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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 8th 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.

  1. 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.

  1. 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.

  1. 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.

  1.   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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1.   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.

  1.  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.

  1.        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.

  1.        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.

  1.        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.
    1.        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.

  1. 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.

  1.   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.

  1. 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 3rd 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 31st 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 13th patient in the government rehab centre, the 10th patient in the private rehab centre and the 8th 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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 methodcoping skillsknowledge intensityhelp resourcesphenomenological 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).

  1. 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.

  1.     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.

  1. 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.

  1. 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.

  1. 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]

EnjoymentEnjoyment 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]

  1. 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 selectionmaintaining 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



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