motivation was the personal resolve to better themselves after negative experiences with drug abuse. Although some of these patients do achieve realisation that drug abuse has affected themselves and their family, the resolve to change was not solely motivated by these factors. Four patients from the government and private rehab centre reported that it was their personal wish to stop drug abuse. Two patients (GP05 and PP08) expressed disappointment and dislike for their past life, and were motivated to change for a better future by healing and improving their quality of life through rehab treatment. Another patient (PP02) reportedly wanted to change because he had enough of the consequences from drug abuse such as loss opportunities for study as well as broken personal and familial relationships. A patient (PP12) also disclosed that as he became older, he became increasingly aware of his responsibility towards his aging parents and his limited opportunities to lead a normal life, after being caught for drug abuse and having a prison record. Moreover, a patient (PP15) also expressed the fear that it was too late to change and start over, in addition to feeling guilty for causing trouble to his parents as a result of his drug habit.

‘I didn’t like that kind of lifestyle anymore. I felt that it was time I stopped and heal myself from this habit.’ [GP05]

‘The main factor was to change myself. I just had about enough of the adverse effects of taking drugs. I have lost a lot of things such as my studies, parents, friends and relationships.’ [PP02]

‘Mainly, I was disappointed with my life and I wanted to change for the better on my own.’ [PP08]

‘I wanted to change. After being caught and entering prison, I can’t have a normal life anymore. I can’t get married and my parents are getting old.’ [PP12]

‘I was feeling tired and felt that this life is never-ending. I did feel a little guilty towards my parents for being involved in this habit. Also, I felt scared that it might be too late to change.’ [PP15]

Religious guidance. Two private rehab patients (PP03 and PP14) also attributed religious guidance through personal prayers or the advice of religious leaders as their motivation to change. A patient (PP03) reported feeling physically and mentally exhausted due to drug abuse, rejection from society and the lack of proper employment. Therefore, he turned to religion as it was his only refuge to be accepted as well as to seek help and new opportunities. Another patient (PP14) relapsed due to socialising with old peers with drug use connections but he also benefited from the advice of religious leaders. A church pastor provided him with time and place to rehabilitate as well as job opportunities on a voluntary basis.

‘I have been involved with drugs for so long that I feel very tired. I have no proper work, and I feel the rejection from my family and society. So, I asked God to help me and the chance to help myself was given.’ [PP03]

‘After I came out of prison, I did not have anywhere to go. So I relapsed after falling back with the old crowd of friends. A pastor whom I knew advised me to enter rehabilitation.’ [PP14]

No motivation. In total, 13 patients from the government rehab centre and three patients from the private rehab centre were in drug rehab primarily under court orders. Out of this, 12 government rehab patients and two private rehab patients reported that they had previous thoughts of stopping drug abuse or were motivated to reduce and eventually stop drug dependency on their own. Only two patients (GP01 and PP11) admitted that they never had any intention to change their drug abuse behaviour. Both patients were caught during drug raids, charged for drug abuse in court and subsequently, entered into compulsory rehabilitation for a period of two years. A patient (PP11) who underwent a prison sentence also disclosed that due to a drug-related offence, he had lost his home, financial freedom and friends. Thus, he had no choice but to gain shelter at the drug rehab centre.

‘To be honest, I entered the centre without thoughts of stopping. I got caught and was sent to rehab through court orders.’ [GP01]

‘Well, I was caught and sent to prison. So there was no longer anywhere to go. I had no more money and friends.’ [PP11]

Figure 4 depicts the themes and sub-themes of factors that initiated the motivation to change drug abuse behaviour among drug rehab patients.

1.      Reasons for entering treatment

The key reasons that made patients actively seek and receive rehab treatment were also sought in the interview. From patients’ and staff responses, there were three main factors identified: (1) extrinsic factors, (2) intrinsic factors, and (3) extrinsic-intrinsic spectrum.

Extrinsic factors. Themes categorised under extrinsic factors include encouragement from others; court and supervision orders.

Encouragement from others. The threesources of encouragement identified were family, NADA/AADK officers and workers from the geriatric home. Twenty-five patients and five staff viewed that the support and encouragement from the family was instrumental towards getting drug users to enter rehab. As shown in the sample quotes below, the patients had strong support from their parents and siblings to initiate and maintain treatment. A private rehab patient (PP03) in particular disclosed that his family members were extremely encouraging and helped research suitable treatment centres locally and overseas to ensure that he received the best available treatment. A private rehab staff (PS03) also noted that familial support made patients value the opportunity to receive treatment, and thus, ensured the completion of treatment regimens.

‘…received the full support from my parents to kick the habit for the opportunity to lead a better life.’ [GP03]

‘…my parents, sisters and brothers also constantly support me and give me encouragement to keep undergoing rehab faithfully.’ [GP06]

‘I received lots of encouragement, support and advice from my family members to undergo rehab. My siblings in particular, wanted me to go to a detoxification centre in Thailand.’ [PP03]

‘Most of them come into rehab with support from family members.’ [GS02]

‘Most patients greatly value rehab if they have the support of family members and parents, for those who still have them.’ [PS03]

Eight rehab patients and three staff reported that NADA/AADK officers, who were often the first point of contact for drug users caught for drug abuse or voluntarily admitted treatment, were strong sources of encouragement to enter rehab.  As shown in the sample quotes below, patients who received emotional support from the NADA officers generally found the treatment process a positive experience. The private rehab staff (PS02 and PS03) were also in agreement that NADA/AADK officers were a good source of support and encouragement. Furthermore, the staff also functioned as a reference point for drug users on where they should seek proper treatment for drug abuse. However, a patient (PP11) did express that he felt lost after serving his prison sentence, as the officers who were in-charge of his case did not provide clear directions on the types of treatment services available and the places that he could receive treatment or information on finding legal employment.

‘During my first time entering rehab, it was because of encouragement from the Anti-Drug Agency officers.’ [GP01]

‘I was lucky enough to have met AADK officers and volunteers who gave me support and advice to stop my drug habit.’ [GP05]

‘There were volunteers when I was serving my prison sentence who encouraged us to stop the habit and find legal work upon coming out of prison but they didn’t exactly told us to go for treatment.’ [PP11]

‘Some who were caught and placed in the police lock-up or have served time in prison for other offences have also had advice and encouragement from AADK officers and volunteers to kick the habit.’ [PS02]

‘Volunteers working in the prison or AADK officers sometimes refer them to our centre as a last resort.’ [PS03]

An elderly patient (GP02) from the government rehab centre entered treatment due to advice and counselling of workers in the geriatric home. The patient reported that the workers encouraged him to enter treatment as a way of strengthening his will to live comfortably without drugs for the remainder of his life.

‘I received counselling at the old folk’s home. The people at the home encouraged me to enter rehab to strengthen my will to live and also so that I can live more comfortably without drugs.’ [GP02]

Court or supervision orders. Thirteen patients from the government rehab centre were admitted into treatment primarily because of court orders. At the point of admission, these patients did not have any intention to stop drug abuse. However, some patients eventually developed the motivation to continue treatment for self-recovery or due to encouragement from their families. A private rehab patient (PP01) entered treatment as part of a supervision order. This patient disclosed that he was underage when caught and charged with a prison sentence. After serving his sentence, he was assigned a supervisor, who was a staff at the private rehab centre, and received treatment for two years with the opportunity to do voluntary work at the church. Reports on his treatment progress were made regularly to NADA/AADK.

‘It was due to court orders that I entered the first rehab centre.’ [GP01]

‘A large part of it was because of the court order to attend rehab.’ [GP06]

‘After completing my prison duty, I was also recommended to sign up for 2 years supervision under a rehab centre.’ [PP01]

Six staff (i.e., five government rehab staff and one private rehab staff) also reported dealing with patients who were mostly in rehab under court orders. It was also observed that patients who entered treatment under legal orders were more likely to relapse after treatment, as they have not found an important reason to change.

‘The drug addicts I worked with were mostly hard-core addicts. They entered the rehab centre after being caught, imprisoned and undergo rehab under court orders by the Sessional Court under the Dangerous Drug Act 6 (1A).’ [GS01]

‘All the rehab patients I worked with entered through the catch, imprison and court order process.’ [GS03]

Intrinsic factors. Themes categorised under intrinsic factors includeself-recovery and voluntary admission.

Self-recovery. Nineteen patients and five staff also cited the determination to self-recover as an important factor that encouraged patients to enter treatment. According to two patients (GP08 and PP03), they regained the determination to self-recover due to the desire to lead a normal life like their siblings and family, such as having a proper job, marriage and good family relationships. A private rehab patient (PP08) also reported wanting to self-recover because he was aware that if proactive steps were not taken to recover from drug dependency, the effects of drug abuse could be fatal to him.

‘…I started to recover my will to cure and recover.’ [GP08]

‘I wanted to be like my other siblings who have a normal life.’ [PP03]

‘I also wanted to cure myself for my own self-recovery. Because I know if I don’t do this, I may die.’ [PP08]

However, a private rehab staff (PS01) noted that the desire to self-recover was a more common occurrence among patients who voluntarily registered for treatment as compared to patients under treatment due to court orders. Another staff (PS03) took the opportunity to emphasise the importance of rehab centres, which often serve as a refuge for those who wished to self-recover.

‘…for those who come in voluntarily, many are motivated by the need to recover or redeem themselves and their lives.’ [PS01]

‘Most of them come here as a refuge to self-recover…’ [PS03]

Voluntary admission. There were five patients who reported entering treatment through voluntary admission. Two private rehab patients (PP02 and PP13) disclosed that they voluntarily entered treatment upon receiving the advice and support from their family. A government rehab patient (GP01) who relapsed after his first time of treatment decided to enter treatment voluntarily the second time as he felt properly prepared to make a positive change to his life.

‘Now, is my second time entering rehab and I volunteered to enter this place.’ [GP01]

‘I voluntarily entered rehab with the advice and support of my parents and family members like my siblings and relatives.’ [PP02]

‘I decided to enter rehab voluntarily this time with encouragement from my parents.’ [PP13]

Similar to findings from the patients’ sample, three rehab staff observed that patients who received the support of their family members were more likely to enter treatment via voluntary admission. It was suggested that voluntary admission into treatment and familial support produced better treatment maintenance and outcomes.

‘In one voluntary case, it was the wife who encouraged him to enter.’ [GS02]

‘Patients who volunteer to come in mostly want to recover on their own. But most of them come in with the advice of parents and family members.’ [PS02]

Extrinsic-intrinsic spectrum. There were several concepts identified when coding patients’ responses on the association of religion and admission into drug abuse treatment admission. Firstly, religion could play an extrinsic role in treatment admission when it is viewed as means to an end (i.e., stopping drug abuse). For instance, there were patients who entered treatment after receiving advice from religious leaders to seek treatment for drug abuse. Secondly, religion could play an intrinsic role in treatment admission when religion is viewed as a priority and goal towards leading a healthier and more positive lifestyle. For example, some patients achieved realisation that drug abuse is a problem and were determined to follow the right path according to religious teachings. Thirdly, religion could evolve from an extrinsic factor to an intrinsic factor. For instance, some patients entered treatment at the urging of their religious teachings but they began to internalise religious values and principles during the treatment process. Eventually, they gain the self-determination to become a better individual without drugs.

Religion.Twelve patients (i.e., 10 private rehab patients and two government rehab patients) and two private rehab staff perceived religion as an important factor that influenced patients to take action and enter rehab. A private rehab patient (PP02) disclosed that previously, he often questioned the existence of God and drifted along life without any religious guidance and direction. However, he began to constantly pray for guidance and finally received the answer to his questions and doubts through devoted prayers for forgiveness and advice from his religious leader to seek treatment. A government rehab patient (GP04) felt that it was the appropriate time to relinquish his sins, faithfully follow the religious teachings and recover from drug abuse. Another private rehab patient (PP15) reported that despite getting religious guidance from pastors in his hometown, they were unable to supervise him all the time. Thus, entering a rehab centre that applies the way of healing through spiritual learning was a better solution for him as he would be able to fully receive the supervision and guidance he needed to recover.

‘I also felt that it was the right time to follow His path and recover myself from all my sins.’ [GP04]

‘It was also due to the calling of God. Before this, I often questioned if God was there? If He was, then I prayed constantly for help and guidance. I finally received the needed guidance and help at the right time together with the determination to recover myself.’ [PP02]

‘Before entering rehab, I had always prayed to God asking for forgiveness and asked Him to lead me to a new path. Previously, I tried to change on my own by consulting my pastors in Sarawak and asking them to pray for me and help me. But as they are unable to be there for me 24 hours, it was difficult. So, entering the centre was a good way to recover through the Christian way.’ [PP15]

This sentiment was agreed by a private rehab staff (PS04), who felt that the patients just needed a place to provide appropriate guidance to overcome drug addiction. Another staff (PS05) was of the opinion that patients who chose to enter the private rehab centre had the intention of strengthening their spiritual development and using it to recover from drug abuse.

‘Most of them that I have dealt with come to heal themselves through religious and spiritual teachings. They just need somewhere to give them the help they need.’ [PS04]

‘Some have come to CCC because of the calling of God. They have decided to follow His path to recover.’ [PS05]

2. Summary

This chapter examined patients’ drug abuse patterns, the prevalence of a drug abuse progression trend, patients and peer relationships with the family, and level of assertiveness at the point of treatment. In summary, the usage of marijuana/cannabis was most highly recorded among rehab patients. It was also noted that ecstasy was among drug types that were least commonly used by patients. This finding contradicted students’ perceptions that ecstasy would be one of the most commonly abused drugs, together with marijuana/cannabis. The findings also indicate that a drug abuse progression trend was not supported. Nevertheless, two patients demonstrated an atypical partial progression (e.g., oscillating from soft to hard drugs, and subsequently using an intermediate drug). The variation in drug abuse patterns suggest that further research is needed to investigate the influence of personality, behavioural phenotypes, and environmental factors as predictors of drug abuse progression or susceptibility to certain drugs.

The findings also indicate that most patients and their peers had close relationships with their parents and the family environment was generally harmonious. Their families had stable incomes with no history of parental drug abuse. Furthermore, most of their peers did not demonstrate clinical levels of rebelliousness and problem behaviours. These findings demonstrate a deviation from typical drug user profiles and suggest that continuous research is needed to identify other potential risk factors.  Most patients perceived themselves as assertive against drug offers but only a small number of patients felt extremely assertive. A self-evaluation on the probability of relapsing also revealed that although 63% of patients were confident that they would not relapse, 37% of patients were still uncertain.

In Chapter 5, comparisons were conducted between rehab patients’ and staff’s responses about factors for drug abuse, drug relapse, and entering treatment. In addition, factors that would motivate patients to change drug abuse behaviour were identified. The thematic findings indicate major similarities between patients’ and staff’s responses about factors for drug abuse (internal factors: tension release, curiosity, enjoyment, personal problems; environmental factors: peer influence, family conflict) and entering treatment (extrinsic factors: encouragement from family, NADA officers and geriatric home, court orders; intrinsic factors: voluntary admission, self-recovery; and extrinsic-intrinsic spectrum: religion). There were differences in opinion between patients and staff on the role of unemployment in drug abuse. While the patients viewed unemployment as a predictor of drug abuse, the staff viewed it as an outcome of drug abuse. The dual role of unemployment as predictor and consequence of drug abuse was acknowledged by past literature (e.g., Kestila et al., 2008; Pirkola et al., 2005; Poulton et al., 1997; Ringel, Ellickson & Collins, 2006). This indicates that despite the difference in opinion, the perspective of both staff and patients were supported.

Major similarities were also found in responses about drug relapse factors (environmental factors, personal problems and methadone replacement therapy). This finding indicates that the pharmacotherapy approach may not be a suitable treatment option for every patient as some patients could be more susceptible to methadone. This study also identified three factors that motivated patients to change drug abuse behaviour: (a) impact of drug abuse; (b) personal wishes; and (c) religion. However, more than half of the patients had no motivation to change during treatment because they were admitted under court orders. This finding highlights the need to: (a) assess patients’ readiness to change prior to treatment; and (b) implement a patient-directed approach to treatment, which allows patients to explore ambivalence, identify the values and goals to change, and explore strategies to overcome addiction and relapse.

Chapter 6: Patient satisfaction and treatment evaluation from the view of rehab patients and staff

This chapter presents findings related to the ninth and tenth research questions. In order to determine differences in treatment satisfaction scores between drug rehab patients and staff, satisfaction scores were analysed using an independent sample t-test. This was supplemented by quantitative findings from the Session Evaluation Questionnaire (SEQ) by Stiles and Snow (1984). The SEQ was able to assess patients’ feelings about their most recent treatment session and their current emotions at the point of interview according to four dimensions: (a) Depth: the perceived power and value of a session; (b) Smoothness: comfort, relaxation and pleasantness felt during the session; (c) Positivity: confidence, clarity and happiness; and (d) Arousal: active and excited feelings as opposed to calm and quiet. The scores were the sum of item ratings for each dimension. Thematic analysis was used to analyse qualitative data on treatment evaluation and patients’ perspective on the probability of relapsing after treatment. Patients’ treatment evaluations were triangulated with staff’s evaluations to identify similarities or differences in patients’ experiences, and treatment providers’ perceptions or expectations. In addition to this, government and private rehab staff provided qualitative evaluations of job satisfaction.

1. Research Question 9:What is the difference in treatment satisfaction scores between patients and rehab staff and patients’ perception of their level of satisfaction?
   1. Comparative treatment satisfaction ratings

As mentioned earlier, an independent sample t-test was used to determine differences in treatment satisfaction scores between drug rehab patients and staff. The rehab staff who were involved in the evaluation were those providing rehab treatment to patients. The purpose of conducting this comparison was to obtain a quantitative measure of differences in patients’ experience with treatment and treatment providers’ expectations. As shown in Table 20, the t-test comparison between programme satisfaction ratings by rehab patients and staff revealed no significant differences in ratings between patients and staff [t (39) = -1.046, p > .05]. Nevertheless, mean ratings for staff was higher (

x̅= 8.10, SD = 2.183) as compared to patients (

x̅= 7.27, SD = 2.180).

2. Evaluation of patient satisfaction using the Session Evaluation Questionnaire (SEQ)

The rehab patients rated satisfaction with their most recent treatment session in accordance to four dimensions in the SEQ: depth, smoothness, positivity and arousal (i.e., post-session mood and emotion of patients). Findings from the evaluation revealed that in regards to patients’ most recent treatment session, the majority of the patients felt it was deep in content (n=28, 93.3%). Only one patient felt that the contents helped resolve problems faced by drug users at the surface level. Another patient felt that occasionally the session was in-depth and thus, was able to learn some skills to resolve daily issues. However, there were also circumstances in which the drug abuse issues and problem-solving techniques discussed as a group were not as useful to their personal situation.

Most patients (n=28, 93.3%) also reported that the sessions were well-conducted, pleasant, easily understood and proceeded smoothly according to schedule. Only one patient reported feeling hassled due to last-minute changes to the programme, as he was an outpatient. Another patient felt that the treatment sessions were relatively smoothly with minor glitches, especially when some counsellors did not arrive for their scheduled sessions or activities were cancelled.

In addition, almost all patients (n=29, 96.7%) felt the sessions provided positive messages and were pleased with the friendly and encouraging attitudes of staff and counsellors at the centre. After the session, they were more focused and confident about working towards their goal of eliminating drug use from their life. Only one patient was rather negative about his treatment experience. This particular patient entered treatment at an old age and reported receiving treatment so that the remaining years of his life would be more comfortable by being free from drug abuse.

At the end of the treatment session, 18 patients (60.0%) reported feeling empowered and excited. Eleven patients (36.7%) felt peaceful and still rather than excited. Only one patient did not feel excited, peaceful or particularly motivated to accomplish his tasks.

2. Research Question 10:To what extent are rehab patients’ responses about favourable treatment components, treatment limitations and suggestions for improvements similar and different to responses from the rehab staff?

The thematic findings indicated that there were major similarities between patients’ and staff’s responses about favourable treatment components. However, there were slight similarities and major differences found in responses related to treatment limitations and suggestions for improvement. The difference in findings was attributed to differences in experience with treatment from the perspective of patients and treatment providers.

1. Multi-perspective evaluation of patient satisfaction with treatment

Patients’ evaluation of their treatment programme can be categorised into three areas: (1) Favourite components, (2) Programme limitations, and (3) Suggestions for improvement. In order to identify similarities and discrepancies in perspective between rehab patients and treatment providers, rehab staff were also interviewed to collect their views on treatment components that are perceived as favoured by their patients and aspects of treatment which required greater intervention.

1. Favoured drug rehab components

As seen below in Figure 5, there were four components cited by rehab patients and staff as a favoured treatment component. Additionally, there were three components unique to patients’ responses.

Four rehab components favoured by patients and staff. The context of each component and the relevant quotes that represent it are as follows.

Spiritual studies. The utilisation of spiritual teachings as the main foundation of treatment was essential to the patients who chose to enter the private rehab centre. Six out of 15 private rehab patients viewed the spiritual studies component as an important step towards healing and recuperating from the effects of drug abuse. A patient (PP01) reported that the prayer and worship sessions were essential towards helping him achieve a more stable state of mind and senses. Another patient (PP02) also felt that bible study and discussions were able to help answer some fundamental questions which have previously caused him to lose his path and engage in drug abuse. This patient also reported learning how to deal with the uncertainties and helplessness felt on account of dealing with various personal problems, which had caused him to be depressed, angry, filled with negative thoughts and subsequently, more likely to distrust others and reject their goodwill. With prayers and spiritual guidance from the church leaders, the patient began to think positively as well as learnt how to trust other people and communicate with others through love and kindness.

‘The spiritual component is very important to me as the prayer and worship helps me have a stable mind.’ [PP01]

‘I like the spiritual part most because it treated my senses. This programme also answered some of the fundamental questions that I always thought of. Previously I was filled with a lot of anger, depression and negative thoughts. Even when others treated me kindly, I thought that there was a motive behind it or they are out to get me. Through this session, I learnt about love, kindness and how to think positively.’ [PP02]

Only three out of five government rehab staff have previously worked in rehab centres that incorporated elements of spiritual or religious teachings, as demonstrated in the quotes below.

‘The programme in the Jerantut centre, Pahang was based on community therapy. However, there was also military physical training and some spiritual element…’ [GS01]

‘The programme at the centre I worked in was a combination of physical training, spiritual or religion and counselling components that was carried out according to different phases…’ [GS02]

‘As the programme in the Tampin centre was based on the psychosocial approach, we made sure the inmates maintain physical fitness, are provided with proper nutrition as well as the necessary knowledge and spiritual guidance…’ [GS04]

Nevertheless, it was acknowledged by a government rehab staff (GS03) that the spiritual studies component was essential towards the patients’ personal development.

‘I feel that programmes with a religious or civic focused component would be important to improve character. For example, the Muslim clients can attend religious classes while non-Muslim clients can go for Moral Education lectures.’ [GS03]

Four out of five private rehab staff viewed that the spiritual studies component in their centre was the best and favoured component. Two staff (PS02 and PS04) observed that the religious components were able to bring about internal changes within the patients as they gained objective and purpose in their life, which they lacked during the pre-treatment days. Another staff (PS03) supported this observation and reported that the spiritual studies component was able to help patients reflect on their past mistakes, resolve their issues and move on towards a positive future with guidance from God and the bible.

