A Study of the Characteristics of a Clinical Population of Substance Misusers in the Uae and an Exploration of Social Drift in This Population

A STUDY OF THE CHARACTERISTICS OF A CLINICAL POPULATION OF SUBSTANCE MISUSERS IN THE UAE AND AN EXPLORATION OF SOCIAL DRIFT IN THIS POPULATION

By: Samya Al Mamari

A dissertation (or thesis) submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Public Health (DrPH)

Baltimore (Maryland), USA June 18, 2018

ABSTRACT

Introduction: Substance use disorder and addiction negatively influence one’s behaviors and actions, and they endanger the health and welfare of individuals and societies at all levels. The scale of their destructiveness imposes a clear threat to public health and makes it one of the biggest public health challenges of modern times.

Aim: This study aims to identify the characteristics of substance abusers receiving treatment in the National Rehabilitation Center (NRC) in Abu Dhabi – UAE and explores the phenomenon of social drift among this population. The study also aims to compare the characteristics of this clinical population in Abu Dhabi with the characteristics of a clinical population in Jordan in the Al Ghafri study (2014). In addition, the study will explore the associations between the nursing interactions with the patients at the NRC and the patients’ satisfaction with the service.

Method: A cross-sectional descriptive design was utilized in this study in the form of a structured questionnaire interview. The study population is a clinical population (in-patients and out-patients) receiving treatment for substance use disorder from the National

Rehabilitation Center – NRC. Two hundred fifty patients who met the inclusion criteria and voluntarily accepted to participate in the study were invited to take part in the structured interview.

Result: The total sample of the clinical population in this study is 250 patients including 242 males and 8 females (response rate of 94%). The mean (SD) age of subjects was 28.52 (8.87) years, with the majority of the patients being under the age of 31 years. 59.6% were single, and

98.8% were educated with the majority at the secondary level and

49.6% were unemployed. The common source of referral was self- referred (51.6%).

Mood disorders were most frequently reported (51.5%) as a psychiatric illness. Hypertension and gastritis were the most common medical problems. Of the 250 participants, 73% were polysubstance users, 18% used drugs only, and 9% used alcohol only. 98.8% reported that they were currently smoking. The youngest age of first use of most of substance was 11 years with a mean (SD) of 17.8 years.

The majority of both groups had moderate severity of dependence (50%, of substance users and 61.5%, of alcohol users). 32% had a CAGE score of 2. 72% of the participants had had treatment before. The majority stated that they would choose the NRC again to receive treatment. More than 56% did not complete their studies, of whom 68% didn’t complete their studies because of their addiction.

The study assumed that there are similarities between Jordanian and

NRC clinical population’s profile due to the assumed cultural and religious similarities. The descriptive analysis of both clinical population’s profile revealed the presence of some similarities and differences. There were no significant associations found between

iii severity of dependence and the variables studied. The same was found in the case of social drift. However, highly significant correlation was found between patient satisfaction and the combined variable of nursing interaction.

Conclusion: The findings gave useful information on the profile of the current patient population that could be used for developing and improving services as well as developing policies and conducting research. They also provide us with a baseline that could be used to monitor trends in the future. The study also enabled a comparison with a regional country with similar culture and demographics. The findings that nursing interaction is strongly associated with patient satisfaction have major implications for developing addiction nursing.

ACKNOWLEDGMENT

Overall the experience over the past four years doing this research has taught me an enormous amount about the research process, the difficulties involved in primary data collection and how to overcome them. It has taught me about ethical considerations, literature searching and reviewing, choosing research designs, statistical analysis and writing in a language that is not my native language. Although there have been high points and low points, overall, it has increased my enthusiasm for research which I intend to continue and also to teach others.

I would like to devote this dissertation to His Highness Sheikh

Mohammed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi and

Deputy Supreme Commander of the UAE Armed Forces. For his continuous support for the youth, for teaching us how to serve our country, for your leadership, your determination and your passion to guarantee the future of our country. Also, I would like to express my appreciation and acknowledgement for the endless support and guidance of His

Excellency Dr. Hamad Al Ghafri, the Director General of the National

Rehabilitation. In addition, I am enormously grateful to the patients who participated in this study.