‘From what I have seen, I think spiritual studies bring the most internal changes in the students.’ [PS02]

‘I think the programme has helped students to reflect on their past and help them move forward for a better future with God’s guidance…’ [PS03]

‘I think spiritual studies are the most effective. Before entering the centre, most students are lost because there is no guidance from God. With Bible studies, it gives them an objective and purpose in life. …we slowly discuss the difficulties faced with them, guide and influence them to work on the Bible studies…’ [PS04]

Vocational workshops. Ten patients (i.e., six private rehab patients and four government rehab patients) reported that the vocational workshops were a favourite. A government rehab patient (GP05) reported liking workshops involving arts and craft because it was a skill that has marketable value and could be used to enable patients to earn a living when starting a new life. Another patient (GP12) also reported that government patients who were unemployed were also provided industrial linkage in line with the skills that were taught. For instance, patients who were skilled in technical and mechanical repairs and agriculture were provided opportunities with institutions such as Majlis Amanah Rakyat (MARA), which enabled patients to gain training and job opportunities. However, this patient observed that there were less industrial linkages available at the point of the interview. A private rehab patient (PP04) also disclosed that the vocational training component was useful and he was able to learn some job skills. He elaborated that although some of the job skills may not be of full interest to him and his fellow patients, it was necessary to learn more if they wanted to change into a better person.

‘I like the vocational aspects of the program such the arts and craft workshop. They let us know the value of skill in the market so that we can support ourselves after the program.’ [GP05]

‘…for those who are unemployed, the programme tries to link the skills taught with relevant jobs which they can consider venturing into.’ [GP12]

‘I think that it is good, especially the vocational component. I was able to learn things. Even if there are some things that normally I would not want to learn, but I know I have to in order to change.’ [PP04]

Two rehab staff (i.e., one government and private rehab staff respectively) also viewed that vocational workshops would be a favourite among patients. The government rehab staff (GS03) explained that vocational training was popular because employment skills were highly relevant and beneficial to the patients after completing treatment. Moreover, another staff (PS05) reported that efforts were made to ensure that the job skills that were taught in the private rehab centre.

‘The vocational component is also important for clients after they leave the centre.’ [GS03]

‘We often ask what their original nature of work is before entering rehab and provide relevant jobs to upkeep their interest…’ [PS05]

Recreational activities. Six out of 15 private rehab patients reportedly cited recreational activities as their favourite component. As shown in the sample quotes below, the patients were happiest when they were able to engage in exercise and play sports such as football, basketball and hockey. A patient (PP11) further explained that recreational activities were enjoyable because it does not require any particular skills.

‘I like the recreational component where I can get some exercise.’ [PP04]

‘I am not really skilled in any area but I like recreational activities the most.’ [PP11]

‘I like recreational activities the most such as football.’ [PP12]

Two rehab staff (i.e., one government rehab and one private rehab staff respectively) similarly viewed recreational activities as a popular component among the patients. A staff remarked (GS03) that in contrast to lectures, sporting activities are more popular among patients. Another staff (PS05) noted that sports activities were a fun way for patients to improve their fitness and physical health, which have declined after years of drug abuse.

‘Most clients like sports activities while lectures are not so popular…’ [GS03]

‘…sports activities are able to maintain their physical fitness…’ [PS05]

Counselling. Nine out of 15 government rehab patients viewed counselling sessions as their favourite component. A patient (GP04) reported liking group counselling because it provided him with an opportunity to openly communicate, share and resolve issues with his peers, who were experiencing the same issues. Moreover, this patient felt that the group discussions were made easier with the help of encouraging and friendly counsellors. Another patient (GP09) reported liking the counselling sessions because it gave him the opportunity to learn from his peers and felt less frustrated when he was able to resolve his problems with the aid of others. A patient (GP13) also noted that the opportunity to listen to his peers’ problems has helped him view things from multiple perspectives and increased his repertoire of problem-solving and adaptive skills. This patient also felt that he gained motivation, strength and confidence from the group counselling sessions when he realised that his problems may be trivial in comparison to others and yet, those serious issues were solvable.

‘The group counselling sessions allow me to interact with friends having the same problems as me. Also the supervisors here are also very encouraging and friendly.’ [GP04]

‘I like that it gives me the opportunity to listen and learn from others’ problems. Finding the solutions with the help of others also helps take out the frustration of resolving something that I can’t get around.’ [GP09]

‘In the group discussions, I can listen to others’ problems and reassure myself that maybe my own issues are not such a big deal. If other people have experienced so much more hardship and they have gotten over it, so can I.’ [GP13]

Although counselling was included as one of the treatment components in most government rehab centres, only two staff particularly viewed counselling as a popular and effective component. A government rehab staff (GS01) noted that although the centre adopted community therapy techniques that were developed based on Western clinical settings, efforts were made to include multiple elements of religion and spiritual guidance in their counselling sessions to meet the needs of patients from a multi-ethnic background and religious beliefs.

‘As the community therapy program is based on the free-thinker philosophy, we added a spiritual element by inviting guest speakers from different religious standings for spiritual counselling and motivation.’ [GS01]

In the opinion of another staff (GS03) who was a qualified counsellor, it was essential that the option of individual counselling be made available in addition to the usual routine of group counselling. The option of such a combination was important in managing patients who have difficulties voicing out issues within a large group setting. This staff personally felt that he had sufficient time to allocate to each patient and in keeping track of their individual progress since the schedule of counselling sessions were largely managed by the counsellor himself.

 ‘There were …individual and group counselling. I feel that the combination of components was ok and suits the type of clients in the centre. On my part as a counsellor, I felt that there was sufficient time because the schedule of each client is determined by me.’ [GS03]

Three treatment aspects unique to rehab patients’ responses. The rehab patients also favourably viewed three treatment aspects: (a) community projects; (b) health talks; and family visits. From the patients’ responses, it was concluded that community projects were favoured because it provided patients with the opportunity to re-engage with the community. Besides that, it allowed them to develop relationships and learn how to work within a team. Talks by health professionals were also favoured because it educated patients on regaining or improving their health, which has deteriorated due to drug abuse. Sessions for family visits were beneficial in helping patients reconnect with their family. Furthermore, they were able to receive social support, which is an important component for recovery from drug abuse. The descriptions and selected quotes below provide deeper insight into favoured treatment components from the unique perspective of rehab patients.

Community projects.Government rehab patients were given the opportunity to engage in community projects as part of their rehab treatment. Three out of fifteen government rehab patients reported that community projects were their favourite component. A patient (GP01) disclosed that being involved in community projects has given him the chance to learn about relationship dynamics that comes with teamwork, how to establish positive family relationships and friendship, in addition to having a varied routine. This patient also liked the community projects conducted at the government centre because it was often well planned with good co-operation between staff from the rehab centre and the project coordinators. According to the patients (GP01 and GP03), participation in projects that contribute to society has also helped patients to re-integrate with the community. Another patient (GP02) noted that the rehab centre allowed the patients to have flexibility in choosing their preferred community projects but patients were discouraged from taking too many projects at a single time, as these projects required time and full commitment.

‘The community projects are what I like best and there is good co-operation between the agency with the project coordinators. I like that there is an opportunity to go out and be involved in community projects like planting flowers and trees for schools, as well as car wash projects. It also helps instil knowledge about friendship and family and is useful for individuals who have never known what real family relationships and friendships are like.’ [GP01]

‘The programme does allow us to work on community projects. They allow us to choose projects that we like but we can’t take up too many at a time or we will be scolded.’ [GP02]

‘I also like the community projects because it helps me integrate back into society.’ [GP03]

Health talks.One government rehab patient reported liking the health talks which were organised by the counsellors and facilitated by health professionals and general practitioners. The patient further disclosed that the health advice given on methods to regain health were especially important to him as he experienced declining health due to drug abuse. This patient also observed that although some of his peers have yet to experience the serious side effects from drug abuse, they did benefit from tips to maintain a healthy lifestyle.

‘I like the talks, advice and health information given to me.’ [GP06]

Family visits.A private rehab patient reported that he looked forward to family visits during public or festive holidays. Although the private was a comfortable in-patient facility, this patient admitted feeling homesick as he was away from his family for a long period. Family visits was also an opportunity for the patient to rest and relax while catching up with the family as the treatment schedule at the private rehab centre wasquite exhaustive, with the patients often starting their day as early as 5 a.m. and being kept occupied daily with vocational workshops, spiritual studies and physical rehab.

‘I like the days in which we can relax and rest, like public holidays. We are also allowed visits from our family.’ [PP06]

2. Strengths of current treatment model from the perspective of rehab staff

To the government rehab staff, the strength of treatment programmes in government rehab centres was that all components (i.e., spiritual studies or guidance, recreational activities, vocational training, counselling, community work) were conducted in a balanced and organised structure to provide a holistic treatment experience. As shown in the sample quotes below, the staff (GS02 and GS04) believed that such programmes would have a positive impact on the patients’ personal development, spiritual strength, and physical wellness, through exercise and a balanced nutrition.

‘The programme at the centre I worked in was a combination of physical training, spiritual or religion and counselling components that was carried out according to different phases. I felt that it was structured and organised. There was also positive impact on the inmates as they learn to treat each other as family and offer help to fellow inmates when needed. They also become more disciplined, hardworking and have a stronger mentality.’ [GS02]

‘As the programme…was based on the psychosocial approach, we made sure the inmates maintain physical fitness, are provided with proper nutrition as well as the necessary knowledge and spiritual guidance. It is quite a balanced programme.’ [GS04]

A similar sentiment was shared by the private rehab staff. A staff (PS01) believed that the strength of the treatment programme in the private rehab centre was providing patients with the three core components of spiritual studies, vocational training and recreational activities. It was viewed that these components helped the patients to become balanced individuals with strong physical and mental strength, who practiced strong religious values and had appropriate job skills.

‘I feel that all three components of the programme work together to help the students become a more balanced person with skills and strength from the guidance of God.’ [PS01]

‘…Providing them with work skills and recreational activities which can help maintain their fitness is beneficial for them in the long run, especially for students who did not complete a proper education or suffered health problems as a result of drugs.’ [PS03]

Despite implementing a standard format in its treatment programme, the private rehab staff perceived that their programme was still able to demonstrate flexibility in its structure. According to a staff (PS02), efforts were made by the group leaders and administrators to adapt to dynamic changes in drug abuse behaviour and drug user profiles. Two other staff (PS04 and PS05) noted that despite the strict treatment schedule at the private rehab centre, adjustments to treatment activities were made based on the patients’ interest or previous work experience to help ease them into the treatment plan as well as to increase its relevance.

‘I feel that this programme is currently under a continuous stage of improvement with various changes taking place in order to stay relevant to the new students coming in.’ [PS02]

‘Although there is a strict schedule daily, there is give and take in our rehabilitative approach. For new students who are initially resistant to the activities, we slowly discuss the difficulties faced with them, guide and influence them to work on the Bible studies, vocational training and sports.’ [PS04]

‘This programme tries to include the students’ interest in the programme activities to make it more relevant…We don’t force them and they are welcomed to spend more time in activities that they like such as cooking, mechanical work, gardening or design and construction.’ [PS05]

3.    Limitations of drug rehab programme

As shown in Figure 6, one limitation affected treatment or working experience of rehab patients and rehab staff. In addition, six limitations were uniquely found in the patients’ responses. The thematic analysis of staff responses about the limitations of rehab programmes further generated three themes and two sub-themes.

Limitation from the perspective of rehab patients and staff. Patients and staff in the government rehab centre were most affected by lack of space. In coding their responses, it was found that the context of lack of space was defined by limited land to conduct physical rehab activities (rehab patients) and limited work space to deal with paperwork (rehab staff). The concept of this limitation is better described and illustrated through the selected quotes below.

Lack of space. A government rehab patient reported that since the centre was located at a road intersection, it consisted of only a block of building with limited landed space surrounding it. Therefore, the grounds were rather cramped and there was insufficient space to conduct outdoor activities such as morning exercises.

‘Also the grounds are quite cramped. There are no proper places to do outdoor exercise.’ [GP01]

A government rehab staff also reported that the minimum office space allocated managed to fit in only two tables with a desktop each and a portable printer, with insufficient space to file paperwork and documentations related to their patients and treatment progress.

‘…staff offices are often crammed with little space for all the paperwork.’ [GS02]

Six programme limitations unique to rehab patients. Six limitations and its corresponding concepts were identified when coding patients’ responses: (a) limited facilities (no medical facilities or personnel available on-site and insufficient shared facilities, which results in disputes); (b) limited rehab activities (limited activities suitable for elderly patients or those with mobility issues and little variation in types of activities); (c) limited job links (limited opportunities for industrial linkage in the government sector and a sense of discontinuity on where to apply job skills among private rehab patients); (d) loss of freedom (conformity to rules, regulations, and strict schedules with little relaxation time); (e) language medium issues (patients from different ethnicities were able to understand the medium of instruction only at the basic level); and (f) non-existent support network (unable to maintain friendships or social support network formed during treatment). The concepts of these limitations are better described and illustrated through the selected quotes below.

Limited facilities. Two government rehab patients reported that the limited facilities available at the centre did cause a certain level of inconvenience to the inpatients and outpatients. A patient (GP02) disclosed that the shared facilities such as television, chairs and tables in the common area as well as the bathroom and kitchen space were often insufficient, resulting in occasional disputes when certain facilities were hogged by another resident. Another patient (GP01) noted that there was no medical facility or medical personnel available within the centre due to limited ground space. This patient felt that this was an inconvenience to him and his peers, who were newly admitted and dealing with withdrawal symptoms without medical assistance. This patient, who was under methadone replacement therapy, reportedly had to obtain his methadone dosage at a private clinic and pay for his medical expenses using his own limited supply of money.

 ‘When drug addicts newly enter the centre, they have not overcome their drug problem and experience withdrawal symptoms in the first two weeks. However, no medical facility is conveniently available within the grounds to help them overcome drug withdrawal. Currently, we have to fork out our own money to go to a private clinic.’ [GP01]

‘…there are limited facilities and we often have to fight for the use of it.’ [GP02]

Limited rehab activities. Four patients (i.e., one government rehab patient and 3 private rehab patients) reported that there limited rehab activities which were suitable for elderly patients and could be conducted indoors. A government rehab patient (GP02) reported feeling bored during the resting hours, since there were no indoor activities that he could engage in like board games or reading materials. The only indoor game played was carom, which was an unfamiliar game to some patients.

Two private rehab patients (PP06 and PP13) also commented that there was limited variation in the rehab activities conducted over the years. In fact, according to a patient (PP13), the activities conducted at the private rehab centre has remained unchanged for more than three decades at the point of interview. However, another patient (PP06) acquiesced that routine activities do enable patients to adapt to a lifestyle that is similar to other ordinary people such as waking up early and preparing for work activities. However, another patient (PP14) noted that some activities such as sport events which were conducted as part of recreational activities, were rather difficult for elderly patients like him as his level of physical fitness and flexibility has declined with age.

‘It is a bit boring during the rest hours as there is nothing interesting to do other than sleep. There are no suitable indoor activities either because I don’t know how to play carom, which is the only game choice currently.’ [GP02]

‘It can be boring but provides a semblance of normalcy as normal people also have routines like waking up and going to work.’ [PP06]

‘…not many changes have been made to the programme since it was conceived 33 years ago.’ [PP13]

 ‘The recreational activities are also a little difficult for me because of my age and physical fitness.’ [PP14]

Limited job links. A government rehab patient and two private rehab patients reported that another aspect that was lacking in most drug rehab programmes was limited job links. The government rehab patient (GP07) voiced his concern that despite being taught a variety of vocational skills, job networks that could help patients link to employers offering jobs in their field were near to none. This patient had also observed that although government rehab centres have industrial linkage with organisations like MARA in the past, the job opportunities and scope were increasingly limited in recent years.

‘I feel the skills taught in the workshop can only be used at the centre as there is no job network established that can help link the skills and proper jobs outside.’ [GP07]

A similar predicament was experienced by the private rehab patients, who subsequently stayed on as staff. A staff who was previously a patient (PS13), disclosed that he decided to work for the rehab centre and church because there were less work opportunities due to his increasing age. In fact, most patients end up staying and working at the rehab centre or helping the church due to a lack of options although it was acknowledged that helping other drug users was meaningful work. Another staff (PS14), who was also previously a patient, reported feeling a sense of discontinuity upon leaving the centre as he was not given information on other potential directions to seek work with employers who would be interested in their work skills. Thus, he decided to return and work at the rehab centre while serving the church.

‘At the moment, we are left on our own once we leave the centre. So, there is a sense of discontinuity.’ [PS13]

‘There are no more chances for me as my age is increasing. After this, I will continue serving the church.’ [PS14]

Loss of freedom. Two private rehab patients (PP05 and PP15) reported instances where they felt a loss of freedom when admitted as they had to conform to rules and regulations set by the treatment programme. A patient (PP15) admitted experiencing some suffering, as he was unable to cope with the strict schedule, with very little or no personal time. However, this patient noted that he and his peers gradually acclimatised to the strict rehab regimen over time.

‘…sometimes I do feel that my freedom is taken away.’ [PP05]

‘Initially, I felt a little suffering because of the loss of freedom.’ [PP15]

Language medium issues. Two patients (i.e., 1 government rehab patient and 1 private rehab patient) reported that the lack of multi-language medium for communication posed an issue in their treatment experience. In the government rehab centre, the treatment programme was usually conducted using the Malay language since a majority of their patients were Malay with the exception of one Chinese patient. The Chinese patient (PS02) was able to understand the Malay language only at a basic level. Thus, the patient reported listening only to ideas or solutions that were relevant or could be understood since complex issues that were discussed in group counselling using higher level Malay was problematic.

‘I only listen to whatever is relevant but it does not really help me overcome my problem.’ [PS02]

The treatment programme in the private rehab centre was conducted using two language modes (i.e., the Malay and English language). Spiritual studies were facilitated in English and translated to Malay. However, a patient (PP14) of Indian ethnicity voiced his concern that there were a few Indian patients, including himself, who only understood a basic level of Malay and English. These patients were more comfortable using their mother tongue language, which was Tamil. According to the patient, he and his peers preferred having Tamil translations included into the study session together with their peers of other ethnicities although they were given the option of having a Tamil translator or pastor provide one-to-one explanations and guidance in a later session.

‘I find the spiritual a little bit difficult to understand because of the language medium.’ [PP14]

Non-existent support network. A government rehab patient (GP07) who was nearing completion of treatment provided feedback on the non-existent support network for patients who left the centre after completing treatment. The patient disclosed that it was difficult for rehab patients to maintain friendships with their fellow residents. This patient also felt that having a support network that keep tabs on their peers’ progress would help rehabilitated and recovering patients cope with changes, prejudice and challenges in changing drug abuse behaviour and building a new life upon leaving the centre. Furthermore, the patient perceived that having a support network that enabled rehab patients to share experiences and resolve issues together as a group would be beneficial towards reducing the risk of relapse during the challenging process of re-integrating into society.

‘There is also no way to keep in touch with friends at the centre to keep tabs on how they are doing and forming a support network.’ [GP07]

Three programme limitations unique to rehab staff.  Three limitations that were unique to staff’s responses, and its corresponding concepts were also identified: (a) health contamination risks (unsafe treatment admission procedures); (b) content structure (lack of depth in treatment sessions due to limited time with patients, and limited emphasis on bridging interaction among patients of different ethnicities); and (c) lack of trained staff (insufficient numbers of counsellors and therapists to meet the needs of patients, and limited patrol staff to ensure security of the rehab centre). The concepts of these limitations are better described and illustrated through the selected quotes below.

Health contamination risks. One government rehab staff (GS02) felt that a major limitation in regards to the health and safety procedures during treatment admission was the health contamination risks. The staff reported facing health hazards when undiagnosed drug users were brought into the centre. As most drug users only receive a medical examination after admission into treatment, the staff faced the potential risk of exposure to transmittable diseases such as HIV and tuberculosis.

‘Staff also face a risk when dealing with drug addicts who just arrived at the centre as we are mostly unaware if they are suffering from illnesses such as tuberculosis or HIV. The diagnosis will only be known after the medical unit at the rehab centre has done a medical examination.’ [GS02]

Content structure. There were two sub-themes identified under the theme of content structure, which are the lack of depth and lack of national unity.A government rehab staff (GS04) commented that lack of depth in some counselling components was a major limitation. As a counsellor, there were circumstances in which he had limited time with each patient, leaving him unable to fully explore and help patients resolve their core issues with drug abuse. Moreover, this staff felt that the standard duration of two years for drug rehab treatment regardless of the severity of addiction, was too short. Rather, the length of treatment should be proportional to the severity of drug abuse.

‘Personally, I feel the counselling sessions are not in-depth enough. The duration of treatment and rehab is also not long enough. It is only two years, that’s why drug addicts are not afraid of being caught. Instead, if our country implemented the same system as Singapore whereby addicts are imprisoned and rehabilitated for a period of 10 years, then no one would dare to be involved in drugs.’ [GS04]

In the view of another government rehab staff (GS05), the lack of national unity in the content structure of treatment programmes was another limitation should be remedied. The staff observed that there was a lack of interaction between patients of different races. The staff was concerned that without proper intervention, the continuation of such an atmosphere would result in greater racial dissociation when the patients re-enter society after treatment.

‘There is insufficient content about national unity taught in the centre. Although the inmates are united within the centre regardless of race and ethnicity, there exists a racial gap when they leave the centre and re-enter society.’ [GS05]

Lack of trained staff. Two government rehab staff (GS02 and GS04) were of the opinion that the lack of staff, including both general workers and professionally trained, was a limitation. Although the grounds of the government rehab centre were small, a staff (GS02) highlighted the need to have sufficient staff to patrol and maintain security within the centre at all times. Another staff (GS04), who was a professional counsellor, commented that there were limited health professionals available to meet the needs of the patients. Although the counsellor practiced a rotation system to ensure that he was able to meet a huge number of patients, the lack of professional staff have led to fragmented counselling sessions, with some patients being able to see their counsellors at most once a month.

‘There is a lack of resources and staff, especially in regards to security.’ [GS02]

‘There was a rotation system for counselling sessions due to insufficient counselling staff. Therefore, rather than continuous sessions, some clients are seen only once a month.’ [GS04]

4. Suggestions for improving drug rehab programmes

In regards to areas for improvement, there were three themes agreed by rehab patients and staff, as shown in Figure 7. In addition, there were two themes that were unique to patients’ responses and five themes that were unique to staff responses.

Three suggestions as agreed by rehab patients and staff. Corresponding to the limitations highlighted by rehab patients and staff in the previous section, there were three themes identified in suggestions for improvement by the patients and staff. The first suggestion was to upgrade treatment facilities, which include the following concepts: (a) improving the general aesthetics of the rehab centre; (b) establishing an on-site medical clinic; (c) upgrading sporting facilities for physical rehab activities; and (d) upgrading the standards of accommodation and food. The second suggestion was to upgrade treatment approaches, which include the following concepts: (a) using newer treatment methods to fit the needs of younger drug users; (b) prioritising patients’ needs in determining suitable types of treatment and counselling based on their individual circumstances; (c) allowing adequate relaxation time for recuperation; and (d) conducting constant evaluation of treatment programmes, with feedback from patients to ensure patients’ needs and treatment goals are aligned. The third suggestion was to provide useful job links. The concepts associated with the provision of job links include: (a) establishing external contact and job relationships through vocational workshops and the spiritual studies component; (b) creating joint ventures with various industries to provide wide exposure to different employment opportunities; and (c) providing good and credible references on the capabilities and conduct of patients. These concepts are described in depth with the aid of the selected quotes below.

Upgrade facilities. Three government rehab patients and one private rehab patient suggested that an upgrade in facilities and services was needed to further improve existing drug rehab programmes.  A government rehab patient (GP06) suggested that since patients spend a majority of their treatment experience at the centre, improving the aesthetic outlook of the rehab centre such as creating a rock garden on the grounds would help increase patient satisfaction and make their treatment experience more enjoyable. Another government rehab patient (GP07) also highlighted the need for an on-site clinic to conduct health checks and the administration of subsidised medication for patients under methadone replacement therapy. This patient reported that it was costly for patients to travel monthly to private clinics and pay for additional medications since they often do not have a stable source of income and were not from financially wealthy families.

‘Improvement in aesthetic facilities such as a rock garden or small fountain would add a nice touch.’ [GP06]

‘It would be convenient to have a clinic within the centre for patients undergoing methadone therapy. At the moment, it is expensive to go to a private clinic monthly for treatment as they charge RM 13 every time.’ [GP07]

An in-patient (GP15) at the government rehab centre also reported that the patients’ accommodation could be further improved by installing sufficient fans and air cleaners. This was particularly important to the patient since at the point of interview, a series of haze and high temperatures was experienced in Malaysia. Moreover, since the government rehab centre was located closely to the main roads, dust and carbon monoxide easily drifted into the patients’ sleeping quarters. A private rehab patient (PP13) however, noted that the food service could be improved with greater variety and higher quality foods. As most of the cooking was done by the patients based on a duty roster, it was suggested that new recipes be experimented and shared among the patients and staff.

 ‘The weather these days are really hazy and hot. Moreover, the location of the centre is just next to the road and the air is really dusty. It would be nice if the sleeping quarters for the residents could be air-conditioned.’ [GP15]

‘Maybe an increase in the quality and variation of food provided.’ [PP13]

An upgrade in sports facilities was also suggested by a private rehab staff (PS04). At the point of interview, the staff observed that the patients mostly played basketball and football, in which they have competed actively and won several district competitions. However, the staff would like to introduce a greater variety of sports to meet the interest of the patients such as physical training at the gymnasium, tennis, badminton or futsal. The staff had to coordinate and rent external venues for patients who would like to engage in sporting activities that the private rehab centre was not able to accommodate. Thus, a greater variety of sporting facilities and higher quality training was proposed.

‘…maybe the improvement of sports facilities. This can help engage the students in a variety of sports. At the moment, students play mostly football and basketball. But there are some students who prefer to go to the gym, play tennis, badminton or futsal. For these, we need to go outside the centre to use proper sporting equipment and facilities.’ [PS04]

Upgrade treatment approach. Four private rehab patients particularly cited that an upgrade in treatment approach was very much needed. A patient (PP01), who was nearing treatment completion, proposed that newer methods of treatment should be introduced to meet the needs of the newer generation of drug users, who were from educated backgrounds. This patient also noted that treatment challenges in the present differ from past, with the rapid invention of designer drugs. Thus, an updated treatment approach was needed to accommodate new side effects. It was proposed that the lead facilitators and rehab staff observe the changes in drug trends and keep their treatment strategies relevant with time. Another patient (PP02) also commented that the new generation of drug users possess at least a college qualification or used to be working professionals and had their own families. Thus, the harsher methods of treatment, which was used in the past to deal with drug users who were mostly hard-core criminals who served prison sentences for their crimes such as military-style training, may not be as suitable.

‘It would be better if they could add more new things to the approach used. There has to be greater challenges in dealing with newer drugs such as designer drugs. Besides, the new drug addicts are no longer hard core addicts. Rather, they come from educated background with jobs and family. The new batches of addicts are unable to accept treatment methods that have existed since the 1980s.’ [PP01]

‘The way of the leaders is a bit old-fashioned. Most of them are in their 50s to 60s. They are used to dealing with the old batch of addicts who are mostly hard-core people. Therefore, they use a lot of hard-core methods to reform.’ [PP02]

Another aspect of treatment in which change was suggested by two private rehab patients (PP03 and PP06) was the allocation of relaxation time for patients. Up to the point of interview, patients in the private rehab centre followed a schedule that was often packed with various activities to teach patients usable skills and how to overcome drug urges. Both patients were in consensus that a schedule that was too exhaustive was not good as patients needed time to recuperate physically and have sufficient time to process the new knowledge obtained from various talks, workshops and bible or spiritual study sessions.

 ‘…personally I would like it if there was a half day for relaxation on Saturdays. The schedule is usually packed on weekdays and the programme usually starts at 5 am. Even on Saturdays and Sundays, we have to wake up early for prayers and church service.’ [PP03]

 ‘Recently, the programme introduced a personal devotion time from 7 to 9 pm. At the end of the day, I feel really drained of energy. Maybe this session can be reduced or removed as in the morning, there is already a prayer and devotion session.’ [PP06]

Four government rehab staff and a private rehab staff also viewed that upgrades in treatment approaches were needed. In particular, three government rehab staff and a private rehab staff suggested the implementation of a tailored treatment approach, which was in consensus with findings from the rehab patients. The private rehab staff (PS02) strongly proposed conducting constant programme evaluation, with feedback from the patients, to improve the treatment programme. Meanwhile, a government rehab staff (GS04) viewed that treatment centres should prioritise patients’ needs rather than the occupancy rates. Another government rehab staff (GS02) recommended that new patients and relapsed patients be treated using different approaches. This was because patients, who relapsed and re-admitted into a rehab centre that utilised a similar treatment approach as the previous rehab centre, were more susceptible to boredom and indiscipline. In addition to this, another government rehab staff (GS03) recommended that a needs assessment be done to determine which treatment approach would be most suitable before patients were sent out to the rehab centres. It was suggested that this would provide patients with a more inclusive experience to treatment (i.e., patients’ opinions are considered in treatment decisions) and ensures patients’ commitment to the treatment programme.

‘The administrative management should constantly evaluate the programme in the quest to continuously improve the programme so as to meet the needs of students.’ [PS02]

‘…it would be more effective if the programme can be tailored to different types of cases. For example, old cases where inmates had been in and out of several rehab centres) should be separated and dealt with differently from new cases with first timers. This is because for old cases, the inmates pretty much about the ongoing of the program while for first timers, they may only be able to accept 30% of what is taught in rehab.’ [GS02]

‘Improvements to the treatment process must be done to ensure the rehab sessions meet the needs of the client. They should evaluate what the clients require, whether at the prison stage or at the agency level before the clients are distributed to different rehab centres based on the categories. For instance, some centres are more religious based while others practice community therapy, psychosocial approach and other approaches.’ [GS03]

‘…the treatment needs of the inmates need to be considered. We need to find out and solve their problems before they are distributed to different categories of rehab centres rather looking at the occupancy rates.’ [GS04]

A government rehab staff (GS01) further recommended that the tailored approach be applied to counselling since the circumstance of each drug user was different. The staff further elaborated that tailored counselling should be applied to patients who faced public discrimination such as patients diagnosed with HIV or had homosexual preferences. Patients who have faced years of discrimination require special care and attention as their hardships may have caused them despair and the loss of will to live. The rehab staff or counsellors need be a source of non-judgemental support to these patients.

‘…there should be special counselling provided for different categories of drug addicts. This is especially so for those who have been diagnosed as HIV+. Because of this diagnosis, most of them have lost the will to live and therefore, it makes no difference to them if they kick the drug habit or not. Similarly, more attention needs to be paid to drug addicts with homosexual preferences as they face discrimination within the centre.’ [GS01]

Provision of job links. Two private rehab patients (PP11 and PP13) suggested that the provision of reliable job links should be made available to patients who have completed treatment. A patient (PP13) commented that this aspect was essential towards ensuring the patients’ livelihood and preventing patients from relapsing into drug abuse behaviour. Moreover, it was suggested that help in establishing contact and relationships with people outside the rehab centre would ease the subsequent re-integration process. At the point of interview, this patient reported feeling a sense of discontinuity since he was unsure of his future after completing treatment. Another patient (PP11) provided an example in which job links could be established through the spiritual study and vocational training components. For instance, the patient reported that opportunities to work for church causes voluntarily outside the centre should be allowed occasionally.

‘I think there can be improvements made to spiritual studies. For example, we can go do voluntary work at churches outside of the centre once a while.’ [PP11]

‘The residents here would like it if the centre can introduce places of work that we can go after graduation. This is important because we need to be able to find a source of living after rehab. At the moment, we are left on our own once we leave the centre. So, there is a sense of discontinuity.’ [PP13]

Two government rehab staff (GS02 and GS05) also highlighted the need to provide more job links to patients who completed treatment and were leaving the rehab centre. A staff (GS05) acknowledged that to ensure better job prospects and instil self-sufficiency among patients, there should be more industrial linkages provided through the vocational component. The staff reported that although some government agencies do provide working opportunities through short internships with car repair and modification workshops, these opportunities were becoming scarce. The staff concluded that the upper management needed to create joint ventures with various industries, to provide patients with a wider exposure of different employment opportunities in the job market. Another staff (GS02) also highlighted the need for rehab centres to provide good and credible references on the capabilities and conduct of patients so that employers would not be wary of employing rehabilitated patients.

‘It would be good if more can be done about work opportunities for former drug addicts. …some employers are wary about taking them as employees because credibility may be affected when there is a constant change in employees.’ [GS02]

‘There is a need to improve occupational opportunities for inmates or clients who have completed rehab. For example, there has been a joint venture with MARA to absorb clients into workshops but so far, this has only been done with the Sepang rehab centre. In fact, all centres require joint ventures such as this.’ [GS05]

Two suggestions unique to rehab patients. Two suggestions that were unique to patients’ responses and its corresponding concepts were identified: (a) expanding range of activities (increasing range of indoor activities for rehab and relaxation, developing relevant physical activities for the elderly and patients with mobility issues, engaging patients in activities that would teach them about sustenance and business ethics such as gardening); and (b) enhance group relationships (strengthening group unity across different cultures and building a strong support network, encouraging effective communication between treatment providers and patients to work towards effective treatment plans and outcomes). The descriptions and selected quotes below provide deeper insight into the themes and concepts identified from the perspective of rehab patients.

Expanding range of activities. Three government rehab patients highlighted the need to expand the range of activities conducted as part of rehabilitative treatment. A patient (GP01) suggested that the centre provide a wider range of indoor activities to fill the patients’ resting time with useful activities. This would help them cope with drug urges. For instance, activities like chess, Chinese checkers and puzzles would help stimulate patients’ mental capabilities.

Another patient (GP02) who was previously in a geriatric home before entering the rehab centre suggested having a choice of activities that were age-relevant. Based on his experience as an elderly patient, he could not participate in many physical activities. Thus, it was suggested that activities which would not physically over-exert elderly patients be included as an option. Besides these suggestions, another patient (GP06) proposed including activities that would help ensure the centre’s sustenance such as creating a garden to plant fruits and vegetables, and using this opportunity to teach patients about conducting business according to the right business ethics by selling the extra produce.

‘It would be useful if more indoor games could be provided to help fill our time.’ [GP01]

‘There is not much to suggest in regards to activities due to my age. Probably, they can consider more age-appropriate activities for elderly drug addicts.’ [GP02]

‘Having a garden in which fruits and vegetables can be planted would be beneficial for the centre’s sustenance and for selling.’ [GP06]

Enhance group relationship. Two patients (i.e., 1 government rehab patient and 1 private rehab patient) cited the enhancement of group relationship as an aspect that requires further improvement. The government rehab patient (GP13) suggested that peer relationship among patients should be strengthened since the patients consist of individuals from different backgrounds, culture and belief. It was viewed that by enhancing the group relationship, group unity would improve and patients would have a stronger support network.

‘I think more efforts need to be done to strengthen the relationship between members undergoing the same programme.’ [GP13]

This view was similarly shared by a private rehab patient (PP02), who felt that a concerted effort from programme leaders to interact with patients and gain an understanding of patients as an individual was needed. This was especially so when the circumstances that leads to drug abuse among the younger generation (i.e., higher-educated backgrounds and privileged families) are very much different from the older generation of drug users. This patient felt that improving the group relationship through effective communication will enable treatment providers to adapt treatment plans accordingly to the different circumstances of each patient for better treatment outcomes.

 ‘I feel that for addicts who are formerly students and from a normal background, there is a need for more interaction between the students or inmates and leaders to learn more about them as an individual.’ [PP02]

Five suggestions unique to rehab staff. Five suggestions that were unique to rehab staff’s responses and its corresponding concepts were identified: (a) improving after-care services (conduct follow-ups to check on patients’ progress and prevent drug relapse, provision of half-way accommodations for patients who have not found external accommodation and employment); (b) management issues (using the bottom-up approach to understand actual circumstances faced by rehab patients and treatment providers; recruit staff with proper qualifications; rehab staff should have a sense of commitment, interest and passion in treating drug abuse); (c) improving patient discipline (enforcement of consequences with non-adherence of treatment or when rules and regulations are flouted); (d) staff development opportunities (continuous training for self-improvement of staff to handle new treatment challenges); and (e) improving security (securing enclosure to ensure patients’ safety on centre grounds, strict monitoring of visitors). The descriptions and selected quotes below provide deeper insight into the themes and concepts which were identified from the perspective of rehab staff.

Improving after-care services. Two government rehab staff viewed improving after-care services as an aspect that required greater attention. A staff (GS03) acknowledged that it was essential to conduct proper follow-ups on patients’ progress even after completing treatment and leaving the centre. It was suggested that regular checks from an assigned supervisor would help ensure that patients were able to cope and maintain their new lifestyle and the process of re-integration, which can be stressful and challenging. This staff also noted that after-care services for patients who were without a home or job upon leaving the rehab centre was needed. The staff gave an example of government service centres which were set-up to help patients of various ethnicities to transition into a new lifestyle more easily by assisting them in finding temporary accommodation and jobs while monitoring their progress.

Furthermore, another staff (GS05) reported that based on his experience with relapsed patients, after-care monitoring and services was essential since most patients are able to cope on their own for an average of three to four months post-treatment. The staff explained that the prevalence of stigmatisation against drug users has led many patients to become disillusioned and vulnerable to relapse. Thus, follow-up sessions would enable rehab staff to catch and resolve the patient’s problems in time before a relapse occurs.

‘…improvement should be done to the after rehab services in which clients who have nowhere to go after leaving the centre will be given a temporary place to stay at the CCSC service centres. The centre will help them find jobs and continue on with additional treatment and rehab to ensure clients are able to completely kick the habit. This centre services clients of all races and ethnicities.’ [GS03]

‘Aftercare services also need to be emphasized as most clients are still alright after 3 to 4 months of being released. However, due to societal stigma regarding drug users, they quickly become disillusioned and easily fall back into the habit.’ [GS05]

Management issues. A government rehab staff (GS04) also viewed that treatment services could be better improved with better handling of management issues. The staff suggested that the upper management should apply the bottom-up approach by interacting with staff working in the field and rehab patients, to obtain feedback and understand the circumstances of treatment issues rather than relying on reports. The staff felt that upper management would then be able to implement relevant and effective policies to resolve treatment issues.

‘Besides studying the results of reports, the upper management needs to take time to go down to level of the inmates and rehab staff to understand the real problems faced in treatment and rehab.’ [GS04]

Another sub-theme found in staff responses about management issues was the need to increase staffing. A senior government rehab staff (GS04) viewed that the existing staff was lacking expertise in the area of counselling and religious teaching. The senior staff further elaborated that the lack of commitment among the younger staff was also an issue and a reason for high employee turnovers. The senior staff observed that the younger staff often found it difficult to cope with the demands of the job, which requires a lot of passion for their vocation as working with drug users to overcome their dependence and addiction is time-consuming, occasionally harsh and requires patience. Thus, the younger staff ended up leaving for easier jobs in other settings. Nevertheless, the senior staff remarked that there should be stricter criteria in selecting rehab staff such as having the proper counselling qualifications or demonstrates interest and passion in working with drug rehabilitation. However, they should have the intention of upgrading their knowledge and skill sets.

‘I feel there should be an increase of religious officers and counsellors placed in the centre. The current ratio is 1 counsellor for every 500 inmates. Besides that, not many officers are committed. However, there should be strict criteria in recruiting counsellors (preferably with proper counselling qualifications, if not then they should at least have the initiative to upgrade themselves with counselling basics and skills)’ [GS04]

Improving patient discipline. Two government rehab staff also felt a particular need for centres to look into methods of improving level of discipline among patients. While each centre has their own set of rules and regulations, a staff (GS02) felt that there should be greater enforcement of consequences, when rules are flouted. This sentiment was echoed by another staff (GS03), especially in regards to participation in all rehab activities since following the prescribed treatment regimen faithfully was essential towards ensuring the achievement of optimum treatment outcomes.

‘Naturally, there should also be punishment when needed so that they are aware of the consequences of their actions.’ [GS02]

‘All clients or patients must follow the each programme strictly.’ [GS03]

Staff development opportunities. A private rehab staff (PS02) also hoped for more staff development opportunities since treatment techniques continue to advance with changes in drug trends and the creation of new drugs. The staff viewed that there was a need for continuous learning and self-improvement to handle new issues that arise with a new group of drug users.

‘The staff also need to keep learning and self-improve to keep up with new issues that arise with a new batch of students.’ [PS02]

Improving security. A private rehab staff also viewed that improving security within the rehab centre was important. The staff described efforts by the management to upgrade security by building stronger gates with a stricter security system to ensure that private rehab patients were not endangered within the centre grounds. Furthermore, it was disclosed that the gates would also help prevent new patients from escaping when they were unable to withstand drug urges and the loss of freedom. In addition, the enforced security would also enable staff to monitor visitors entering and leaving the centre, especially acquaintances who may be drug dealers.

‘…the centre is currently working on upgrading the security of the centre such as building stronger gates to prevent new drug addicts from escaping. This will better allow us to control the ins and outs of visitors and residents within the centre compound.’ [PS05]

5. Adaptations made to drug rehab programmes

Despite various suggestions to improve existing drug rehab programmes, government rehab staff felt that it was important to acknowledge two main adaptations that were in place.

Inclusion of local spiritual elements. Efforts to merge local cultural and spiritual values into counselling techniques and rehabilitative approach, which were often based on Western philosophy, were made to increase the relevance and effectiveness of treatment techniques. As reported by a staff (GS01), patients’ specific cultural beliefs and religious inclinations were included in the community therapy programme, which was initially developed according to the freethinker philosophy so that its techniques were applicable to patients in the United States, regardless of their religious beliefs. This adaptation was made to fit into the societal mind-set of Malaysians who mostly have specific religious beliefs. Furthermore, the staff reported that religious leaders were invited to guest-counsel the patients so that they could have a religious perspective on overcoming addiction as well as receive adequate support and motivation to complete their treatment.

‘As the community therapy programme, which was adopted from the US, is based on the free-thinker philosophy, we added a spiritual element by inviting guest speakers from different religious standings for spiritual counselling and motivation.’ [GS01]

Provision of after-care services. According to a government rehab staff (GS03), these services were catered to patients who were left homeless after completing drug rehabilitation. Temporary shelters were setup for these patients while they searched for jobs and earned sufficient money to rent outside accommodations. A plus point of this shelter was that it provided services to patients of various ethnicities and thus, gave patients the opportunity to interact and support each other.

 ‘…in recent years there is improvement done to the after-rehab services in which clients who have nowhere to go after leaving the centre will be given a temporary place to stay at the CCSC service centres. The centre will help them find jobs and continue on with additional treatment and rehab to ensure clients are able to completely kick the habit. This centre services clients of all races and ethnicities.’ [GS03]

 

6. Probability of relapse

At the end of the interview session, patients were also requested to reflect on the probability of relapsing after completing their treatment. Responses from rehab patients in both government and private rehab centres were largely grouped into two categories which are no relapse and unsure.

Confident of no relapse.Nineteen patients out of 30 patients from the government and private rehab centres reported being almost 100% confident that they would no longer relapse after completing treatment from the rehab centre. Ten government rehab patients provided five reasons in which they would not relapse, as shown in the sample quotes below. The reasons include having a strong determination to kick the habit, the prospect of aging, possessing a greater sense of responsibility among patients towards their elderly parents, awareness of drug abuse consequences from the experience of peers who did not obtain treatment or relapsed as well as having the confidence to overcome personal issues.

‘I am 100% confident that this time I won’t relapse because I am determined to give up the habit voluntarily.’ [GP01]

‘I am 100% confident this time I will be able to stop as the skills taught here have helped me to resolve my problems.’ [GP05]

‘I am confident that this time I won’t relapse because I have a responsibility towards my family now that my parents are in their old age.’ [GP07]

‘Definitely 100% no. I don’t want to be involved in drugs anymore and will make sure that I won’t mix with the same group of friends who got me in trouble.’ [GP11]

‘I am confident this time I won’t relapse because I am strongly determined to go along the right path after seeing what happened to my friends who continued using drugs.’ [GP13]

Similarly, nine private rehab patients reportedly gained confidence to avoid relapsing. A patient (PP02) felt confident that there would be no probability of relapse because he has increased awareness of the harm in misusing drugs as well as better knowledge of coping skills, anger management techniques and dealing with distorted imagery through the guidance of counsellors and book resources at the rehab centre. Another patient (PP03) also reported being confident of not relapsing because he intended to continue serving the centre as an employee and working closely with the church in order to receive continuous guidance and supervision. A patient (PP15) was feeling confident as he was focused on building a secure future such as having detailed plans to start up his own workshop or business upon leaving the centre besides having past aspirations of serving the church as a pastor.

‘I am confident there is no probability of relapse. The centre equip us with knowledge on how to stand up to triggers, problem-solving and coping skills, anger management, distorted imagery. Book resources are available such as the ‘Battlefield of the Mind’ which sets me thinking.’ [PP02]

‘I don’t think I will relapse again after leaving this centre. Now I have God, who is giving me the gift of guidance. Besides, I have plans to devote myself to God 24 hours after leaving the centre by working in a church. This will allow me to obtain continuous guidance and supervision from the pastors.’ [PP03]

‘I am very confident that I won’t relapse. When I graduate from this centre, I have plans of opening my own mechanical workshop, especially since I have previous training and work experience. After all, before getting involved with drugs, I used to dream in being a pastor.’ [PP15]

Unsure.Eleven patients out of thirty patients from the government and private rehab centre reported feeling unsure about not relapsing after completing treatment. Five government rehab patients were feeling uncertain although they expressed confidence in overcoming addiction. A patient (GP03) however, cited that the knowledge and application of coping skills taught by their instructors would be beneficial in helping him deal with drug urges. A patient (GP06) also expressed that while he would try his hardest to avoid relapsing, there must be greater efforts to prevent drug supplies from being smuggled in and circulated. Another patient (GP14) also would not affirm that he would not relapse but expressed greater confidence in overcoming drug addiction after attending the rehab programme.