My special thanks to Professor David, Dr. Lilly and Dr. Shamil for the time, efforts and advice because without their continuous support and guidance I would not have able to complete this journey. without them

I would not be with you here today. Also, my appreciation is extended to all the supervisors and mentors who helped me throughout my study.

I would like also to thank Ms. Fatima Al Suwadi, Dr. Mohamed Alsayed,

Dr. Hisham Al Arabi from the National Rehabilitation Center (NRC) in

Abu Dhabi and Professor Anwar Batieha, Faculty of Medicine- Jordan

University of Science & Technology for their support, assistance encouragement and valued comments that helped shaped the production of this thesis.

My special thanks goes to my family for their endless patience, support and believing in me.

Samya Al Mamari

TABLE OF CONTENTS

ABSTRACT ...... ii ACKNOWLEDGMENT ...... v TABLE OF CONTENTS...... vii LIST OF TABLES ...... x LIST OF FIGURES ...... xiii 1. CHAPTER ONE: INTRODUCTION ...... 1 1.1. Problem Statement ...... 1

1.2. Significance ...... 4

1.2.1. Significance of Substance Abuse Problem in the United Arab Emirates ...... 6 1.3. Social Drift ...... 8

1.4. Study Aims ...... 9

2. CHAPTER TWO: SYSTEMATIC LITERATURE REVIEW ...... 12 2.1. Search Strategy ...... 13

2.2. Overview of Search ...... 16

2.3. Review of Papers ...... 20

2.3.1. Substance Abuse Profile in Arab Countries ...... 23 2.3.2. Substance/Alcohol Abuse and Social Drift ...... 49 2.4. Conclusion ...... 51

3. CHAPTER THREE: METHODLOGY ...... 52 3.1. Study Aims and Hypotheses ...... 52

3.2. Protection of Human Subjects ...... 54

3.3. Study Design, Including Study Population, Controls, and Design ...... 55

3.3.1. Study Population ...... 55 3.3.2. Sample Size ...... 56 3.3.3. Study Design...... 57 3.4. Source of Data ...... 58

3.4.1. The National Rehabilitation Centre (NRC): ...... 58 3.4.2. The Questionnaire...... 59 3.5. Piloting ...... 64 vii

3.6. Procedure ...... 66

3.7. Data Entry and Quality Assurance ...... 67

3.8. Data Management and Analysis ...... 68

3.8.1. Variables and Measures – operational indicators ...... 68 3.8.2. Analysis plan...... 70 3.8.3. Detailed analysis plan to address research questions ...... 71 3.9. Conclusion ...... 76

4. CHAPTER FOUR: RESULTS ...... 77 4.1. Response Rate ...... 78

4.2. SECTION ONE: The characteristics of the clinical population of substance abusers receiving treatment in the NRC (UAE): ...... 78

4.2.1. Part 1: Demographic Data: ...... 78 4.2.2. Part 2: Addiction History ...... 84 4.2.2.1. Substance Abuse and Smoking ...... 84 4.2.3. Part 3: Social...... 103 4.3. SECTION TWO: Hypothesis # 1: The characteristics of the clinical population of substance abusers receiving treatment in the NRC will be similar as the clinical population of substance abusers studied in Al Ghafri - 2014...... 112

4.3.1. Patient Background: ...... 113 4.3.2. Psychiatric & Medical Data: ...... 116 4.3.3. Substance Abuse and Smoking History: ...... 117 4.4. SECTION THREE: Hypothesis #2: Severity of Dependence Associations ...... 120

4.5. SECTION THREE: Hypothesis #3: Social Drift Associations ...... 122

4.6. SECTION FOUR: Hypothesis #4: Increased nursing interactions will be associated with higher level of patient satisfaction with the nursing services ...... 123

4.7. Conclusion ...... 123

5. CHAPTER FIVE: DISCUSSION ...... 125 5.1. Main Findings ...... 125

5.1.1. The characteristics of the clinical population of substance abusers receiving treatment in the NRC (UAE): ...... 125

viii

5.1.2. Hypothesis # 1: The characteristics of the clinical population of substance abusers receiving treatment in the NRC will be similar as the clinical population of substance abusers studied in Al Ghaferi’s 2014...... 136 5.1.3. Hypothesis #2: Severity of Dependence Associations ...... 138 5.1.4. Hypothesis #3: Social Drift Associations ...... 139 5.1.5. Hypothesis #4: Increased nursing interactions will be associated with higher level of patient satisfaction with the nursing services...... 139 5.2. Strengths and Limitations ...... 142