‘I can’t say for certain that there is no possibility. But, should I be ever be met with the urge, this time I will use the lessons and techniques learnt here to overcome it.’ [GP03]

‘I will try my best not to indulge in drugs again when I am out. But naturally, more efforts must be done to stop the supply of drugs from entering the society.’ [GP06]

‘It would be lying if I were to say that I am 100% sure I won’t relapse. But at least after this programme, my confidence in overcoming my drug habit has increased.’ [GP14]

Six private rehab patients also reported feeling uncertain about the probability of not relapsing. As can be seen in the sample quotes below, a patient (PP01) particularly mentioned that he was uncertain about the society’s reception to him as an individual with a history of drug use. Another patient (PP04) who was newly admitted into treatment was extremely unsure of his future and the possibility of relapsing after leaving the centre as it greatly depends on the situation. His sentiment was supported by another patient (PP05), who confided that there was a high probability of relapse if he returns to stay with his family, which had a history of organised violence. Thus, he would need to relocate and start a new life somewhere else to avoid relapsing. A patient (PP07) reported having reflected and gained self-awareness of the circumstances that could potentially lead to relapse and thus, derived contingency plans such as avoiding social drinking, which was a situation that led him into drug abuse.

‘Well, I cannot be 100% sure enough to say that will not relapse. I am still unsure how the society will receive us. But personally, I know that I need to work harder on learning to say ‘No’.’ [PP01]

‘I myself am still unsure and don’t know yet if there is a possibility. I think it depends on the situation.’ [PP04]

‘I know that if I go back to my hometown after graduating, there will be a high probability of relapsing, maybe even 100%, because of my family’s involvement with gangsterism. I will need to start a new life somewhere else to stay clean.’ [PP05]

‘Honestly, I am not 100% sure if I will not relapse when I leave the centre. But I will try all I can to avoid things that can lead to drug abuse like social drinking.’ [PP07]

3. Job satisfaction evaluation among drug rehab staff

Besides evaluating drug rehab treatment from their perspective as treatment providers, the government and private rehab staff were also invited to provide feedback on job satisfaction. From their responses, a difference in factors that influenced job satisfaction in the government and private centre was found. Job satisfaction among government rehab staff was influenced by extrinsic factors while job satisfaction among private rehab staff was more greatly influenced by intrinsic factors.

Extrinsic factors. The government rehab staff felt that comfortable facilities were suitably provided to do required paperwork and conducting activities with patients, although more storage space for documents would be preferable. In addition, staff who roomed in hostel facilities and undertook the role as hostel supervisors felt that good security was provided. Moreover, it was reported that there was strict monitoring of individuals who were allowed entrance into the premises for visitation and hostel curfews.  Nevertheless, there were staff who expressed dissatisfaction when they were unable to resolve a client’s problem due to lack of expertise.

‘…the facilities provided to the staff were ok. There is ample security provided in the hostels for both inmates and staff.’ [GS01]

‘I feel especially dissatisfied when I am unable to solve the clients’ problems.’ [GS04]

Intrinsic factors. From the responses of private rehab staff, there were two dominant sub-themes coded in relation to job satisfaction. The sub-themes were work objective and personal growth. The private rehab staff were often former patients themselves. They reportedly found their calling and work objective in helping other drug users to overcome drug addiction. Moreover, working closely with the church has given them the time and space needed to achieve personal growth in their service to God.

 ‘I am satisfied working here as it allows me help others and serve God at the same time.’ [PP02]

‘I am satisfied working here as I can assist people who need help in overcoming their addiction.’ [PP05]

 

6.4 Summary

This chapter investigated the difference in treatment satisfaction scores between patients and rehab staff and patients’ perception of their level of satisfaction with treatment. In summary, there were no significant differences in satisfaction ratings between patients and staff. A majority of patients were satisfied with treatment because they perceived that: (a) the content of treatment sessions were valuable and applicable towards resolving drug issues; (b) the sessions were well-conducted and easily understood; (c) positive messages were received from the sessions and treatment providers were friendly and encouraging; and (d) the patients felt empowered and excited to achieve treatment goals. However, difficulties in meeting specific patients’ needs within a group setting and cancelled treatment sessions without specified reasons have led to dissatisfaction among some patients. These findings highlight a need to: (a) supplement group counselling sessions with individual sessions to help patients with specific treatment needs; (b) conduct multi-perspective evaluations of drug treatment programmes to identify discrepancies between patients’ needs and treatment providers’ expectations; and (c) recruit committed and passionate staff.

In Chapter 6, similarities and differences between staff’s and patients’ responses on favourable treatment components, treatment limitations and suggestions for improvements were also investigated. From the thematic findings, major similarities were found in patients’ and staff’s responses about favourable treatment components. A balanced combination of four treatment components (i.e., counselling, spiritual studies, vocational workshops and recreational activities) was generally favoured. However, there were three additional components that were favoured by patients which are community projects, health talks and family visits because these components provide patients with the opportunity to: (a) re-engage with the community and build teamwork; (b) learn and improve their health status; and (c) receive social support, which is important for recovery from drug abuse.

However, there were slight similarities and major differences found in responses related to treatment limitations and suggestions for improvement. Major differences were attributed to differences in experience with treatment from the perspective of patients and treatment providers. The patients reportedly had limited space to conduct physical rehab activities while the staff had limited workspace to process and store documents. Additional limitations from the patients’ perspective include: (a) limited facilities (e.g., on-site medical facility and sports facility); (b) limited range of rehab activities (indoor activities and physical activities for the elderly or patients with mobility issues), (c) limited industrial linkages; and (d) non-existent support network after leaving the treatment centre. From the staff’s perspective, additional limitations include: (a) health contamination risks since patients are only provided medical check-up after treatment admission; (b) limited emphasis on national unity, which led to communication issues between patients of different ethnicities and culture; and (c) limited trained staff (e.g., counsellors and vocational therapists).

These findings highlight the need for drug rehab programmes to: (a) upgrade treatment to a patient-centred approach that prioritises patients’ needs; (b) upgrade treatment facilities (e.g., medical facility, aesthetic outlook of the rehab centre); (c) upgrading after-care services (e.g., follow-ups via telephone or face-to-face, expanding services for half-way houses); (d) expanding the range of rehab activities (e.g., indoor activities for rehab and relaxation, developing physical activities for the elderly and patients with mobility issues, including skills for individual sustenance and business ethics in vocational workshops), (e) formation of more industrial linkages to increase patients’ job opportunities; (f) enhancing group relationship (building a strong support network, encouraging effective staff-patient communication); and (g) resolving staff management issues (applying bottom-up management approach, hiring qualified staff or provide opportunities for professional development, hiring staff with commitment and passion to reduce high employee turnover).

The findings above also indicate a need to identify factors that affect job satisfaction among drug rehab staff and improve work conditions. In this study, the government rehab staff required extrinsic motivators to increase job satisfaction such as comfortable facilities to conduct rehab activities and deal with paperwork. However, the private rehab staff required intrinsic motivators such as clear work objective (e.g., using past experience with drug abuse to help others overcome addiction) and opportunity for personal growth (e.g., personal and spiritual growth) to increase job satisfaction.

Chapter 7: Integration of findings across three sample groups

A diverse range of responses from university students, drug rehab patients and rehab staff were collected from the survey and interview components of this study. The range of responses were largely influenced by sociodemographic factors such as family history of drug use, past exposure to drug awareness and prevention programmes in school, personal interest in social health issues within the community as well as exposure to drug abuse topics via the media.

Three types of triangulation were conducted in this study to identify similar and unique themes across individual perspectives and subsequently, integrate and validate the findings. The methods of triangulation were: (a) data triangulation: comparing data across the three sample groups; (b) methodological triangulation: the use of surveys and interviews to collect quantitative and qualitative data concurrently for constant comparison); and (d) investigator triangulation: the use of three raters in coding and interpreting data.

Through triangulation, a series of similar and unique themes were found across several research areas. An example of a research area where themes were compared across the three sample groups was drug relapse factors. Although the university students in this study have no experience with drug abuse, they have been educated about drug abuse and relapse during drug awareness and prevention programmes in school. A comparison between students’ perceptions and the reality of drug abuse through the experiences of drug rehab patients and staff revealed that the students were able to retain basic knowledge on drug abuse and relapse as they had a rather accurate perception of drug relapse factors. The students perceived old peer influence and the lack of willpower as reasons for drug relapse. These two themes were supported by accounts from two government rehab patients (GP02 and GP06) and one private rehab patient (PP10) who reported relapsing due to peer influence from their past and current workplace.

‘There was also the influence of friends from the old group and workplace.’ [GP02]

‘…my group of friends were also users and it was hard to avoid them.’ [GP06]

‘…the group of friends I was involved with upon coming out from rehab.’ [PP10]

However, it was found that the effect of old peer influence differed with age. An elderly private rehab patient (PP09) reported that old peer influence was not a factor for drug relapse in his case, because most of his friends have died of old age or succumbed to the long-term effects of drug abuse.

‘It was no longer due to influence of friends because most of my friends are no longer around. Most of them have died because of drugs.’ [PP09]

Further comparisons between the responses of rehab staff and patients revealed that drug urges and family conflicts were also attributed as factors for drug relapse, besides old peer influence. In the context of drug urges, it was found that rehab patients had the tendency to attribute internal factors (i.e., lack of willpower) as reasons for submitting to drug urges.

 ‘I just wasn’t strong-willed enough to stand the urge of taking the drugs.’ [PP07]

‘…it was mostly due to my own lack of willpower.’ [GP08]

In contrast, the rehab staff revealed a tendency to attribute external factors such as old peer influence as a reason for patients’ submission to drug urges.

‘…once they are released back into society, most of them are unable to stop their urge towards drugs when they fall back into the same group of friends.’ [GS01]

‘…former inmates tend to fall back to old habits when there is strong external influence from friends.’ [GS02]

Family conflict was also a common factor for drug relapse from the perspective of rehab patients and staff. For instance, a private rehab patient reported that he started using drugs again to cope with stress and pressure felt from fights and disagreements with family members. In fact, a government rehab staff (GS02) perceived that family conflict was more likely to contribute to drug relapse rather than the initiation of drug abuse.

‘I was really unhappy and stressed at that time due to many family conflicts occurring.’ [PP06]

‘Family issues and conflicts were more often the reason for relapse rather than initiation of drug abuse.’ [GS02]

Triangulation of responses between rehab patients and staff also yielded common themes in four research areas: (1) drug abuse factors, (2) drug relapse factors, (3) treatment admission factors, and (4) evaluation of drug rehab programmes. Common themes were also found between students and rehab staff on relapse prevention strategies that were perceived as effective. Summaries of common and unique themes identified via constant comparison across two or three sample groups by research category are as follows:

7  Integrating the research areas and its findings into the drug rehab treatment and prevention education systems

Figure 8 provides an overall representation of components involved within the drug rehab treatment system and its interaction with drug prevention education. These components were derived based on field observations and feedback across the three sample groups (university students, rehab patients and rehab staff).  Feedback from university students was essential towards identifying knowledge gaps on drug abuse and drug relapse issues by contrasting their perceptions with life experiences of rehab patients and treatment providers. Furthermore, the students helped identify the strengths, limitations of past prevention education programmes and provided valuable feedback on areas to improve. Feedback on current drug rehab treatments helped identify the strengths, limitations and the areas to improve across perspectives of patients and treatment providers. Similar and contrasting feedback on satisfaction with treatment was instrumental towards differentiating patients’ needs and the expectations of treatment providers. Field observations of both sample groups also provided insight into the admission and treatment processes, besides identifying information that should be established by rehab staff at different levels of treatment (pre-treatment, treatment and post-treatment). This would help facilitate the formation and implementation of an inclusive and patient-centred treatment plan. In addition, the researcher was able to observe patients’ reaction to treatment sessions, which were corroborated by findings from the Session Evaluation Questionnaire (SEQ).

The table accompanying Figure 8 lists the key terms and description for each component based on the research findings. At the pre-treatment level, it is essential that drug treatment providers establish factors related to drug abuse, motivation to change and factors that encouraged drug rehab patients to seek treatment. At the start of treatment, patients’ drug use history should be collected and explored. Together with the information collected at pre-treatment, it should guide treatment providers and patients in forming treatment goals and plans which would meet patients’ needs. It is essential that the patients be made aware of the possible phases that they will experience and treatment providers could use the Transtheoretical Model of Change (Prochaska, DiClemente & Norcross, 1992) as a basic guideline. Patients’ motivation to change and achieve treatment targets should be continuously explored and monitored during the course of treatment. Additionally, potential relapse factors should be explored and drug rehab patients should be equipped with knowledge and practice of a range of relapse prevention strategies until they achieve high self-efficacy.

At post-treatment, drug rehab patients should be given the opportunity to self-evaluate their progress and provide feedback about the treatment programme. Ratings of treatment satisfaction and feedback from the rehab patients and staff will enable treatment providers to identify the presence of discrepancies. In addition, the feedback and ratings will influence the types of after-care services that are offered to patients. Besides knowledge about drug abuse and prevention, it is essential to educate children, adolescents and the public about the overall process of treating drug abuse within the rehab system, which would go a long way towards changing societal attitudes and views about drug abuse.

Feedback from drug rehab patients and treatment providers as well as observations of the treatment process indicated a need for more assessment studies on standard operating procedures of drug rehab treatment, involving a larger number of drug rehab centres. Despite the reorganisation of structure and services in government and private rehab centres, treatment providers acknowledged an increasing need to move treatment approaches toward a more interactive, tailored and patient-centred direction. Figure 8 can function as a basic guideline towards implementing this treatment approach while maintaining the flexibility to accommodate treatment components according to the expertise of different centres. Furthermore, the assimilation of the drug treatment and drug prevention education systems could: (a) help improve collaboration between treatment providers and agencies involved in public education. This measure could increase public understanding about drug abuse issues from a medical and psychosocial perspective; (b) improve and maintain transparency of resources and expertise that goes into treating drug users; and (c) provide the community (parents, teachers and neighbourhood) with a clearer definition of their roles in working together with rehabilitated patients to maintain a healthy and addiction-free lifestyle at post-treatment.

Chapter 8: Discussion

To recapitulate, this research study was conducted with the following aims: (a) to obtain insights into issues related to drug abuse and relapse in Malaysia from different perspectives (i.e., university students without drug abuse experience, drug users and rehab staff); (b) to understand knowledge gaps in drug prevention education; and (c) to evaluate patient satisfaction with treatment in a government and private drug rehab centre.

With the purpose of understanding knowledge gaps in drug prevention education, perceptions of university students about factors for drug abuse and drug relapse, and effective relapse prevention strategies were contrasted against the real-life experiences of rehab patients and staff. Although the university students who participated in this study had no experience with drug abuse, they had exposure to drug prevention education in school. Additionally, students’ perceptions about commonly abused and easily accessible drug types were contrasted with patients’ drug use history and information from the Malaysian drug statistics. The similarities in students’ responses with patients’ and staff’s responses or the national drug statistics is a good baseline measure of students’ ability to retain knowledge on drug abuse and prevention issues. In addition, it was of further interest to investigate the presence of gender differences in university students’ perceptions. This study also examined students’ awareness and beliefs about rehab services in government and private rehab centres to gauge knowledge gaps and misconceptions about drug rehab services. In order to gain an understanding of students’ educational needs, this study explored students’ perceptions about drug prevention education in school and their experiences with past prevention programmes. Qualitative feedback on improvements that should be implemented at school and tertiary education level provides further insight into content and implementation issues in drug prevention education, from the perspective of university students. To understand and improve modes of delivering drug prevention education and drug awareness messages to students, this study investigated the preferred medium for searching and sharing information about drug abuse, drug prevention and treatment.

During the interview sessions, it was also observed that treatment providers should consider two components to achieve a good level of patient satisfaction with treatment: (a) a deep understanding of patients’ background and drug abuse circumstances; and (b) identifying patients’ need versus treatment providers’ goals and expectations. A deep understanding of patients’ background and circumstances is essential towards identifying patients’ treatment needs and formulating a treatment plan that would cater to those needs. Thus, patients’ demographic information were investigated to better understand patterns in drug abuse through their drug use and treatment history, in addition to their personal circumstances such as family relationships among the patients and their peers, socioeconomic conditions and educational status. The current study also examined factors that motivate change in drug abuse behaviour among rehab patients and their reasons for seeking treatment as these factors could influence patients’ treatment adherence. Satisfaction ratings and qualitative feedback on the strengths and limitations of drug rehab programmes between rehab patients and staff were triangulated. The patients’ satisfaction ratings were further triangulated with patients’ evaluation of treatment sessions using a Session Evaluation Questionnaire. Findings from the triangulation process would help determine similarities or differences between patients’ and rehab staff’s perspective on treatment goals, needs and expectations. Suggested improvements for drug rehab programmes also provide a unique opportunity to gain insight into treatment priorities of patients and rehab staff.  Besides evaluating the drug rehab programme, the current study also provided patients with the opportunity to self-evaluate their treatment progress such as the ability to decline drug offers at the point of treatment and probability of relapsing after completing treatment.

In the following sections, the research findings are presented and discussed in response to the research questions. These findings are then compared against predictions, which were formed from past results found at the pilot survey and focus group stage, to determine whether the predictions are supported or rejected. The strength and limitations of the research study, suggestions for future research and its implications to the current understanding of drug abuse and relapse, drug prevention education and rehab treatment services are also discussed.

1. Difference in perception of factors for drug abuse and relapse, and effective relapse prevention strategies between male and female university students (Research Question 1)
   1.      Drug abuse factors

The overall analysis indicated that life stresses and the social environment were often perceived by university students as factors for drug abuse. However, they disagreed that being uneducated could lead to drug abuse. In response to Research Question 1, further analysis indicated that female students were significantly more likely to rate unemployment (disposition factor) as a reason for drug abuse. This finding was very different from Prediction 1, which initially predicted that female students were significantly more likely to perceive factors related to problem and coping, sensation-seeking, and the social environment as reasons for drug abuse. The current findings also indicated that male students were more likely to view being uneducated and weak-willed (disposition factors) as reasons for drug abuse, although gender difference was not significant. This finding was rather similar to Prediction 1, whereby it was expected that male students were more likely to perceive disposition and social environment factors as reasons for drug abuse. Thus, in regards to the prediction on drug abuse factors, Prediction 1 was only partially supported.

The perception among female students about unemployment as a significant factor for drug abuse could have been influenced by gender role stereotypes. Despite increasing numbers of successful career women in Malaysia, males were stilled viewed by the society as the primary family breadwinner. This stereotype, coupled with the fact that most drug users in Malaysia comprise of males (e.g., 25,655 males versus 1,013 females in 2015), could have influenced the perception that unemployment plays a major contributory factor towards drug abuse. A study by Mugisha, Arinaitwe-Mugisha and Hagembe (2003) supported this notion through its suggestion that gender differences in perceptions of illicit drug abuse was influenced by gender stereotypes and the nature of upbringing. As females were traditionally associated with the role of being the ‘nurturing female’ and thus, were more often in charge of the household and the daily survival of their children and the elderly, it was proposed that this could have influenced coping styles as well as cognition and perception. When faced with obstacles, females are less likely to lose hope, find alternative methods to resolve issues and group together with their peers to better organise their cause (Mugisha, Arinaitwe-Mugisha & Hagembe, 2003). Males however, were often associated with the traditional gender roles of being the ‘achieving male’, and were viewed to be less adjustable to unemployment because their career becomes an integral part to their identity (Leana & Feldman, 1991). Thus, when faced with situations such as unemployment or an accident in the workplace, males were more likely to adopt the escapist coping patterns such as engaging in drugs and alcohol use, violent behaviour and abandonment of their familial responsibilities (Bisilliat, 2001).

In addition to this, the female student respondents were also more likely to rate personal sufferings, family conflict, coping with life, curiosity, associations with drug-dependent peers and influence of media portrayals as reasons for drug abuse as compared to male student respondents, although the gender difference was not significant. The role of these risk factors and predictors towards drug abuse has been vastly documented in past research studies (Pedersen, 1990; Nielsen, 1996; Lonczak et al., 2007). The loss of personal relationships, inability to cope with work demands and dealing with chronic pain conditions were among some personal problems identified as risk factors for drug misuse, which was subsequently confirmed in the rehab patient sample. The negative emotions and chronic distress derived from emotional stressors, such as the loss of personal relationships, and the inability to cope with work demands and personal expectations, is positively associated with addiction vulnerability from clinical and population-based studies (Sinha, 2008). The misuse of prescribed medication however, is an area that is less emphasised in Malaysia. An example is the misuse of opioids among patients with chronic pain. The sense of euphoria and relief from pain is often irresistible to patients suffering from chronic pain, leading to a physical dependence and potential risk for addiction (Satterly & Anitescu, 2015). Identified risk factors that lead to physical dependence and opioid addiction include the administration of high opioid doses, high levels of pain, the use of short-acting opioids, numerous complaints of pain and self-reported craving (Hojsted & Sjogren, 2007).

Despite the good family relationships experienced by most rehab patients in this sample, family conflict was cited by patients as a factor for initiating drug abuse and relapse in the qualitative analysis. Family conflicts occurred predominantly among patients whose parents had divorced or a parent had passed away. Upon remarriage, chaotic and unsupportive family conditions were experienced in interactions with the step-parent and step-siblings, although these patients reported maintaining a loving parent-child relationship with the biological parent. The significant association between family conflict and unsupportive family conditions with drug abuse was supported by various past studies (Cooper, Peirce &Tidwell, 1995; Lonczak et al., 2007; Madu & Matla, 2003).

Peer influence was also an environmental factor that was cited by all three sample groups (university students, rehab patients and staff) as a major contributory factor to the initiation of drug abuse and relapse. Some patients in this sample admitted using drugs for fun and enjoyment when they were offered drugs by their peers during socialisation. This situation was similarly found in a study by Boys, Marsden and Strang (2001). Besides this, patients from both government and private rehab centres reported initiating drug abuse during adolescence (mean ages of 18.87 and 18.60 years respectively). At this developmental stage, peer influence plays an important role in feeling accepted and it was disclosed that they would have done anything possible to belong to a particular group identity. The relationship between peer influence and engagement in risky behaviour like drug abuse was supported by past studies such as Pedersen (1990) and Verkooijen, de Vries and Nielson (2007). A patient also revealed that upon seeing drug abuse among their peers, curiosity and the need to experiment had led them into drug dependency. This finding was supported by Pedersen (1990) and the national drug statistics (NADA, 2014). The patient also admitted being immature during his adolescence years and lacked the sense to think about the consequences of drug abuse towards his life. Patients in the private rehab centre also reported higher incidences of using drugs as a coping mechanism to manage tension, stress and anxiety. This rising phenomenon was also similarly observed by government and private rehab staff among professional and highly educated groups, besides adolescents. The emphasis on high achievement has led to reports of some patients experiencing academic pressure in their adolescence and work pressures in their adult life. This further resulted in drug abuse for relaxation and coping with depression and anxiety. Past studies (Nielsen, 1996; Boys, Marsden & Strang, 2001) have shown that adolescents who were unable to perform according to high parental and teacher expectations were at higher risk of using drugs to cope. This finding was also supported by Cloward and Ohlin’s (1960) strain theory, which proposed that young people were more likely to engage in drug abuse when there is a significant difference between personal aspirations and perceived opportunities for achievement. In these circumstances, drugs were often used as a coping mechanism to manage stress connected to academic failure, or the desire to achieve more within a short period.

The influential role of media (television dramas, films, magazines, and internet) towards the development of curiosity and will to experiment with illicit drugs was more commonly observed among university students and rehab staff, rather than the rehab patients. A private rehab staff noted that the positive portrayal of drug abuse (i.e., being a cool way of life, fun and consequence-free) in some films, television dramas and music that portray drug abuse has led the young to experiment with drugs to recreate a similar sensation. Past studies (Aina & Olorunshola, 2008; Christenson, Roberts & Bjork, 2012; National Center on Addiction and Substance Use, 2005) supported this observation through research findings which have shown an increased risk and reinforcement of drug abuse among adolescents and young adults with increased features of drug abuse in R-rated movies and popular music. Such research findings highlight a need for proper parental guidance when viewing media content since the portrayal of drug abuse as a socially accepted behaviour could potentially risk the onset and sustenance of drug abuse among young children, leading to earlier ages of drug initiation.

Results about gender differences in perceptions of drug abuse factors showed that the perceptions of female student respondents partially matched reported findings from Cirakoglu and Isin’s (2005) Turkish sample. In both studies, females attributed problem coping as reasons for drug abuse. Nevertheless, their findings demonstrating the tendency to attribute sensation seeking as a drug abuse factor among male samples, was not found in the current study. In the current study, the male student respondents had a tendency to perceive being uneducated and weak-willed as reasons for drug abuse although the gender difference was not significant. The role of low educational status and weak willpower has been supported by past studies (Carroll, 2006; Crosnoe, 2006; Grant et al., 2012; Lynskey & Hall, 2000). Based on the observation and experience of family members of drug users, Carroll’s (2006) study indicated that 55% of respondents viewed weak willpower as a major factor for drug abuse while 27% viewed it as a minor factor. Educational status has been proven by Crosnoe (2006) as well as Lynskey and Hall (2000) to be closely related to academic achievement. Academic achievement is also a known risk factor and outcome of drug abuse. Drug abuse could result in academic failure as it serves as distraction to the students’ academic commitment, resulting in high dropout rates from formal schooling (Crosnoe, 2006; Grant et al., 2012) since academic learning was no longer a priority. Based on the current findings and the supportive evidence from past studies involving drug user samples, it can be concluded that the university students have quite an accurate perception of the circumstances leading to drug abuse, despite having no experience of drug abuse. Indirectly, this indicates that drug prevention education conducted in the past have been of some effect. However, limited evaluation research in this area has made it difficult to gauge its level of effectiveness.

2. Relapse factors

The analysis indicated that the university students perceived lack of family support as the main factor for drug relapse, followed by lack of self-efficacy and peer influence in importance. Further analysis indicated that there were no significant differences in perception of drug relapse factors between male and female university students. In regards to the prediction on drug relapse factors, Prediction 1 was supported. Comparison of the current findings with past studies showed that the university students have quite an accurate perception of drug relapse factors. These perceptions were supported by past studies (Ibrahim, Kumar & Samah, 2011; National Institute on Drug Abuse, 2014) in Malaysia and the United States. The loss of family support, encounters with old peers who were still involved in drugs and a strong correlation between low self-efficacy and relapse tendencies were proven by both studies to be significant risk factors for relapse. Low self-efficacy played a more apparent role as a relapse factor among drug rehab patients who were released from treatment with inadequate job and self-sufficiency skills in preparation for re-integration into society (Ibrahim, Kumar & Samah, 2011).

3. Relapse prevention strategies

The overall analysis indicated that university students perceived that avoidance strategy (breaking unhealthy relationships), social activities (keeping busy with healthy activities and building supportive social networks), change strategies (practising caution with medication, believing in overcoming problems, and being active in skilful areas) and help-seeking strategies (learning stress management, maintaining communication with recovery doctors and having constant consultation with rehab centres) were effective in preventing drug relapse. However, they perceived that two change strategies (limiting places to visit and not carrying too much money) were ineffective in preventing drug relapse. The students also neither agreed nor disagreed that listening to music (social activity) or forgetting the past and building a new life (change strategy) were effective methods of preventing relapse. In response to Research Question 1, further analysis revealed that gender differences were found in perceptions of effective relapse prevention strategies. Female students were more likely to view three help-seeking strategies (learning stress management, maintaining constant communication with recovery doctors and consulting rehabilitation centres), two change strategies (caution with medication and believing in overcoming problems) as well as one social activity strategy (building supportive social networks) as effective. This finding was similar to Prediction 1, whereby it was predicted that female students were significantly more likely to perceive social activity, change and help-seeking strategies as effective. However, the current findings were contrary to Cirakoglu and Isin (2005), whose Turkish female participants were less likely to view help-seeking, social activity and self-change as effective relapse prevention strategies. However, the current findings was supported by Gentry et al.’s (2007) study, which found that females were significantly more likely to perceive and use adaptive coping strategies such as talking to friends and family, actively fighting the causes of stress, as well as engaging in exercise and praying.

Overall, the mean scores of female students were generally higher than mean scores of male students. However, the mean score of male students for a change strategy (i.e., forget the past and make changes to life) was very close to the mean score of female students. Nevertheless, this finding was still in contrast to Prediction 1, which expected that male students were more likely to perceive change and avoidance strategies as effective methods of preventing drug relapse. Thus, in regards to relapse prevention strategies, Prediction 1 was only partially supported. Findings from Cirakoglu and Isin’s (2005) study showed that Turkish males were more likely to view avoidance strategies (i.e., breaking unhealthy relationships) as effective towards relapse prevention. There is mixed support from past literature, which proposed that young and adolescent boys were more problem-oriented and would use either more direct methods to solve their problems (Folkman & Lazarus, 1980), or avoid the stressor (Gentry et al., 2007) by relocating to a new place to avoid neighbourhood peers who are involved with drug abuse and dealing. Efforts to terminate drug abuse by leaving the geographical area has been termed ‘geographical cure’ (Biernacki, 1986) and was reported to be more effective for curbing addiction to illicit drugs as compared to other addictions such as alcohol (Cloud & Granfield, 2001).

Understanding gender differences in students’ perception about drug abuse and drug relapse issues has important implications towards tailoring content for drug prevention programmes in schools, college and university. By understanding patterns in perception according to gender, it will enable drug educators and counsellors to emphasise different points about drug abuse, relapse and prevention according to the school environment (i.e., girls’ school, boys’ school and mixed gender school). For instance, although males have a tendency to view change and avoidance strategies as effective relapse prevention measures, they should also be made aware of the benefits of adaptive coping strategies (i.e., having strong social support and actively referring to help resources) as methods of preventing drug relapse.

2.       Knowledge of drug rehabilitation and perceived effectiveness of government and private rehab centres among the university student sample (Research Question 2)

In response to Research Question 2, most of the university students reported having knowledge about existing drug rehab programmes in Malaysia. Furthermore, more students believed that private rehab centres were more effective than government rehab centres. This finding supports Prediction 2. The current findings were in contrast to earlier findings by Low et al., (1996), whose survey found that most youths in Peninsular Malaysia had little awareness about drug rehab services in 1995. However, a possible explanation for the difference could be that compared to youths in 1995, the youths of today have easier access to information about drug rehab services through wider internet coverage and availability of electronic resources. These resources include e-books, official websites of registered drug rehab centres and online pamphlets.

The perception that private rehab services are more effective could be influenced by age-old beliefs carried over from experiences with private and government medical care. It was generally perceived that private healthcare settings are more efficient and responsive to patients’ needs (Rosenthal & Newbrander, 1996). Furthermore, there is a strong perception that private rehab and healthcare are able to provide the most advanced treatment and engage the service of field experts due to huge financial backing (World Bank, 2011a). Additionally, private rehab facilities were viewed as more capable of accommodating larger numbers of patients without a long wait list (World Bank, 2011b). Despite the high treatment costs incurred, most patients and their families were willing to go for treatment in private healthcare centres because they could be assured of more treatment options, higher chances of treatment success and a comfortable environment to recuperate (Babar & Izham, 2009).

3. Perception of drug types among university students: Commonly abused and easily accessible (Research Question 3)

In response to Research Question 3, it was found that the university students perceived ecstasy and marijuana/cannabis as drugs that were most commonly abused and easily available. This finding supports Prediction 3. Further comparisons between students’ perceptions of drug types with rehab patients’ drug use history, and the drug statistics (NADA, 2015) yielded some similarities and differences. Comparatively, there were also distinct differences in drug abuse patterns between findings from the rehab patients and the Malaysian drug statistics (NADA, 2015). The perception among students that ecstasy and marijuana/cannabis were most commonly abused and easily available was partially supported by findings from the rehab patient sample. Among the patients, marijuana/cannabis was recorded as the most commonly abused drug but ecstasy was only listed as the sixth commonly abused drug. The students’ perceptions also differed greatly from the drug statistics, whereby heroin and morphine (61% of drug users) were listed as the most commonly used drug (NADA, 2015) and ecstasy was listed as the fourth commonly used drug. Heroin was perceived by students as the second most commonly abused and easily available drug and this perception concurred with findings from the rehab patient sample. However, it differed from the drug statistics, which listed methamphetamine as the second most commonly abused drug. Morphine was perceived by students as mid-rank in both commonality and availability, which again, differed from the rehab patient sample (seventh place) and the drug statistics (first place). Opiate derivatives (excluding heroin and morphine) were perceived as less commonly abused and available with a rank of 7. This perception was supported as there were no users registered in the 2013 to 2015 statistics (NADA, 2015) and patients’ drug use history.

There were also major differences in perception about amphetamine-type substances (ATS). The perception of methamphetamines as the third commonly abused drug with a rank of 6 in terms of easy availability concurred with the rehab patient sample but differed from the drug statistics, whereby methamphetamine was second placed. The students also perceived that amphetamine was less commonly abused and available while ketamine was viewed as the least commonly abused and available drug. In contrast with findings from the rehab patient sample, ketamine was recorded as the fourth commonly abused drug but there was no record of amphetamine use for comparison. The 2015 drug statistics however, listed amphetamine and ketamine as the fourth and fifth commonly abused drug, respectively.

Ketum leaves were viewed by students as a drug that was least commonly abused but most easily available. However, there was no recorded use of ketum leaves among this sample of rehab patients. The fact that ketum leaves has yet to be classified under the Dangerous Drug Act, as cited by the news article ‘Ketum leaves may be classified as dangerous drug: Zahid’ (2013), has enabled this herb to be planted easily in the rural areas without detection and legal consequences. The debate on whether ketum leaves should be classified as a dangerous drug is still taking place until today, with some parties arguing against the bill due to the supposed medicinal benefits of ketum leaves. Usage of ketum leaves at low doses produces stimulant effects (e.g., elevated levels of alertness, physical energy and socialisation) while at high doses, opiate, sedative and euphoric effects could be produced (Drug Enforcement Administration, 2013). However, the use of ketum leaves also has negative side effects such as loss of appetite, itching, sweating, nausea, dry mouth, increased urination and constipation, just like any other illicit drug (Drug Enforcement Administration, 2013). This further justifies the reason for ketum leaves to be placed under the Dangerous Drug Act.

The students also perceived psychoactive pills to be less commonly abused but were most difficult to obtain. Subsequent comparisons showed that the students’ perception about psychoactive pills was supported by the 2015 drug statistics (least commonly abused) and the rehab patient sample (fifth place). From the explanation given by students, it was found that there was a perception among students that psychoactive pills could only be obtained by prescription from a psychiatrist as medication for psychological disorders or dealing with physical pain. In fact, the scope of drug types classified as psychoactive drugs is much wider. Besides medication (i.e., narcotics, psychostimulants, anti-depressants and anti-psychotics), psychoactive drugs include drugs that alter an individual’s consciousness (i.e., caffeine, alcohol and cannabis) and entheogens for religious or spiritual ceremonies (i.e., salvia, LSD and mushrooms) (Metro North Mental Health – Alcohol and Drug Services, 2013). These findings communicate an urgent need to implement a more comprehensive drug education syllabus in schools and universities. In addition, there should be frequent features on drug abuse and drug education in popular media to correct public misconceptions.

Despite the difference between students’ perceptions and findings from the rehab patient sample and drug statistics (NADA, 2015), this does not indicate that the students’ perceptions are inaccurate. Rather, their views could represent the genuine state of their surroundings (i.e., neighbourhood, college, university and workplace) as they were expected to answer the survey according to existing knowledge, observation or experience with a peer or family member. The differences found between public perceptions and statistical data however, indicates a need for caution when using the statistical data to interpret actual availability and commonality of drugs. There could be a certain level of unaccounted bias in the statistical report as these data were derived from the profiles of drug users who could be desperately in need of treatment (i.e., heavy or long-term users with experience in a range of illicit drugs including ‘hard’ drugs). For instance, users of heroin and morphine (drugs with high ratings of dependence, physical harm and social harm) were more likely to require rehab as compared to users who recreationally use ecstasy and cannabis (drugs with low harm ratings) (Nutt, King, Saulsbury & Blakemore, 2007). These data were also less likely to capture the profiles of recreational drug abusers who do not perceive themselves as conventional drug abusers (Parker, Williams & Aldridge, 2002) and are less likely to seek treatment unless the abuse is severe (Siliquini, Morra, Versino & Renga, 2005).

From the review of past literature, it was also noted that there was limited information on the accessibility of illicit drugs from the perspective of the Malaysian community. There were no studies found within a Malaysian research setting. At the point of review, the only study which examined the accessibility of drugs within drug-using youth and adult samples was conducted by Hadland et al., (2012) in Vancouver, Canada. An interesting finding from Hadland et al.’s (2012) study, which was highly relevant to the Malaysian context, was that different types of drugs were more readily accessible to different groups of users. For instance, heroin and cocaine were more easily accessible to adults while crystal methamphetamine and marijuana were more readily accessible to youths (Hadland et al., 2012). Besides age group, users from urban and rural areas in different geographical locations in Malaysia (West Peninsular Malaysia and East Malaysia/Malaysian Borneo) were likely to be accessible to different types of drugs, which would subsequently influence the choice of drug used (Elements Behavioral Health, 2013).

4. Favoured medium to seek and share information about drug abuse among university students (Research Question 4)

In response to Research Question 4, it was found that in terms of searching for information on drugs and prevention, internet websites and blogs (online media) were their prime resource. Paper-based media such as newspaper and magazines were viewed as the second preference while brochures, pamphlets and posters were the third preference. Both social media and books were least preferred by students in searching for information about drug prevention. In terms of information on drug rehab services, the students relied primarily on television and radio (conventional mass media), followed by newspapers, magazines, brochures and pamphlets (paper-based media). The least preferred medium for treatment resources were family members and peers. The current findings partially supported Prediction 4, which initially predicted that internet resources such as websites and blogs would be most favoured by university students to learn about drug abuse, drug prevention and rehab treatment. However, it can be concluded from the current findings that university students demonstrated a preference for different types of medium, depending on the type of information they were seeking. The preference for a variety of medium to search for drug-related information among youths such as internet resources, radio, television, magazines and newspapers, was supported by Stetina et al.’s (2008) study. In contrast with Stetina et al.’s (2008) sample respondents from Australia, North America, as well as English and German-speaking European countries, the students in this study were less comfortable with using their peers or friends as a source of information about drug rehab. A possible explanation for this is that drug abuse or substance use disorder is a condition that is still highly stigmatised (Room, 2005). Thus, topics related to drug abuse and treatment  are considered sensitive topics for discussion among peers. For many decades, drug abuse has been associated to a wide scope of other stigmatised health conditions (e.g.: HIV, hepatitis C and psychological disorders like depression, anxiety and schizophrenia), social issues (e.g., poverty and criminal activity) and risky behaviours (e.g.: impaired driving and unsafe sexual activities) (Room, 2005). Moreover, drug abuse has been perceived as a moral and criminal issue for too long, making it more difficult for society to view it from a medical health perspective (Room, 2005). Besides this, there are common misperceptions that drug users have personal control over drug addiction, which causes society to hold drug users responsible or blamed for their own problems (Corrigan, Kuwabara & O’Shaughnessy, 2009). The use of illegal drugs are thus, viewed with disapproval and the negative stereotypes linked to drug abuse subsequently translates into social action, such as a refusal to help and avoidance of drug users (i.e.: stigmatisation and marginalisation) (Corrigan, Kuwabara & O’Shaughnessy, 2009). Hence, there may be underlying fears among students that mooting such a discussion topic with their peers could result in worry, concern and unfounded assumptions from their community.

Social media was also perceived as a less preferable resource on drug abuse and prevention issues because students found it difficult to identify the reliability and credibility of circulated information. While past research have generally shown that online users often judged ordinary blogs as credible, an experimental study by Schmierbach and Oeldorf-Hirsch (2012) demonstrated that social media like Twitter were considered less credible than information posted on an online newspaper site and failed to convey importance as well as a newspaper or blog. This finding also has important implications towards educating the public about methods to evaluate the reliability and credibility of information on the internet and social media. According to Metzger, Flanagin, Eyal, Lemus and McCann (2003), there are three criteria that social media users should always consider when evaluating the authenticity of circulated information: (a) medium credibility (i.e., individual’s perceived credibility of information medium), (b) content credibility (i.e., informational quality, accuracy and currency), and (c) source credibility (i.e., expertise and trustworthiness of information source).

Printed books were also less popular among the younger generation due to the need for quick information. Moreover, the students observed that printed books on drug abuse were often limited and costly. In fact, with the limited space available, most libraries are purchasing less printed books and offering more digital content, as they are cheaper and easier to access (Schneider & Evans, 2012). Chaudhry and Low (2009) demonstrated that convenience was a primary factor in choosing an information resource. Out of 180 Singaporean readers between the ages of 28 to 43 years, 90% reported that they would choose to search for information on the internet first because of easy access to information. When it was necessary to verify the authenticity of information using printed books, proximity to book facilities was an encouraging factor. More than 50% of readers expressed the willingness to read more printed books provided the bookstores or libraries were closer to their homes (Chaudhry & Low, 2009).

In terms of sharing information, social media and internet websites (online media) were the most preferred medium, followed by radio and television (conventional mass media) and drug prevention education. This finding supports Prediction 4, whereby it was expected that social media such as Facebook and Twitter would be favoured by university students for sharing information. Explanations given by students for choosing social media were the convenience and ability to easily reach selected or wide circles of readers. As internet users across various age groups own at least one social network account which is accessible through the computer, smartphones or tablet PCs, the role of social media has rapidly expanded from building relationships to sharing information and promoting discussions (Collin, Rahilly, Richardson & Third, 2011). Social media have the ability to engage distributed audiences by maintaining connectedness, encouraging open participation and driving the message through conversations with the community. This potential makes social media a viable option for driving drug prevention messages into the foundation of society through creative content (Collin, Rahilly, Richardson & Third, 2011). Internet websites and blogs were equally popular mediums for seeking and sharing information, simply because they were viewed by students as more credible and reliable avenues (Schmierbach & Oeldorf-Hirsch, 2012).

Radio and television was also perceived by university students as good resources to share information due to its ability to reach audiences of all groups and ages (UNESCO, 1995). In addition, radio and television play a major role in forming perception, attitudes and sentiments among individuals who are strongly influenced by mass media. Public opinions and behaviours could be unconsciously influenced by television programmes such as drama series and movies that dramatise drug abuse and drug users. The advancement of television technology with improved visual and audio dimensions, further cemented the power of television as an information-sharing medium. The radio has less impact in this sense as it relies only on audio dimensions (UNESCO, 1995).

Despite the increasing influence of social media, internet websites and blogs, the role of mass media (e.g., television and radio) and prevention education are still necessary towards drug prevention. The current findings showed that most individuals in Malaysia do not have the self-initiative to seek and share information on public health issues like drug abuse and prevention. Thus, mass media and prevention education programmes are still prime methods of reaching children, young adults and working professionals.

5. Difference in actual and perceived age and school grade of exposure to drug prevention education and perceptions of past prevention programmes (Research Question 5)

In response to Research Question 5, a significant difference was found between the actual and perceived age of exposure to drug prevention education among university students. This was in contrast to Prediction 5, whereby it was predicted that there would be no significant difference in university students’ actual and perceived age of exposure. It was of interest to note that the students advocated initiating prevention education at a slightly older age (between 11 to 12 years, which is equivalent to Primary 5 and 6 in Malaysian schools) than the ages they received prevention education (between 10 to 11 years, i.e., Primary 4 and Primary 5). Despite the significant but small discrepancy between the actual and perceived age and school grade, this finding has important implications towards determining the appropriate developmental stage to initiate drug prevention education among students. A possible explanation for the students’ suggestion to initiate drug prevention education at an older age (between 11 to 12 years) would be because the formal operational stage of cognitive development commences within this age group (Inhelder & Piaget, 1958). Although 10 to 11-year-old children (i.e., concrete operational stage) are capable of associating consequences to actions, children between the ages of 11 to 12-years-old are more capable of realising the consequences of concrete events and are more capable in understanding moral and ethical issues that could arise from negative actions such as misusing drugs (McLeod, 2010). Thus, initiating drug prevention education between the ages of 11 to 12 years would have a greater impact to students because they are cognitively equipped to comprehend complex issues like drug abuse. Nevertheless, there were students who perceived that some basics of drug prevention education should be initiated as early as 4 years-old (pre-school level). Taking into consideration of the overall feedback from students, it may be beneficial to develop a proper drug education syllabus for each schooling level. At pre-school and early primary level, educators could start off by educating students with basic information about drug abuse, identifying drug symptoms and whom to contact for help. As the students mature cognitively, students should be provided with more advanced information about drug abuse, the consequences of drug abuse, prevention methods, available treatment services and help resources (e.g. healthy coping strategies and important contacts for professional help).

The findings above clearly showed the benefits of including feedback from students to improve drug prevention education in school and develop effective drug educational policies. Although the Malaysian drug statistics (NADA, 2015) indicated that the earliest age of exposure to drugs was 13-15 years, it is insufficient to decide when drug prevention education should be initiated based on this information alone. In the process of inclusive policy-making, it helps to get feedback from students for additional insight into when they perceive drug prevention education should be initiated, the areas that could be improved and their reasons behind it. For students, the knowledge that their opinions about drug prevention and the drug education structure are considered important by educators, governmental agencies and NGOs could encourage students to actively participate in drug prevention activities. This could help eliminate an obstacle to effective drug prevention education in Malaysia, which is lack of student participation (Chan, Lim, Sidhu, Wee & Abdul Hamid, 2015).