5.2.1. Strengths ...... 142 5.2.2. Limitations...... 143 5.3. Implications for Practice ...... 145

5.4. Implications for Policy ...... 147

5.5. Further Research ...... 149

5.6. Overall Conclusions ...... 150

APPENDIX – 1: PATIENT INFORMATION SHEET ...... 151 APPENDIX – 2: CONSENT FORM ...... 152 APPENDIX – 3: QUESTIONNAIRE ...... 153 APPENDIX – 4: NRC IRB APPROVAL ...... 165 REFERENCES ...... 166 CURRICULUM VITA ...... 173

LIST OF TABLES

Table 3- 1 Examples of modifications made in the questionnaire ...... 63

Table 3- 2 The Study Hypothesis and their Variables (independent and dependent) ...... 69

Table 4- 1 Frequency Distribution of the participants' Demographic Data .. 80

Table 4- 2 Frequency Distribution of the participants' Psychiatric & Medical Data ...... 83

Table 4- 3 Frequency Distribution of the participants by Substance of Use 84

Table 4- 4 Frequency Distribution of Substance of Use by age of 1st Use ... 85

Table 4- 5 Frequency Distribution of Current smoking status and smoking history categorized by gender ...... 86

Table 4- 6 Frequency Distribution of Current Use of Substance & Alcohol Over the Past 1-2 Months ...... 87

Table 4- 7 Frequency Distribution of the Participants' View of the Importance of Use of Substance & alcohol ...... 87

Table 4- 8 Frequency Distribution of the Participants' Satisfaction of their Use ...... 88

Table 4- 9 Frequency Distribution of Dependency Criteria for Substance & Alcohol Users ...... 90

Table 4- 10 Frequency Distribution of Severity of Dependency ...... 90

Table 4- 11 Frequency Distribution of CAGE Criteria ...... 91

Table 4- 12 Frequency Distribution of CAGE Score ...... 92

Table 4- 13 Frequency Distribution of withdrawal Symptoms ...... 93

Table 4- 14 Frequency Distribution of Previous Treatment Experiences and Follow ups ...... 96

Table 4- 15 Frequency Distribution of Numbers of Previous Inpatient and Outpatient Treatment Encounter...... 97

Table 4- 16 Frequency Distribution of Participants' Views on how NRC Respond to their Needs ...... 98

Table 4- 17 Frequency Distribution of Participants' Views on the Coordination in-between Different NRC Services ...... 99

Table 4- 18 Frequency Distribution of Participants' Respond to coming back to NRC ...... 99

Table 4- 19 Frequency Distribution of Participants' Satisfaction with NRC Nursing Services ...... 100

Table 4- 20 Frequency Distribution of Family History of psychiatric problem, addiction problem, suicide problem and the current health status ...... 101

Table 4- 21 Frequency Distribution of Participants' View of Factors associated with relapse ...... 102

Table 4- 22 Frequency Distribution of Participants' Employment Status .. 104

Table 4- 23 Frequency Distribution of Participants' Employment Type ..... 104

Table 4- 24 Frequency Distribution of perceived effect of addiction on employment as reported by participants ...... 105

Table 4- 25 Frequency Distribution of perceived effect of addiction on employment as reported by participants ...... 107

Table 4- 26 Frequency Distribution of the Substance Users living with the participants as reported by participants ...... 108

Table 4- 27 Frequency Distribution of the Participants’ Education Status 109

Table 4- 28 Frequency Distribution of the Participants’ Marital Status ..... 110

Table 4- 29 Frequency Distribution of the Participants’ Source of Income 111

Table 4- 30 Frequency Distribution of the Participants’ Financial Status . 112

Table 4- 31 Frequency Distribution of the Comparison of Patient Demographic between Al Ghafri’s study and the current study...... 114

Table 4- 32 Chi-square test between the two clinical populations characteristics ...... 116

Table 4- 33 Frequency Distribution of the Comparison of Psychiatric & Medical Data between Al Ghafri’s study and the current study...... 117