Therefore, the current study had students qualitatively evaluate the strengths and limitations of past drug prevention education and areas that could be improved. There were several notable findings from the evaluation. It was found that students perceived past programmes as useful because it increased awareness of various drug types, instilled interest in drug abuse issues by employing interactive teaching learning methods, provided access to help resources and initiated early prevention against drugs. However, there were some major limitations which reduced the effectiveness of past drug education programmes. These limitations include the use of unsuitable jargon by facilitators, the presence of an ineffective knowledge environment (i.e., limited opportunities to reinforce knowledge with most programmes being conducted annually), limited exposure to real-life perspective (i.e., little access to case studies or the chance to conduct social work and observations in rehab centres), lack of clarification about action taken against students caught for drug abuse or drug pushing, and limited impact of some drug prevention programmes. Students who were exposed to drug prevention programmes with limited impact attributed it to educational content that was unable to maintain students’ attention, a general lack of awareness among the younger generation about the importance of drug abuse and prevention, and unanticipated reverse impact from exposure to drug abuse topics (i.e., instilling curiosity, and reinforcing stigma and stereotypes about drug abuse, which could be influenced by educators’ personal mind-set about drug abuse and its users). Thus, the students suggested that educators in school and higher education institutions: (a) use teaching and learning methods that would encourage student participation, such as educational games and producing short films or videos; (b) focus on the behavioural and psychosocial aspects of drug abuse by adequately exposing students to drug addiction models and theories; and (c) increase emphasis on coping, adaptive skills and assertiveness training. Furthermore, it was suggested that increased awareness among students and educators about the consequences and proper procedures in dealing with drug cases in school and higher education institutions is needed.

From the findings on the usefulness of past drug prevention programmes and suggestions for improvement, Prediction 5 was supported with the addition of various limitations and other notable findings (i.e., early prevention, exposure to drug addiction models and theories, and clarifying proper procedures in dealing with drug cases). Although these evaluations were made based on past prevention education programmes, the limitations and suggestions for improvement highlighted here are still highly relevant as these issues continue to persist in current drug prevention programmes. It is essential that students and educators in school and higher education institutions identify the limitations of prevention programmes within their respective institution. They should also amplify efforts to increase awareness and educate the public about drug abuse and addiction from a psychosocial aspect. This would help to prevent societal attitudes and views from stagnating to the original cycle of misconceptions, stigma and stereotypes about drug abuse and drug users.

6. Drug rehab patients: Patterns of drug abuse progression and conditions of family and peer relationships (Research Question 6)

In response to Research Question 6, the prevalence of drug abuse progression was not supported based on the overall analysis of patients’ recorded drug abuse. This finding was in contrast to Prediction 6, whereby it was expected that drug rehab patients would demonstrate a pattern of drug abuse progression (from soft to hard drugs). Furthermore, most of the rehab patients and their peers did not demonstrate the usual patterns of family dysfunctions nor exhibit clinical levels of problem behaviours such as stealing, robbery or involvement in fights. This finding also differed from Prediction 6, which initially predicted that patients and their peers would experience poor relationships with their family.

In contrast with past studies (Kandel, Yamaguchi & Chen, 1992; Yamaguchi & Kandel, 1984), 15 rehab patients in this sample did not demonstrate the drug progression trend as compared to 13 patients who did. Out of 15 patients who did not demonstrate the progression trend, two patients demonstrated atypical drug abuse patterns, in which drug users did not initiate drug abuse with soft drugs (Mackesy-Amiti, Fendrich & Goldstein, 1997). Instead, other types of hard or intermediate drugs were used. Both findings of atypical and no drug progressions were supported by Golub and Johnson (1994), whose study found that 15% of serious drug users initiated drug abuse with cocaine or intravenous drugs without first using marijuana, which is a soft drug. Their study also found that a large sample of serious drug users started with marijuana, and alcohol was not a prerequisite to marijuana use. Although a higher proportion of rehab patients did not demonstrate a drug progression trend in the current study, the results were insufficient to concur either with Peele and Brodsky (1997), who dismissed drug progression trends as a cultural myth, nor with Coffield and Gofton (1994), whose sample of drug users did not categorise drug abuse on a soft to hard continuum.

It should be noted that 13 patients clearly demonstrated transitions from soft, intermediate to hard drugs. This pattern was in line with the Gateway Hypothesis, which proposed that drug abuse is initiated with the use of legal drugs (i.e., nicotine and alcohol) before moving on to the use of soft illicit drugs such as marijuana, and subsequently harder drugs like cocaine, methamphetamine and heroin (Kandel & Kandel, 2015). Although the current study only focuses on illicit drugs, the sequencing of soft to hard drugs was clearly demonstrated by these 13 patients. An interesting drug abuse trend that has yet to be highlighted in past research was the presence of a partial progression as demonstrated by two rehab patients in the current study. Both patients oscillated from soft to hard drugs before settling for an intermediate drug.

Findings indicating that most of the rehab patients and their peers were not from families exhibiting dysfunctional relationship patterns and did not display clinical levels of problem behaviours emphasised that drug user profiles have shifted from old stereotypes. These findings further signify a need to apply tailored and patient-centred approaches to drug abuse treatment. The wide variance in drug abuse patterns across individual drug users can be justified using the concept of common liability to addiction (CLA), in which biobehavioural characteristics and mechanisms play a role in influencing the type of drug used (Vanyukov et al., 2012). The individual characteristics that influence variation of addiction risk include personality or behavioural phenotypic variation, and environmental correlations such as being in an environment that facilitates access to drugs (e.g., parental drug abuse, socialisation through drinking and partying, exposure to stressful situations) (Vanyukov et al., 2012).  These individual characteristics all work together to create individual footprints in drug abuse patterns (Vanyukov et al., 2012), which should influence the formation of treatment plans and decisions.

7. Self-evaluation of assertiveness against drugs among rehab patients at the point of treatment (Research Question 7)

In response to Research Question 7, it was found that most rehab patients perceived they would be assertive in resisting drug offers from friends or strangers in a social party. This was followed by patients who perceived themselves as extremely non-assertive. Only a minority of patients perceived that they would be extremely assertive against drug offers. The findings above support Prediction 7. This finding emphasised the need to focus on assertiveness training in drug rehab programmes in Malaysia. A study by Semple, Strathdee, Zians, McQuaid, and Patterson (2011) demonstrated that lower levels of assertiveness in refusing drug offers among a sample of HIV-positive male drug users, were associated with lower levels of self-esteem and larger amounts of methamphetamine use, in greater frequency.

Hence, assertiveness training was designed to help rehab patients develop behavioural components that are essential towards improving their resilience against relapse episodes (Wesley & Mattaini, 2008). These components include establishing self-confidence, increasing self-esteem, reducing social anxiety and improving their assertive beliefs and behaviour (Wesley & Mattaini, 2008). However, Iruloh and Amadi (2008) cautioned that assertiveness training should not be considered a therapeutic technique as it only teaches patients to assert themselves in the face of external pressures or intimidation. Another study by Agbakwuru and Stella (2012) demonstrated that assertiveness training was effective towards improving levels of resilience among adolescents. However, the improvement was more profound among girls although assertiveness training equally affected boys and girls. An advantage of assertiveness training was the skills that were taught within a specific context are easily maintained and can be generalised for use in other situations at post-treatment (Hawkins, Catalano Jr., Gillmore & Wells, 1989). However, it is essential that recovered patients continue practicing assertiveness skills when they encounter trained or untrained situations. Lack of practice could result in a gradual decline of acquired skills within a time frame of one-year post-treatment (Hawkins, Catalano Jr., Gillmore & Wells, 1989).

8. Similarities and differences in responses between rehab patients and staff on factors for drug abuse, relapse factors and entering treatment; and factors that motivate patients to change (Research Question 8)
   1. Drug abuse factors

In response to the first part of Research Question 8, responses from drug rehab patients indicated that a combination of internal and external factors consisting of peer influence, curiosity, negative family relationship, tension release/stress coping and unemployment, were themes commonly associated with reasons for drug abuse. Moreover, the patients often cited multiple factors when recounting their individual experiences with drug abuse. In addition, there were four additional drug abuse factors highlighted by the rehab staff (i.e., lacking religious guidance, self-confidence issues, living in an undesirable neighbourhood and possessing low educational status). These findings support Prediction 8, whereby it was expected there would be large similarities and moderate differences in patients’ and staff’s responses about factors for drug abuse.

The association between a combination of internal and external factors and drug abuse was supported by various past studies (Lonczak et al., 2007; Nielsen, 1996; Pedersen, 1990; Tam & Foo, 2012). Comparisons with perceptions of university students showed that these five factors were similarly perceived as contributory factors to drug abuse, with the addition of enjoyment and personal problems. The students viewed that the need to seek enjoyment and alleviate personal problems such as depressed moods, played a role in increasing the risk of drug abuse and this sentiment was supported through the real-life account of drug rehab patients and past studies (APA, 2010; Boys, Marsden & Strang, 2001).

The role of unemployment however, was more complex. A difference in opinion about the role of unemployment in drug abuse was found between rehab patients and staff. Some rehab patients reported that there were circumstances whereby unemployment did lead to drug abuse, such as when they had lots of free time but limited activities to keep occupied. This subsequently led to socialisation with the wrong crowd and drug abuse. Some patients also reported experiencing unemployment as a circumstance leading to drug abuse and subsequent drug pushing, as a job. In contrast, some rehab staff viewed unemployment as an after-effect of drug abuse rather than the cause of drug abuse. The dual role of unemployment as a predictor and consequence of drug abuse was supported by various past studies (Andrews, Henderson & Hall, 2001; Fryers, Melzer & Jenkins, 2003; Henkel, 2011; Jacobi et al., 2004; Kestila et al., 2008; Legleye, Beck, Peretti-Watel & Chau, 2008; Lynskey & Hall, 2000; Pirkola et al., 2005; Poulton et al., 1997; Ringel, Ellickson & Collins, 2006).

Based on their perspective and experience with various drug cases, the rehab staff also reported four additional factors that would contribute to drug abuse which were: lacking religious guidance, self-confidence issues, living in an undesirable neighbourhood and possessing low educational status. The association between low religious guidance and drug abuse was supported by past studies conducted within a Western setting (Chu, 2007; Engs & Mullen, 1999). Both studies demonstrated that individuals with strong religious commitment wereless likely to beassociated with drug abuse and religious behaviour would inhibit the continuation of drug abuse. This finding was also supported by a local study (Noon, Haneef, Yusof & Amin, 2003) which analysed the views of Malaysian youths on certain aspects of religion and its impact on involvement in social problems such as drug abuse. It was found that the general consensus among Malaysian youths was the more religious an individual is, the probability of being involved in drug abuse was perceived as lower. Research on ethnic diversity, religiosity and drug abuse have demonstrated that religiosity is a possible explanatory mechanism in understanding why drug abuse is more prevalent in certain ethnicities. For instance, within a young adult population in South Florida, US, the Whites were more inclined to use drugs than African Americans, Cuban Hispanics and non-Cuban Hispanics (Rote & Starks, 2010). Furthermore, the Whites were also less inclined to self-identify as religious and attend religious services (Rote & Starks, 2010).

Self-confidence is associated with the general self-esteem of an individual. It was observed by the rehab staff that both over-confidence and low self-confidence were risk factors for drug abuse. The characteristics of individuals with healthy levels of self-esteem include a strong belief in the importance of the self, having good self-confidence and a firm trust in the decisions made, and having no hesitation to ask for help when needed (The Counseling and Mental Health Center, 1999). Over-confident individuals tend to believe that they were immune to addiction and could stop drug use whenever they wanted (The Counseling and Mental Health Center, 1999). This perspective was supported by early studies like Lindesmith’s (1938) sociological theory of drug addiction. Past studies (Alavi, 2011; Boys, Marsden & Strang, 2001; Thomas, 1995) also showed that individuals who suffered from low self-confidence were inclined to use drugs to facilitate social contact and reduce social tension when socialising with peers. This was because they were more likely to feel lonely, alienated and exhibit disinterest in the self and others. These emotions were influenced by low levels of self-esteem, which led individuals to think that they were unimportant, instilled distrust in others and constantly expected public humiliation (The Counseling and Mental Health Center, 1999).

All three sample groups (i.e., university students, rehab patients and staff) reported neighbourhood factors (e.g., geographical area and socioeconomic status – SES) as an external factor that increased the risk of drug abuse. A government rehab patient disclosed that living in a residential area with high concentration of drug users and drug pushers was a factor that led to eventual drug abuse. This finding was supported by Smart, Adlaf and Walsh (1994), whose cluster analysis revealed that the largest number of drug cases and drug users were from locations with the lowest SES characteristics. This includes living in low-cost, substandard housing or government-subsidised housing, located near disadvantaged locations or schools that are well known as drug coping places, as well as studying in problem schools with high rates of social problems and delinquency.

Low educational status was also observed by university students and rehab staff as an internal factor leading to drug abuse. However, research evidences demonstrating the association between drug abuse and school dropout or low educational status were generally mixed (Townsend, Flisher & King, 2007). Some studies (Obot, Hubbard & Anthony, 1999; Staff, Patrick, Loken & Maggs, 2008; Wood, Sher & McGowan, 2000) have demonstrated significant association between drug abuse and educational achievement. For instance, Obot, Hubbard and Anthony’s (1999) study found that African-American high school dropouts were two times more likely to start injection drug use as compared to neighbourhood peers who completed high school education. However, other past research (Bray, Zarkin, Ringwalt & Qi, 2000; Gotham, Sher & Wood, 2003; King, Meehan, Trim, & Chassin, 2006) found that this association was not significant when control variables such as low SES were included. This prompted Grant et al. (2012) to investigate whether drug abuse and addiction would still be linked to lifetime educational achievement while controlling for family background characteristics. It was found that daily drug use remained significantly associated with years of education, despite having access to educational benefits in the later years. From the findings and research evidences above, it was concluded that early drug abuse is associated with early school dropout and low educational status.

2. Drug relapse factors

In response to the second part of Research Question 8, it was found that peer influence, family conflict and drug urges were cited as three main reasons for drug relapse by rehab patients and staff. Some differences were found from additional comparisons with students’ perceptions. Among students, it was perceived that the lack of social support (i.e., family, community and employers) and self-efficacy were also major reasons for drug relapse, besides peer influence. These findings partially support Prediction 8, in which large similarities were found between patients’ and staff’s responses about drug relapse. No differences were found between patients’ and staff’s responses but minor differences were found in comparisons with students’ perception.

The influence of old peers, family conflict and temptation to drug urges as reasons for drug relapse was supported by Wang and Wang (2007). The frequent occurrence of family conflict is not conducive to recovery as the unstable environment could result in mental stress, which could lead to a relapse in drug abuse. Social isolation and the lack of social support from their families and the community could cause recovered patients to fall back into the company of drug-using peers, for the sense of belonging and being accepted (Dishion & Owen, 2002; National Institute on Drug Abuse, 2014). The increased opportunity for drug abuse, coupled with negative emotions such as frustration, depression and loneliness could increase patients’ susceptibility to drug urges on their own or through peer influence (Wang & Wang, 2007; Yang, Mamy, Gao & Xiao, 2015). Low levels of emotional and concrete social support from family and peers as well as low self-efficacy are also prominent drug relapse factors as evidenced by Ibrahim, Samah, Talib, and Sabran (2009).

These findings suggest that building good social support network and enhancing patients’ self-efficacy are two aspects that should be emphasised in relapse prevention (Copello & Walsh, 2016; Marlatt, Baer & Quigley, 1994; Yang, Mamy, Gao & Xiao, 2015). Social support of family members and close social networks should be incorporated into treatment plans. For example, social behaviour and network therapy (SBNT), and couples behaviour therapy (CBT) have been incorporated successfully into drug abuse treatment programmes in the UK. In Malaysia, efforts were made by Zall and Mahmood (2013) to adapt and implement Collective Family Therapy (CFT) into relapse prevention in a government drug rehab programme. CFT incorporates a combination of Structure, Adlerian, Social Constructivism and multi-cultural theories. However, it was adapted only to suit the Malay collectivist and religious values (Zall & Mahmood, 2013). As Malaysia is a collectivist, multi-ethnic country, there is a need to ensure that family-based or social network-based therapies can be practiced with patients, families and peers from various cultures and religious beliefs, with consideration for specific cultural and religious needs. Besides helping rehab patients to gain useful skills to overcome drug addiction, family-based or social network-based therapies have the added benefit of having a therapist provide assistance to family members and peers of drug users, who are also impacted by drug abuse. Family members and peers often experience stressful situations (e.g., financial conflicts and family relationship problems) and negative emotions (e.g., anxiety, depression, social isolation, aggression and hostility) (Orford, Velleman, Natera, Templeton & Copello, 2013). Family or social network-based therapies is advantageous in getting patients, family members and their social network to work together towards achieving drug abstinence and could help them build essential skills such as communicating and listening effectively, conflict resolution and problem coping (Geel, 2016).

However, there are two identified obstacles in implementing family or social network-based therapies in Malaysia. Firstly, it would be a challenge towards getting existing family members and friends to willingly commit towards helping patients in therapy (Zall & Mahmood, 2013). This is due to the depth of relationship conflicts and existing societal perceptions about drug abuse as a moral and criminal issue, and its association with other stigmatised health conditions (Zall & Mahmood, 2013). Secondly, stigmatisation and marginalisation of drug users and their families (Room, 2005) by society still exist. This is due to persistent beliefs that drug users are hard-core criminals, which was cemented by widespread reports of its crime-by-association (i.e., fraud, snatch theft, burglary, homicide, drug selling and suicide) (Rusdi, Noor Zurani, Muhammad & Mohamad, 2008). Despite these issues, it is undeniable that social support is a very important element towards relapse prevention. Furthermore, it is not impossible to incorporate family or social network-based interventions into relapse prevention programmes in Malaysia, provided there are sufficiently trained therapists to guide patients and their social network, and a change in public mind-set towards viewing drug dependency as a medical and psychological condition.

As mentioned above, students also perceived self-efficacy as an important internal factor leading to drug relapse. Past studies (Marlatt, Baer & Quigley, 1994; Schwarzer & Fuchs, 1995) supported this finding with the identification of four types of self-efficacy (i.e., harm-reduction, action, coping and recovery self-efficacy) that was crucial towards relapse prevention. Based on the structure of current rehab programmes in Malaysia, an increased focus towards enhancing patients’ self-efficacy across different stages of recovery is needed. This would ensure that drug rehab patients gain the necessary confidence to use learned competence and skills to control further damage and strengthen belief in their capabilities in minimising future risks (Schwarzer & Fuchs, 1995). Good self-efficacy would also help patients to achieve desired treatment goals through the development of detailed plans to avoid drug abuse, imagining success scenarios, taking instrumental actions (Marlatt, Baer & Quigley, 1994), and maintaining successful treatment outcomes through relapse prevention training. Patients can be trained to prevent drug relapse through exposure to various situation-tailored coping strategies (Curry & Marlatt, 1987; Curry, 1993; Gruder et al., 1993) when faced with high-risk situations (e.g., depression, social anxiety or temptations). In addition, treatment providers need to provide patients with skills to quickly restore self-efficacy after a relapse and make a recovery plan after reviewing and reattributing the situation. Alternative coping strategies should also be adapted to meet situational needs, and social support networks should be mobilised to help control damages after a relapse episode.

3. Reasons for entering treatment

In response to the third part of Research Question 8, it was found that there were major similarities between rehab patients’ and staff’s responses about factors for entering treatment. From the responses of both sources, factors that encouraged patients to take action by seeking and entering treatment could be categorised into extrinsic factors (support from the family and NADA/AADK officers; court orders), intrinsic factors (voluntary admission and the intention to undergo self-recovery) and religion, which falls along the extrinsic-intrinsic spectrum. The minor difference found was an additional extrinsic factor found in patients’ responses, which was support from workers in the geriatric home. The findings above partially support Prediction 8, whereby it was expected that there would be large similarities between patients’ and staff’s responses about factors for entering treatment. However, only a minor difference was found, in contrast to the moderate differences expected in patients’ and staff’s responses.

According to Tracy, Munson, Peterson and Floersch (2010), there are three categories of social support, which are relevant towards treating drug abuse: (a) informational support (i.e., guidance and advice), (b) emotional support (i.e., encouragement), and (c) concrete support (i.e., tangible help and assistance). This categorisation was similarly found in rehab patients’ and staff’s responses. In particular, patients reported that their families were good sources of emotional and informational support when they entered treatment. This finding was supported by Gifford (2011), whose study showed that family involvement and support in the form of frequent interaction and visits, was important towards patients’ recovery during and after treatment. Moreover, family members would benefit from the opportunity to gain a new perspective about drug addiction and self-monitor their own behaviour (Gifford, 2011). Most patients also reported receiving emotional and informational support from the NADA/AADK officers. In addition, only the NADA/AADK officers who were directly involved in rehabilitation were able to provide concrete support to patients. For an elderly patient, emotional support was also received from workers at the geriatric home.

The rehab patients and staff in this study also viewed religion and the intention to undergo self-recovery as reasons that encouraged drug users to enter treatment. In this sample, drug users who achieved realisation that drug abuse is a problem and were determined to follow the right path according to religious teaching or to lead a healthier and more positive lifestyle, were more likely to enter treatment voluntarily. This finding was supported by the spiritual model, which emphasised the spiritual path of recovery through recognition of a Higher Power (i.e., God) (SAMHSA, 2012). The spiritual model assumes that the individual cannot find recovery through will power and the path to spiritual health involves surrendering individual will to a Higher Power. Examples of treatment approaches that utilises the Higher Power-help concept is the twelve-step programme (SAMHSA, 2012) and transcendental meditation (TM) (Greaves, 1980), which was initially suggested as a replacement to the pleasurable and stress-relieving effects of drugs. TM has been widely practiced over the past 30 years in drug abuse recovery and relapse prevention (SAMHSA, 2012) and a review concluded that TM is valuable as a primary treatment approach or a complementary therapy in drug rehabilitation programmes. This was due to the benefits of TM in reactivating delayed development, relieving stress as well as enhancing psychosocial and psychophysiological functioning (Hawkins, 2003).

There were quite a number of drug rehab patients who initially entered treatment only because of court orders. These patients were judged according to a legal system which follows the moral model. The moral model views drug abuse and relapse as a set of behaviour that violates moral, religious and legal codes of conduct (SAMHSA, 2012). The moral model runs on the assumption that individuals who choose to abuse drugs lacked self-restraint and discipline besides, creating suffering for the self. Drug abuse was also viewed as a moral choice and changes could only be affected through strong willpower (Institute of Medicine, 1990). Unfortunately, patients who are in treatment due to court orders often do not have the three critical components that are essential towards behaviour change, which are willingness, readiness and the ability to change (Miller & Rollnick, 2013). These patients do not view drug abuse as a problem, lacked realisation on the impact of drug abuse towards the self and others, and perceived drug rehab treatment as an event of low importance (UNODC, 2008). Thus, these patients were also more liable to resistance or denial. Some patients also refused to change because they lacked confidence in their ability.

The findings from this study indicate that there is much work in-store for treatment providers within the Malaysian drug rehab system to help unmotivated patients gain the required motivation to willingly change drug abuse behaviour. It is essential that treatment providers work together with patients to help them develop a sufficiently large perceived importance of change, by reflecting on the discrepancy between their status (i.e., what is happening now) and their goals (i.e., what is valued in the future).  This would initiate change by helping patients search for possible avenues that are perceived would work (general efficacy) and which patients believe they could perform (self-efficacy). Some patients may not be ready for change although they view behaviour change as an important goal and have high levels of confidence and self-efficacy (Miller & Rollnick, 2013). It is important that patients find personal intrinsic value (i.e., important and cherished) in the act of receiving treatment within an empowering and accepting treatment environment that allows the exploration of sensitive and painful issues (Miller & Rollnick, 2013). A method in which patients and treatment providers can work collaboratively to explore and find personal intrinsic value in changing drug abuse behaviour and receiving treatment is motivational interviewing (MI) (Miller & Rollnick, 2013). The practice of MI in treating addiction to amphetamine and cannabis/marijuana has been documented in Malaysia although it is unknown how many rehab centres utilise this treatment approach and what are its outcomes (Norliza, Norni, Anandjit, & Mohd Fazli, 2014).

In order to gauge the treatment culture in Malaysia, the best approach would be through a review of clinical practice guidelines in treating illicit drug dependence. However, this document was not made available for public review. The closest equivalence was a clinical practice guideline in treating tobacco dependence (Ministry of Health, 2003) and notes from the researcher’s observation of the drug rehab process. Based on the observation and review of the brief intervention, treatment providers initially do take on a hierarchical role whereby they advise their patients to quit in a clear and strong manner (e.g., ‘I think it is important for you to quit now and I can help you’) and expect the patients to follow. However, the treatment provider’s approach changes when the patient showed unwillingness to quit. Some principles of MI are applied in motivational interventions to help patients resolve factors that led them to resist change (e.g., lacking knowledge about the effects of drug abuse and demoralisation due to past failures), explore ambivalence and initiate talks of change. Besides this, the objective of the motivational intervention is to promote patient autonomy and build patients’ self-efficacy. From the researcher’s observation, motivational interventions are carried out in group counselling settings in the rehab centres that participated in this study. From this, it can be concluded that the use of MI in drug rehab treatment is not unfamiliar and some counsellors have applied a patient-centred approach to treatment. Furthermore, they encouraged the formation of a collaborative relationship between treatment providers and patients. However, the use of MI in drug rehab treatment could be more widespread and the first step forward would be to ensure that treatment providers are trained in motivational interviewing techniques.

4. Motivation to change

In response to the fourth part of Research Question 8, there were three main factors that motivated patients to change drug abuse behaviour, which are impact of drug abuse (to the self, health, family and work), personal wishes and religious guidance. More than half of the rehab patients also reported having no personal motivation to stop drug abuse at treatment admission and were only in rehab due to court orders. These findings support Prediction 8.

The finding that rehab patients were more motivated to change when they gained awareness and realisation about the impact of drug abuse on the self, their health, family and work was supported by past studies (Sobell, Sobell, Toneatto & Leo, 1993; Varney et al., 1995). Sobell, Sobell, Toneatto and Leo (1993) suggested that an individual’s ability to evaluate the impact of drug abuse to his life was pivotal to behaviour change. The process of recognising negative consequences of drug abuse, the harm and hurt inflicted on family, friends, employer and colleagues is also influential in motivating some individuals to take action and make positive behavioural changes (Varney et al., 1995). Cognitive appraisal (i.e., weighing the pros and cons) attributed to 30-60% of changes reported in natural recovery cases (Sobell, Sobell, Toneatto & Leo, 1993).

In addition, some drug rehab patients personally wished for a positive change after experiencing a prolonged distressful lifestyle due to drug abuse, with the aid of religious guidance. This finding was supported by past studies (Leventhal, 1971; Sobell, Sobell, Toneatto & Leo, 1993; Tucker, Vuchinich & Gladsjo, 1994), which demonstrated that patients were more willing to seek help and initiate positive behaviour change after experiencing distress from severe depression and anxiety, or critical life events such as spiritual inspiration and religious guidance or conversion. These positive behaviour changes include adopting a healthier lifestyle and overcoming negative habits such as smoking, alcoholism and drug abuse.

Sixteen out of thirty rehab patients in this study also reported that they had no personal motivation to stop drug use at treatment admission. They were only in rehab due to court orders. Out of these, 12 patients reported having thoughts of stopping drug use but did not translate these thoughts into action. Four other patients admitted that they never intended to stop drug use during their experience with drug abuse. Drug users who had no motivation to stop drug use often do not fully recognise that they have a problem or that their life problems are associated with drug abuse (UNODC, 2008). Thus, it is essential that treatment providers help such patients see the connection between drug abuse and negative consequences to the self and others (Varney et al., 1995). Regardless of patients’ readiness to change when entering treatment, all patients will experience ambivalence, which is a state of fluctuating and conflicting motivations (UNODC, 2008). Treatment providers need to help patients to resolve their ambivalence, increase awareness on the need to change and help them move through the stages of change (UNODC, 2008).  The recommended technique to achieve this is motivational interviewing (MI), which is a directive, patient-centred method to enhance patients’ intrinsic motivation (Treasure, 2004). As mentioned earlier, MI elicits change by exploring and resolving ambivalence, initiating talks of change; avoiding causes that result in resistance to change, exploring motivation, and enhancing commitment among patients as they go through stages of change (Miller & Rollnick, 2013). Since patients’ readiness to change is an important factor that would determine the success of treatment outcomes, it is recommended that treatment providers in Malaysia explore drug users’ willingness to change within the framework of Prochaska, DiClemente and Norcross’ (1992) Transtheoretical model of change and complement it using MI techniques.

Past studies (Mental Illness Fellowship Victoria, n.d.; Prochaska, DiClemente & Norcross, 1992) have shown that MI and the Transtheoretical model of change have been successfully utilised together, as part of evidence-based practice in treating drug abuse across Australia, US and the UK. Since the MI is reliant on the Transtheoretical model of change, a combination of both techniques would help treatment providers to plan and implement tailored and individualised treatment within a structured and patient-centred environment. This is important since drug abuse and relapse manifest differently for each individual (Winters, Botzet & Fahnhorst, 2011). Furthermore, patients often enter treatment at different levels of readiness to change and the first step would be to assess patients’ readiness to change. The most common method would be to have patients assess their readiness to quit/reduce drug use on a scale on a scale of 0-10. Subsequently, patients’ scores are matched to the phases of change in the Transtheoretical model of change:

1. Scores of 0-3 (not ready): Patients are in the pre-contemplation or contemplation phase;
2. Scores of 4-7 (unsure): Patients are in the contemplation phase; and
3. Scores of 8-10 (ready): Patients are in the determination or action phase

As mentioned in the literature, there are five phases of change (Prochaska, DiClemente & Norcross, 1992) and drug rehab patients may move back and forth across these five phases. The characteristics of each phase are as follows:

1. Pre-contemplation: Patients are often unaware that drug abuse is a problem and have no intention to change. The role of treatment providers in this phase is to get patients to consider that they have a problem;
2. Contemplation: Patients begin to acknowledge drug abuse as problem behaviour and are seriously considering change. Patients open up to information and education, and are increasingly aware of the pros and cons of changing, which creates a state of ambivalence. At this phase, the role of treatment providers is to raise awareness of drug abuse as a problem through observation of behaviour;
3. Determination/Preparation: Patients are prepared to act within the next month, and have begun to set goals, plans and strategies to change (e.g., consulting a counsellor, entering treatment or using self-help books to manage drug addiction). At this phase, the role of treatment providers is to encourage patients’ plans, support the change process and getting patients to commit to the changes;
4. Action: Patients make specific modifications in their lifestyle within the past six months (e.g., gradual reductions in drug dosage, resolving thoughts and issues that led to drug abuse, and engaging in pharmacological, cognitive and behavioural therapies to manage withdrawal symptoms). The role of treatment providers is to encourage and collaborate with patients to make action plans, reinforce changes, as well as provide support and guidance;
5. Maintenance: Patients abstain from drug abuse and focus their efforts on preventing drug relapse. Patients learn to clearly identify situations and behaviours that lead to relapse and build their self-confidence with every continuous positive change. The role of treatment providers is to support continuous change and help with relapse prevention.

The Transtheoretical model of change also takes into consideration of relapse episodes, which could occur between the Action and Maintenance phase. When a relapse occurs, patients may return to an earlier phase of the model such as pre-contemplation (Prochaska, DiClemente & Norcross, 1992). When this happens, it is essential that treatment providers communicate to patients that drug relapse should be viewed as an opportunity to learn which strategies and plans were effective or ineffective. As mentioned earlier, a benefit of this framework is each action and strategy that is taken towards behaviour change is recorded. Thus, patients are able to select effective behaviour change strategies used in the previous cycle and continue moving towards their treatment goal.

While the Transtheoretical model of change provides structure to drug treatment interventions, MI provides patients with a safe and open environment to explore and resolve ambivalence and discrepancies. In order to achieve this, treatment providers practice five principles: (a) Expressing empathy through reflective listening (building rapport with patients, be aware of and practice culturally accepted norms, periodically summarise patients’ statements to reconfirm understanding); (b) Developing discrepancy (listening closely to patients’ statements about their personal and community values, highlighting concerns that could help patients realise the difference between drug abuse behaviour and their ideal goals and values); (c) Avoiding argument, direct confrontation and persuasion (arguments with patient are counterproductive and could result in hostile emotions and defensiveness, patients need to argue positively for change); (d) Roll or adjust to resistance (respect patients’ autonomy and views, signs of resistance indicate a need to listen carefully and respond in a new or different way); and (e) Supporting self-efficacy and optimism (highlight patients’ strengths, communicate to patients that they are capable of change, reassert to patients that treatment providers are available for support but change and achieving treatment goals are the patients’ responsibility) (Miller & Rollnick, 2013). By practicing these principles, treatment providers are able to enhance patients’ motivation for positive changes and increase treatment adherence because patients are responsible for deriving the solutions to their problems and executing action plans (Miller & Rollnick, 2013). Furthermore, MI’s focus on acceptance and respect for patients’ unique views, feeling and values enabled the formation of collaborative and non-judgemental partnerships between treatment providers and patients (Miller & Rollnick, 2013).

The concepts of acceptance, empathy, and respect for patients and their experience, as well as consideration for patients’ cultural norms in MI are particularly relevant when counselling multi-ethnic drug rehab patients in Malaysia. While some patients may be unfamiliar with a patient-directed counselling style, the structure and treatment goals associated with patients’ level of readiness to change in the Transtheoretical model of change could help patients to identify their progress, track actions and treatment strategies that were useful and provide patients with clear expectations of treatment providers’ role.

9. Difference in treatment satisfaction scores between patients and rehab staff and patients’ perception of their level of satisfaction (Research Question 9)

In response to Research Question 9, no significant difference in treatment satisfaction scores was found between patients and rehab staff. Despite that, patients’ mean score was lower than the staff’s mean score. This finding supports Prediction 9. From a quantitative perspective, this finding could be interpreted as there were no significant differences between patients’ expectations towards the programme and the rehab outcomes received from their treatment provider (Stimson & Webb, 1975). Thus, rehab patients are generally satisfied with treatment services and their providers. Satisfaction with treatment is extremely important because it is associated with higher treatment compliance (Hirsh et al., 2005). These findings were found to be supported by the Session Evaluation Questionnaire (SEQ). Most rehab patients viewed that the treatment sessions were deep in content and were beneficial towards learning problem-solving and coping skills. In addition, most treatment sessions were reportedly well organised, pleasant, easily understood and proceeded according to schedule. Most patients felt the sessions provided positive messages and were pleased with the presence of friendly and encouraging staff or counsellors at the centre. Furthermore, the supportive environment helped patients to be more focused and confident about working towards their treatment goal after the session. In terms of their mood and emotion after treatment sessions, most patients reported feeling empowered and excited to move forward with their treatment. These findings support Prediction 9, whereby it was expected that most patients would report being feeling satisfied with the treatment across the four dimensions of SEQ (depth, smoothness, positivity and arousal. The results from patients’ satisfaction ratings and the SEQ suggested that the rehab patients in both rehab centres were highly engaged in treatment. High engagement in treatment contributes to significant improvements across all domains of life (Harris, Humphreys, Bowe, Finney & Tiet, 2010).

Although the patient satisfaction rating by patients were at the higher continuum of the rating scale, it is a fact that most treatment outcomes are defined by the professionals and may differ from those of importance to the patients. Even though patients are fully aware of the treatment objectives and expected treatment outcomes, this slight discrepancy could result in less satisfactory treatment ratings (Bond & Thomas, 1991). Thus, patients’ satisfaction rating was consistently lower than perceived ratings of rehab staff in the pilot and actual surveys. Furthermore, there were a few issues that affected patients’ satisfaction with treatment although most treatment needs were met. Firstly, some government rehab patients reported an inconsistent depth of content during group counselling sessions. A patient also felt that the contents discussed in group counselling were only able to help him resolve problems at the surface level. Another patient took a more neutral stance and viewed that the counselling sessions were occasionally in-depth and he was able to learn some problem-solving skills. However, other techniques were not as useful to his situation. Secondly, a government outpatient was also troubled by last-minute changes to the programme schedule, as he had to re-schedule time off from his workplace with limited notice. Another patient felt that although treatment sessions were relatively smooth, there were problems when counsellors did not arrive for their scheduled sessions or rehab activities were cancelled for unspecified reasons. Both findings above support Prediction 9, in which it was expected that issues such as the inconsistent depth of content during group counselling sessions, unexpected changes or cancellation of treatment sessions, and non-arrival of counsellors for unspecified reasons would result in some dissatisfaction with treatment.

Thirdly, there were also a variety of patient issues that were difficult to manage within group settings. Group counselling becomes more complex when patients of varying levels of cognitive functioning, mental health, symptoms and response to pharmacological therapy, are combined together for treatment sessions (SAMHSA, 2005). Corroborative accounts from staff showed that considerable tolerance was needed for varied levels of participation and ability to communicate. Furthermore, it was acknowledged that deeper attention towards patients with co-occurring disorders (e.g., schizophrenia and paranoid personality) is needed as they must be incorporated gradually at their own pace since they do not fit well in groups (SAMHSA, 2005). Therefore, patient satisfaction could be affected in treatment programmes with a large reliance on group therapy settings as it would be difficult to meet the specific needs of all patients. Therefore, drug rehab programmes would be more effective if group counselling is augmented with individual counselling since individual contact is important to meet specific patient needs (SAMHSA, 2005). This recommendation was supported by a patient’s disclosure that he did not feel excited, peaceful, or particularly empowered to accomplish treatment goals at post-treatment. It was conjectured that this patient may still be unable to recognise or accept that his drug abuse habit is a problem (UNODC, 2008) or is unable to associate negative consequences to the self with drug abuse (Varney et al., 1995). Therefore, an individualised approach (e.g., motivational interviewing) may have been more suitable for this patient as sufficient time is needed to explore the rationale and factors that could motivate this patient to accomplish treatment goals willingly. Furthermore, the patient would only be able to achieve a sense of empowerment after acquiring a set of specific skills that would help the patient to achieve important treatment goals. The feedback from rehab patients clearly demonstrates that there are various limitations prevalent in current drug rehab programmes despite the fairly high rating by rehab staff.

Additionally, there is a possibility of biases in the staff’s evaluation. There were two possible factors that could have affected the implementation of a fair and objective evaluation by the staff. The first factor was fear of the career consequences for providing negative feedback and the second factor was strong pride and belief in their work (Bonoma, 1977). Besides threatening their professional interests (status, livelihood and standards), evaluation practices has the potential to uncover widespread dissatisfaction (Sitzia & Wood, 1997), which are more likely to affect rehab staff with higher levels of commitment and involvement in the programme (i.e., concept and development, programme objectives and treatment outcomes) (Taut & Brauns, 2003). Moreover, due to the sense of personal involvement, evaluative judgments about the programme may extend to their individual performance, which could result in a loss of self-confidence and image. On a larger scale, evaluation outcomes are associated with important tangible consequences such as the loss of huge time and effort in developing and evaluating a programme, the loss of career status or the closure of the treatment programme (Taut & Brauns, 2003).

10.   Rehab programme evaluation: Similarities and differences between rehab patients’ and staff’s responses about favourable treatment components, limitations and improvements (Research Question 10)

Thematic findings from rehab patients and staff were triangulated in response to Research Question 10. Major similarities in themes were found between patients’ and staff’s responses on favourable treatment components (i.e., group counselling, vocational workshops, spiritual studies and recreational activities). However, major differences in themes were found between patients’ and staff’s responses on treatment limitations and suggestions for improvement as treatment experiences differ according to the perspective of patients or staff. These findings support Prediction 10.

1. Favourable components

It was found that a combination of group counselling, vocational workshops, spiritual studies and recreational activities were favoured by rehab patients. Drug rehab programmes which include the four treatment components above were more beneficial towards overall physical and mental health (Mazlan, Schottenfeld & Chawarski, 2006). This perspective was similarly shared by the rehab staff. Some patients reported that they were pleased with the opportunity to participate in community projects, appreciated health talks conducted by health professionals and sessions for family visits. Vocational workshops were favoured and important to patients in both government and private centres. However, the job skills that are taught often do not require high professional qualifications. The patients have expressed concern that this may have limited their opportunities for gaining employment within a wider job scope. In local drug rehab centres, two areas that are lacking in vocational training are job placement opportunities and a shortage of trained and qualified vocational therapists to educate patients. This finding was supported by Scorzelli (2007), who recommended that patients should be provided with skills related to work performance, quality of work, building relationships with supervisors and fellow employees, dress codes, time management and coping. These skills are beneficial to the recovered patients when they re-enter the workplace and society (Scorzelli, 2007).

2. Limitations and suggested improvements from patients’ perspective

Limited rehab activities, non-existent social support and reported loss of freedom were among the limitations highlighted by patients. Consequently, the rehab patients suggested a need to expand the scope of rehab activities, enhance group relationship, and increase voluntary admissions. In retrospect, drug treatment programmes in Malaysia provide intense focus on replacing drug-use activities with constructive and rewarding non-drug-using activities such as physical training, sporting or recreational activities, and religious guidance through civic education or spiritual studies. Group or individual counselling therapies were also used to motivate patients to overcome drug dependence, build resilience towards drugs through coping skills and improve problem-solving abilities. Drug rehab patients were engaged in a variety of meaningful activities (i.e., any form of education, training and employment) to help patients develop personal recovery capital factors such as self-esteem and self-efficacy (Best, 2012), which would improve patients’ overall health and quality of life (Best et al., 2013; Farabee, Rawson & McCann, 2002).

A review of rehab activities conducted in the government and private rehab centre showed that there were a range of compulsory activities that must be accomplished by patients. However, it was suggested by the rehab patients that accommodations and expansion of activity options be made. In particular, attention should be given to the development or implementation of special exercises and recreational activities for elderly rehab patients and patients with some form of physical or mental disability as a result of drug abuse. A decline in mobility due to the loss of muscle mass, reduction in muscle strength and endurance, decline in balance ability (Sakuma & Yamaguchi, 2012) as well as the development of chronic diseases and multiple disabilities due to aging (Tinetti, 1986) have made it difficult for elderly patients to participate in intensive military-style exercises. Impairments in cognitive, sensory and locomotor functions due to aging (Tinetti, 1986) or effects of long-term drug abuse are other aspects that should be considered when planning and implementing exercise and recreational activities for rehab patients. Besides improving muscle strength and reducing the risk of non-communicable diseases like cardiovascular disease, Type-2 diabetes, cancer and hypertension (Kokkinos, 2012), physical activity and light exercises can also improve and strengthen cognitive functioning.

Past research studies (Bixby et al., 2007; Busse, Gil, Santarem & Filho, 2009; Scherder et al., 2005) have indicated that physical activity and light exercises improve executive functions in the brain, and was associated with better selective attention, cognitive flexibility and processing speed. Despite possible mobility and disability issues, options of exercises that are of moderate intensity (e.g.: aerobic exercise, brisk walking, dancing, Tai Chi) should be made available to elderly rehab patients (Chodzko-Zajko et al., 2009), with the choice of tailoring or modifying these exercises to the patients’ physical and mental capability. A combination of active and passive activities was more beneficial towards the maintenance of long-term treatment outcomes (Farabee, Rawson & McCann, 2002).

Enhancing group relationship or cohesion was another aspect that the rehab patients felt should be improved. This aspect involves encouraging active interaction and mutual respect among rehab patients, regardless of race, beliefs and religious practice. Based on the content structure of existing rehab programmes, little emphasis has been placed on building national and group unity. Yet, it is essential to develop positive group cohesion across all ethnicities to enhance group spirit. The formation of close associations and deep emotional commitment within group members, and the establishment of an open and honest environment, would encourage members to support and spend time with one another (Gillaspy, Jr., Wright, Campbell, Stokes & Adinoff, 2002). Therefore, the inclusion of activities that would encourage group unity, mutual respect and acceptance was suggested. Patients from broken families or dysfunctional family relationships should be given priority in receiving behavioural and group therapy to facilitate the development of good interpersonal relationships through social skills training. This would help improve the patients’ ability to function in the family and community. Group cohesion experiences have also been found to increase self-esteem (Lorentzen, Sexton & Høglend, 2004), decrease global symptomatology of addiction, increase goal attainment (Tschuschke & Dies, 1994), and encourage the formation of healthy norms and role modelling (Moos, 2008). Literature on group cohesion within psychotherapeutic settings also revealed positive relationships between group cohesion and patient improvement (Taube-Schiff, Suvak, Antony, Bieling & McCabe, 2007). Moreover, high group cohesiveness was associated with stronger endurance of conflict during specific stages of treatment (MacKenzie, 1994). This enabled rehab patients undergoing group therapy to experience stronger positive outcomes.

Increasing voluntary admissions was also an important issue to patients as they perceived that individuals who voluntarily sought treatment were generally highly motivated to change drug abuse behaviour. Patients who were less motivated to undergo treatment or had no intention to stop drug abuse (i.e., admitted by court orders) were more likely to complain about the loss of freedom upon entering treatment. Therefore, interacting with patients who were intrinsically motivated to change would serve as a source of inspiration to less motivated patients. Past research have shown that higher levels of pre-treatment motivation in patients were associated with the development of better therapeutic relationships, favourable perceptions of treatment providers’ competence and the peer support received (Broome, Knight, Knight, Hiller & Simpson, 1997), and improved treatment attendance (Simpson, Joe, Rowan-Szal, & Greener, 1997). In addition, pre-treatment motivation was also positively related to treatment confidence, counselling rapport and therapeutic engagement (Joe, Simpson & Broome, 1998).

3. Limitations and suggested improvements from the staff perspective

In Malaysia, there were two critical issues that were viewed as weaknesses in drug rehab programmes: (1) limited depth in content structure, and (2) lack of trained staff. As such the rehab staff suggested four key areas that should be improved: (1) implementing tailored treatment approaches, (2) upgrading after-care services, (3) management issues and (4) adaptation of Western treatment approaches to local needs.