Table 4- 34 Comparison of Substance of Use between Al Ghafri’s study and the current study ...... 118

Table 4- 35 Comparison of current smoking status and smoking history between Al Ghafri’s study and the current study ...... 118

Table 4- 36 Comparison of substance by age of 1st use between Al Ghafri’s study and the current study ...... 119

Table 4- 37 Comparison of current use of substance and alcohol between Al Ghafri’s study and the current study...... 120

Table 4- 38 Unadjusted and adjusted Regression analysis of Severity of Dependence ...... 121

Table 4- 39 Unadjusted and adjusted Regression analysis of Social Drift . 122

Table 4- 40 Unstandardized and Standardized Coefficients analysis of Patient Satisfaction ...... 123

xii

LIST OF FIGURES

Figure 2- 1 PRISMA Chart – Section One: Substance/Alcohol Use and Arab Countries ...... 18

Figure 2- 2 PRISMA Chart – Section Two: Social Drift and Substance/Alcohol Use and Arab Countries...... 19

Figure 3- 1 Data collection Procedure ...... 67

xiii

1. CHAPTER ONE: INTRODUCTION

This chapter is an introductory chapter for the dissertation paper. It describes briefly the problem statement and the significance of the problem globally and specifically in the UAE. Finally, the aim of the study and the thesis investigated in this paper will be mentioned at the end of the chapter.

1.1. Problem Statement

Addiction is defined as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” In other words, addiction negatively influences one’s behaviors and actions. Such behaviors foster compulsive substance misuse regardless of the destructive consequences to both individuals and, more widely, the society in which it takes place. Addiction just like any other chronic diseases has its relapse and remission cycles. This makes quitting and maintaining sobriety very difficult and hinders the individual’s ability to fight the strong drug seeking desires (American Society of Addiction Medicine,

2011). National Institute on Drug Abuse (NIDA) (2016) defined addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences”. In both definitions addiction was described as “a brain disease.” due to the changes in the brain’s structure and functions, which might be long-term changes and result in self-destructive behaviors.

Substance use disorder and addiction endanger the health and welfare of individuals and societies at all levels. In 2016, the United Nations

Office on Drugs and Crime (UNODC) reported that approximately 247 million people of the adult population worldwide (aged 15-64 years) used an illicit substance in the 2014, and of those, over 29 million people have drug use disorders (United Nations Office on Drugs and

Crime, 2016).

Out of the 29 million people who have drug use disorders, 12 million are drug injectors, and out of this number, 1.6 million are living with

HIV and 6 million are living with hepatitis C. Worldwide, drug-related deaths in 2014 were estimated at 43.5 deaths per million people aged

15-64, and of those, a third and a half are due to overdose deaths

(United Nations Office on Drugs and Crime, 2016).

In 2010 the global consumption of alcohol of people aged 15 years or older was around 13.5 grams of pure alcohol per day. Also, about 16% of those who drink aged 15 years or older are involved in heavy episodic drinking. In general, as the economic wealth of a country increases, the alcohol consumption increases and the number of abstainers decreases

(World Health Organization, 2014).

Based on the 2014 Global status report on alcohol and health, around

3.3 million deaths (5.9%) of all deaths in 2012 were related to alcohol consumption out of which 7.6% of deaths were among males and 4.0% of deaths were among females. Around 5.1% of the global burden of

disease was related to the harmful consumption of alcohol (World

Health Organization, 2014).

According to the 2013 WHO drug use and road safety, over 39,600 road traffic deaths were due to driving under the influence of illegal substances. Use of drugs such as amphetamines, benzodiazepines, cannabis and cocaine resulted in 8.8% to 33.5% road traffic accidents with fatally injured persons (World Health Organization, 2016) ("Global status report on road safety: Supporting a decade of action," 2013).

The scale of destruction caused by substance use disorders and alcohol imposes a clear threat to the public health. It is a major contributor to family breakdown, domestic violence, child abuse, failure in school, loss of employment, productivity losses, healthcare costs, and crimes

(National Institue on Drug Abuse, 2016) (United Nation of Drug and

Crime, 2014).