Previously, most government rehab centres practised the institutionalisation approach, with a special emphasis on military-style training. This was because patient populations in the past consisted primarily of hard-core addicts, with a history of criminal activities. However, the staff were aware of a shift in the profiles of drug users in recent years and emphasised the importance of implementing a tailored treatment approach. This means that services and treatment settings would be matched to individual patient’s needs. This approach could increase patients’ probability of completely overcoming drug dependency and functioning normally at home and in the community. These findings were supported by past research such as McLellan et al., (1997) whose study showed that patients who received matched needs services (i.e., individual sessions in family or social relations, psychiatric health or employment skills based on identified needs) were more likely to complete treatment and improve in psychiatric and employment areas as compared to patients in the standardised treatment group. Moreover, patients in the matched needs groups were significantly less likely to be treated for drug relapse during the six-month follow-up. Smith and Marsh’s (2002) study also showed that matched counselling services (e.g., domestic violence services and family counselling) were associated with reduced levels of drug abuse among female patients with children, while matched ancillary services (e.g.: housing, occupational training and legal services) were associated with patients’ satisfaction with treatment. The staff were aware that a combination of various treatment components and services would be needed since patients’ needs may change along the course of rehabilitative treatment. Therefore, it was proposed that patients’ progress and evolving treatment plans should be constantly monitored. Furthermore, proper referrals should be arranged in circumstances whereby the centre does not have the required expertise. This was necessary when dealing with complex drug rehab cases, whereby specialised treatment services were needed for patients with severe somatic and psychiatric disorders (WHO, 2009). Staff in the government rehab centre also acknowledged a need for greater sensitivity towards the needs of LGBTs and HIV patients within Malaysian rehab centres. As stated in the principles of drug dependence treatment by WHO (2009), LGBT and HIV patients have equal rights to receive drug rehab treatment. Discrimination should not occur on any grounds, be it gender, ethnic background, religion, personal inclinations, political belief, or health, economic, legal or social conditions (WHO, 2009).

Due to multi-ethnicity in Malaysia, the staff also highlighted a vital need for a more culturally-sensitive design and delivery of drug treatment programmes. An analysis of drug treatment programmes designed for Australian Aborigines by Brady (2002) revealed several structural features that are equally relevant for implementation in Malaysia. Firstly, residential treatment programmes should ensure that patients of various ethnicities are offered rehab activities that would allow them to immerse themselves in their culture and spiritual beliefs such as agriculture and horticulture experiences, permaculture training, building and carpentry skills, healing circles, massage, Reiki therapy, as well as art and carving. Secondly, it was suggested that residential treatment programmes are staffed with treatment providers of multi-ethnic origins as they would be in a better position to understand and manage patients’ culture-based needs. Thirdly, rehab programmes should create a family-oriented atmosphere since Malaysia is a collectivistic country. Patients would be able to relate and communicate better with treatment providers, whom they view as family. Although rehab patients in Malaysia are accorded the opportunity to engage in therapeutic activities like gardening and arts and craft, the current range of rehab activities that would allow cultural immersion in rehab centres are comparatively limited. However, improvements such as encouraging more active family involvement in the patient’s treatment, making greater accommodations for different religious beliefs, languages and dialects, upgrading special facilities for women rehab patients who prefer women-only environments and assurance in confidentiality issues should be greatly considered in future treatment development.

The staff also called for the expansion of after-care services in variety and range. Past research like Jiloha (2011) has shown that it takes time to overcome drug dependency and there is a higher probability of relapsing when patients leave the rehab centre. This was attributed to greater exposure to high-risk situations such as coping with pain, illness, injury or fatigue, frustration, anger, anxiety and other negative emotional states in the workplace and neighbourhood (Jiloha, 2011). In these situations, patients may be tempted to give in to direct or indirect social pressure to use drugs to increase feelings of enjoyment, happiness and freedom. Furthermore, recovered patients may be tempted to test their personal control against drug abuse or their capacity to engage in controlled or moderate drug abuse (Jiloha, 2011). Therefore, it is of critical importance that after-care services be made easily accessible to rehab patients and its services should be expanded and improved. Based on the treatment structure guidelines by the United Nations Office on Drugs and Crime – UNODC (2003), after-care services like psychosocial support, social reintegration and self-help groups should be offered from a month to considerably longer periods, after treatment is completed. The purpose of after-care services is to provide continuous support to patients at the required level to maintain earlier treatment outcomes and goals. It can be done through regular phone contact as well as scheduled and unscheduled appointments. Under a structured programme, patients receiving after-care services are also encouraged to access self-help groups, community support and advice services (UNODC, 2003). Besides the patients, after-care services also include the provision of guidance to patients’ family members and peers on creating a caring family and community environment that is conducive to patients’ recovery (UNODC, 2003).

Based on the account of a government rehab staff, halfway houses were established during the last restructuring of the drug rehab system for the benefit of patients who were homeless and unemployed upon completing treatment. A deeper look into after-care services provided in Malaysia revealed that these services were mostly offered by halfway houses under the care of private organisations such as PENGASIH and PEMADAM. However, government rehab centres are gradually developing and offering similar after-care services via Cure and Care Service Centres (CCSC), Community Caring House (CCH) as well as Cure and Care Vocational Centres (CCVC) (Kaur, 2012). However, there is a need to actively upgrade the provision of basic services such as aiding patients in finding employment, housing and educational opportunities. In addition, follow-up assessments on patients who have re-entered society and gained successful employment should be actively implemented to intervene and reduce the probability of drug relapse. The establishment of sober living houses (SLH) that provide recovering patients with a drug-free living environment and access to peer support (Polcin, Korcha, Bond, & Galloway, 2010) would also help patients to maintain a healthy living.

The rehab staff also raised two management issues that are experienced by most rehab centres in Malaysia. These issues are the severe lacking of staff with treatment expertise and high employee turnover rates. A government rehab staff suggested that existing staff should be re-evaluated by the upper management in NADA/AADK to ensure that the current workforce have the necessary skills and expertise to deal with drug cases. Staff who were directly involved with rehabilitation should have the necessary qualifications to manage patients’ drug abuse and mental health issues. These qualifications include training in counselling, coping and adaptive skills, as well as experience in practicing various cognitive and behavioural therapies. Those who lack certain skills should be given the equal opportunity to obtain proper education, training and clinical experience through short-term placements. Moreover, it was suggested that stricter criteria for staff recruitment should be enforced. This would ensure that only individuals with high levels of passion and commitment, and the ability to cope with challenges are employed to reduce employee turnover rates. There have been reports by patients that drug withdrawal management under medical supervision was not available to patients in smaller-scale facilities. These facilities often did not have on-site medical officers and the rehab staff lacked training on managing drug withdrawal symptoms. The rehab staff also viewed that treatment services should be properly coordinated since drug abuse treatment is a collaborative effort. The programme co-ordinator needs to establish links and networks between key experts to enable organisation of joint assessment and case reviews.

The rehab staff also voiced concerns about having limited staff with proper expertise in individual or group counselling techniques and in handling large patient caseloads. In reviewing the background of in-service counsellors, it was found that most of them were employees from the Ministry of Home Affairs, Ministry of Social Welfare, and Department of Prisons, who received government-sponsored drug counselling training (Scorzelli, 1987). Despite that, drug counselling was provided within the minimal level in rehab and after-care programmes conducted by government organisations and NGOs. Some of the in-service counsellors were recovered patients with a history of drug abuse but lacked the necessary training (Scorzelli, 1987). This was a common situation in the private rehab centre. Hence, although there are many patients requiring assistance, the limited number of trained counsellors has resulted in a heavy caseload for the qualified counsellors.

The staff also observed a need for more adaptations of Western treatment approaches to local needs. As most drug treatment modules were developed in the Western countries like the US and UK, it is essential to properly integrate these modules with relevant local cultures. A government rehab staff disclosed that adjustments were made to a community therapy programme, which was based on the freethinker philosophy, to match patients’ specific cultural beliefs and religious inclinations. Zall and Mahmood (2013) also documented their efforts in integrating Collective Family Therapy – CFT (i.e., combination of Structure, Adlerian, Social Constructivism and multi-cultural theories) with Malay collectivist and religious values. Their study managed to identify and define Malay traditional values that posed a challenge towards effective communication such as lack of open communication, the fear of being taken for granted and alienation from their family and community. Moreover, Malay collectivistic values were successfully integrated with psychotherapy and counselling concepts such as levelling, openness, feedback and confrontation (Zall & Mahmood, 2013). The integration was made easier due to some similarities between Malay collectivistic values and the original objective of CFT, which was to encourage patients and their families to mend ties, rebuild communication, gain acceptance and establish social support networks for rehab by including family members in the treatment process (Zall & Mahmood, 2013). The integration of CFT with Malay collectivistic culture and religious values was able to ensure that a culturally-sensitive treatment option was made available to Malay drug rehab patients. Furthermore, treatment modules that were adapted to local cultures were associated with positive treatment outcomes and higher satisfaction with treatment because patients’ treatment need was better met (WHO, 2009).

Improvements related to the four issues above (i.e., implementing tailored treatment approaches, upgrading after-care services, resolving management issues and adapting Western treatment approaches to local needs) were suggested by staff in the government and private rehab centres. However, there was one additional issue that was suggested for improvement by staff from the government rehab centre. The government staff felt that an improvement in patient discipline was needed in regards to compliance with rules and regulations in the rehab centre and adherence to treatment regimen. However, contrasting opinions were revealed when comparisons were made with responses from patients in the private rehab centre. This finding clearly indicates that there is a major difference in the treatment environment created in government and private rehab centres. Private rehab patients felt that the existing rules within the treatment centre were too strict, to an extent that a part of their freedom was taken away. There was little or no personal time as in-patients were often busy with treatment activities and workshops from morning to evening. Some private patients reported being unable to cope with the strict schedule and suffered from limited hours of rest. Treatment providers need to be mindful that quality sleep is essential towards recovery from drug addiction (Fisher, 2015) although compliance to rehab activities is equally important. Many drug rehab patients develop sleep disorders (e.g., insomnia) during recovery due to drug withdrawal and other bodily adaptations. Sleep problems can cause drug rehab patients to experience a rise in stress levels, temporary cognitive impairments (e.g., hallucinations) and the loss of willpower to recover due to exhaustion, lethargy and irritability (Fisher, 2015; Miranda, 2012). This could further lower and alter their inhibitions, making patients more susceptible towards drug relapse (Fisher, 2015; Miranda, 2012). Therefore, treatment providers and patients need to work together towards maintaining a balanced treatment schedule that would ensure patients benefit from an optimum amount of rehab activities and healthy sleep patterns, which would promote successful recovery (Fisher, 2015).

Based on findings from the rehab patients and staff, it is concluded that there is still much improvement needed to create an effective drug rehab system in Malaysia. The upper management needs to appropriately acknowledge and address the issues raised by both rehab patients and treatment providers. Furthermore, greater attention from treatment providers is urgently needed on issues that could impede patients’ treatment progress such as legal, medical, social, financial and psychological problems (Etheridge, Craddock, Dunteman & Hubbard, 1995).

11.   Strength, limitations and future recommendations

There were several strengths and indirect benefits of conducting drug abuse research across different sample groups. A major benefit of studying the perceptions of university students was it revealed gaps in students’ knowledge about drug abuse and drug relapse issues despite having received drug prevention education in school. Comparisons of student perceptions with real-life experiences of drug abuse through the accounts of drug rehab patients and treatment providers also provided deeper understanding of the gap between perception and reality of drug abuse. The survey study also recruited university student samples from several states within Malaysia to obtain a wider range of opinions about drug abuse and relapse. Besides the state of Selangor and Kuala Lumpur, university students were recruited from colleges and universities in Penang, Sabah and Sarawak.

Since a research aim of this study was to gain insights into drug abuse and relapse issues from different perspectives, interview sessions with drug rehab patients and staff were arranged through NADA. The process and procedure of getting permission to conduct interviews at both public and private rehab centres was educational and proceeded smoothly. The overall experience of interacting with drug rehab patients and staff was pleasant and the respondents were extremely cooperative. The interview sessions were eye-opening and useful observational input was obtained from personally viewing the admission procedures, conditions of the rehab centres and the treatment process.

There were also several limitations and challenges identified in the survey and interview components. Firstly, there is the possibility of response bias in the survey component, which is an issue prevalent in all self-report research. Although the SPQ is administered anonymously, it is a self-report measure and there may be a tendency for some students to respond in a way that is perceived as socially desirable (Chan, 2009).

Secondly, although the SPQ is essentially an opinion survey, basic knowledge about drug abuse and drug types is still needed to comprehend and respond to the survey items. However, it was difficult to assess the levels of knowledge retained from past drug prevention education. Despite past exposure to drug prevention education, some students reported that they lacked familiarity with the legal names of drugs. Research like Corazza et al. (2014a) suggested that young people may be more familiar with drugs promoted using attractive street names or popular brand names. However, drug types were listed using their legal names in the SPQ because it was assumed that students from Malaysian schools have basic awareness and knowledge of the legal names through prevention programmes organised by NADA, PEMADAM and other NGOs. In addition, street names for each drug differ according to location and country. Furthermore, students’ knowledge of different street or brand names of drugs would depend on the type of media they were exposed to (i.e., TV shows, Western or Eastern films, and online entertainment sites).

Thirdly, the SPQ was not designed to gauge the accuracy of university students’ pre-existing knowledge although the survey items did measure basic knowledge of drug abuse and drug relapse factors, drug types and relapse prevention strategies. In future, it is recommended that schools and higher education institutions adopt a pre and post-test approach or a longitudinal approach to assess students’ levels of awareness and current knowledge about drug abuse and prevention. This measure is necessary because students are exposed to different forms of drug awareness and prevention activities throughout their schooling period.

Fourthly, there was unequal recruitment of male and female university students. Methodologically, it was difficult to control the gender composition of university students due to specific conditions of anonymity and voluntary participation from the ethics committee. In addition, past research like Underwood, Kim and Mattier (2000) showed that females respond to web and paper-based surveys at higher rates than males. The survey was also subjected to non-response bias in two forms (Fraenkel & Wallen, 1993), which are total non-response bias (ten paper questionnaires were not returned) and item non-response bias (fifty online responses were eliminated due to incomplete responses). However, the gender composition of university students obtained in this study is reflective of general gender imbalance in student enrolments across public and private higher education institutions in Malaysia. A research by Ismail (2015) demonstrated that there is an over-representation of females in the student population as females outperformed male students in entry qualifications to public universities. Available gender statistics from the Department of Statistics Malaysia also indicated that the ratio of female students enrolled in university was 64.8% as compared to 35.2% of male students, in 2010 (Ismail, 2015). It could be argued that the current findings could be less representative since males may have greater awareness about drugs because a greater proportion of drug users are males. Furthermore, male drug users were more likely to have experimented with a wider range of new synthetic drugs and drug abuse patterns as compared to female drug users (Corazza et al., 2014b; McCabe, Cranford, Boyd, & Teter, 2007). However, this does underline the core issue of whether females truly lack awareness about new synthetic drugs. There is a possibility that despite females’ awareness about various synthetic drugs, they chose not to use certain drugs because they were motivated by different grounds for drug abuse. Several studies have shown that drug abuse among females were often highly related to treating anxiety and mood disorders (Conway, Compton, Stinson, & Grant, 2006), eating disorders (Hudson, Hiripi, Pope & Kessler, 2007) and severe premenstrual syndrome or premenstrual dysphoric disorder (Terner & de Wit, 2006). Thus, this study further highlights the importance of conducting gender-based studies on perception, drug abuse factors, and drug relapse prevention to develop gender-sensitive drug prevention.

Fifthly, the university student sample was mostly from higher learning institutions in urban areas. Other extraneous factors that could have stemmed from differences in geographical location and local culture would influence perceptions and beliefs about drug abuse. For instance, a research based on the Treatment Episode Data Set (TEDS) reported differences in choice of drug abuse and treatment motivation in rural and urban settings in the United States. Urbanites were more likely to use cocaine and heroin while those from the rural areas were more likely to use non-heroin opiods and stimulants (Elements Behavioral Health, 2013). In addition, urbanites were more likely to seek treatment due to family pressure or voluntarily while rural dwellers only sought treatment under law enforcement for a drug abuse offence (Elements Behavioral Health, 2013). Besides these differences, university students and young professionals in urban areas were likely to have higher levels of knowledge about novel psychoactive drugs due to greater exposure to recreational settings like bars and nightclubs (Martinotti, et al., 2015).

Based on the limitations mentioned in the survey component, the following areas were recommended for future research:

• Consider the impact of urban and rural geographical factors on cross-population research and expand the sample size and variation in respondent demographics. For instance, students and working professionals from rural and urban areas could be recruited across all states in Malaysia to gain an extensive understanding of young people’s knowledge and perception on drug abuse and relapse.
• Examine the influence of cultural values, diverse beliefs, and exposure to drug information through different types of media, on perceptions of drug abuse and attitudes toward drug users.

There were also some challenges experienced in the interview component.  Firstly, there were language barriers for some private rehab patients and staff as they were less fluent in English and Malay languages. In this circumstance, Chinese dialects were used to conduct interviews with some rehab patients and staff since conversing in a language that is familiar to interview respondents could help establish trust between the interviewer and respondents (Tsang, 1998). Furthermore, the respondents would be able to express their thoughts naturally to the interviewer (Tsang, 1998). Secondly, the interviews could only be conducted within a limited time frame. The interview sessions were usually arranged during short breaks for patients and staff to minimise interruption to the treatment programme. Hence, the interviewer had to ensure that the research briefing and interview questions were direct and specific so that the required responses can be obtained within a short period of time. Thirdly, the permission to conduct interviews was received from drug rehab centres that only treated male rehab patients.

Based on the limitations mentioned in the interview component, the following areas were recommended for future research:

• Replicate the study with female drug rehab patients to understand the influence of gender on awareness about various drug types, factors for drug abuse and relapse, as well as drug choices.
• Conduct evaluation studies on drug rehab approaches that are used across rehab centres in Malaysia, to gain insight into treatment processes that are conducted in government and private rehab centres.
• Evaluate cultural barriers in drug rehab treatment and the cultural-sensitivity of  existing treatment programmes in design and delivery since drug users in Malaysia are multi-ethnic, with a majority being the Malays (80.0%), followed by the Chinese (7.94%), Indians (7.92%) and ethnic groups from East Malaysia (3.45%) (NADA, 2015).
• Evaluate whether counselling therapies that are integrated with local culture and spiritual values are able to meet patients’ culture-based needs.
  12.       Conclusion and research implications

Despite the limitations and challenges within this study, the findings were beneficial towards creating awareness about how individuals view drug abuse and prevention issues from different perspectives (i.e., university students, drug users or patients and drug rehab staff). Findings from the semi-structured interviews with rehab patients and staff have important implications towards understanding current drug user profiles and drug abuse patterns, identifying issues that affect patient satisfaction with treatment and improving drug rehab programmes through evaluative feedback from rehab patients and staff. The take-home messages from the interview component are:

• Evaluative feedback and recommendations from both patients and staff should be included to improve drug rehab treatment. Multi-perspective evaluations are valuable because it gives treatment providers a different insight into their rehab programme (i.e., patients’ perspective).
• The drug rehab system in Malaysia should be made more patient-centred by having patients actively participate in the development of treatment goals and providing input on progress with treatment activities and treatment decisions.
• A safe and secure treatment environment should be created for patients to explore issues affecting motivation to change. Treatment providers should also demonstrate acceptance, empathy, and respect for patients and their experience to ease the formation of a collaborative partnership between patients and treatment providers. These conditions will help increase commitment from patients to participate in rehab activities that would lead to positive behaviour change (i.e., reducing and abstaining from drug abuse).
• At the start of the treatment, treatment expectations of rehab patients and treatment providers should be discussed. Clear rules on the action and consequences of non-adherence to the treatment plan should also be outlined.

Survey findings from the university student sample also have significant implications towards identifying knowledge gaps about drug abuse and relapse, improving drug prevention education and contributing to drug abuse literature. The take-home messages from the survey component are:

• Feedback from students about drug abuse issues (e.g., factors for drug abuse and relapse and effective relapse prevention strategies) can help educators and programme developers to gauge the effectiveness of past educational programmes.
• More gender-based studies on the perception of drug abuse issues are needed to develop gender-sensitive content for drug prevention programmes.
• Schools and higher education institutions should adopt a pre and post-test or a longitudinal approach to assess students’ levels of awareness and current knowledge about drug abuse and prevention.
• Students’ feedback on drug prevention education (e.g., usefulness of prevention programmes in school, limitations and suggestions for school and university-based programmes) could help educators to determine the relevance of educational content, identify and meet students’ learning needs, encourage active participation in drug prevention activities and increase the level of commitment from students.
• Understanding information-seeking and sharing practices are helpful towards educating the public and specific at-risk groups (i.e., children, youths and young working professionals) by disseminating information effectively through the preferred media. Organisations that would benefit from these findings are the Ministry of Education Malaysia, NADA/AADK and NGOs.

A guideline that assimilates resources and stakeholders in the drug rehab and drug prevention education systems was also derived from triangulation of findings across three sample groups (university students, rehab patients and rehab staff) and field observations. Implementation of this guideline could help:

• Improve collaboration between treatment providers and agencies involved in public education. A collaborative partnership between treatment providers and educators would ensure that the public is informed about the latest developments in drug abuse trends, potential risks and methods to avoid engaging in drug abuse. Furthermore, it could increase public understanding about drug abuse issues from a medical and psychosocial perspective.
•  Improve and maintain transparency of resources and expertise that goes into treating drug users.
• Clarify the roles of the community (parents, teachers and neighbourhood) in working together with recovered patients to maintain a healthy and addiction-free lifestyle at post-treatment.

On the whole, this study was able to gain insight into drug abuse and drug relapse issues in Malaysia across multiple perspectives (i.e., university students who do not use drugs, drug users and rehab staff). This study also provided a deeper understanding of knowledge gaps that are prevalent in young people despite having past exposure to drug prevention education. Furthermore, this study provided drug rehab patients and staff with the opportunity to evaluate satisfaction with treatment and express their views on how existing drug rehab programmes could be improved. The research findings, which were summarised and discussed in sections 8.1 to 8.10, also fulfilled the requirements of the 10 research objectives. At the same time, there were various challenges and benefits to conducting a multi-perspective study on drug abuse and relapse, drug prevention education and treatment evaluation using a concurrent, mixed method design.

Nevertheless, this study was able to bring forward evidence that at present, improvements in the drug rehab system and drug educational systems (school, tertiary education and public) are still needed to continuously educate the young about drug abuse and improve maintenance of drug treatment outcomes. It is hoped that the findings and recommendations in this study will be of guidance to educators and treatment providers who are interested in working together to create an interactive yet current drug education syllabus. In addition, the recommendations may be useful to treatment providers who would like to adopt a patient-centred approach to drug counselling (e.g., MI and Transtheoretical model of change) as well as encourage active participation and feedback from patients in treatment.