The situation in the Middle East is not different than the rest of the world. Despite the fact that drug and alcohol use is forbidden legally and religiously, the prevalence of drug and alcohol use is unexpectedly high. In fact, Afghanistan is the world’s leading manufacturer of opium and marijuana. In addition, the number of illegal opiate users in the region is counted for one fifth of the number of illegal opiate users worldwide, even though the region has only 6% of the global population aged 15-64 years (United Nations Office on Drugs and Crime, 2014).

Since the independence of the United Arab Emirates (U.A.E.) in 1971, several aspects of life have transformed quickly and people moved from

Bedouin life into a fairly luxurious life. Proximity to opiate-producing countries, long land borders and extensive international air connections, globalization and rapid social and economic changes created a rich environment for drug trafficking. In other word, the problem of drug abuse in the UAE appears to be on the increase, and there is concern it could become a serious problem in the future

(Sarhan, 1995).

1.2. Significance

Substance use disorders jeopardize individual welfare and threatens the communities’ stability, security and economic and social development throughout the world. In fact, the international figures of mortality rates and the financial costs related to substance use disorders are alarming. Dealing with substance abuse consequences is one of the major public health challenges that societies must confront.

The magnitude of the substance use disorder problem is represented clearly in the disturbing figures of drug-related deaths as they are always premature and happen at a quite young age. Out of the 207,400 drug-related deaths in 2014, 43.5 deaths per million people were among those aged 15 – 64. Although, the figures of drug-related deaths worldwide haven’t changed, these deaths are unacceptable and preventable. Looking at overdose related deaths, it was reported that these deaths make approximately a third and a half of all drug-related deaths, and are due to opioids in most cases (United Nations Office on

Drugs and Crime, 2016).

Drug injectors suffer from some of the most severe health-related conditions due to unsafe drug use practices. High risk of non-fatal and fatal overdoses, and higher chance of premature death are among the most common poor health outcomes that drug injectors end up with.

All reported data indicated that one out of seven drug injectors is living with HIV, and one in two has hepatitis C. UNODC estimated that the global prevalence of HIV among people who inject drugs is 11.5 percent and 51 percent is the global prevalence of hepatitis C virus (HCV) among the drug injectors. The hepatitis B virus (HBV) global prevalence among people who inject drugs is estimated at 8.4 percent (United Nations

Office on Drugs and Crime, 2016).

The same could be said about the harmful use of alcohol. It caused approximately 5.9% of all deaths annually and alcohol consumption attributed to 5.1% of the global burden of disease. Men are more seriously affected by the harmful use of alcohol than women.

Worldwide, alcohol is attributed to 6.2 percent of all male deaths compared to 1.1 percent of female deaths. In United States, alcohol is the fourth leading preventable cause of death. Globally, alcohol misuse was reported to be the fifth leading cause of premature death and disability and the first among people between the ages of 15 and 49.

Alcohol is the principal risk factor for death in men ages 15–59, as a result of injuries, violence and cardiovascular diseases. Also the total burden of the harmful use of alcohol in men is 7.4 percent compared to

1.4 percent in women (World Health Organization, 2014), (National

Institutes on Alcohol Abuse and Alcoholism, 2017).

Road trafﬁc accidents lead to more than a million deaths yearly with estimated financial consequences to be billions of dollars. An estimated

10.3 million people aged 12 or older reported driving under the influence of illicit drugs during the year prior to being surveyed (World

Health Organization, 2013).

In the United States alone, the estimated total overall costs of substance use disorders exceed $600 billion annually, out of which, roughly $193 billion for illicit drugs, and the same for tobacco, while alcohol costs around $235 billion. Directly and indirectly drug abuse and alcohol are the underline case of many social problems. Around half of the arrested individuals for major crimes such as murder, robbery, and assault were under the influence of illegal drugs (National Council on Alcoholism and

Drugs Dependence, 2015).

1.2.1. Significance of Substance Abuse Problem in the

United Arab Emirates

Since the union of the seven emirates in 19971, the UAE has undergone rapid changes in every aspect of life. This rapid development has required a substantial influx of a foreign and multinational labor force which has considerably impacted Emirati culture, traditions, and social and family structures. This in addition to Westernization and globalization.

Substance misuse in the UAE was not viewed as a problem until 1980s, when the Ministry of Social Affairs observed an increase in the number of drug users and the amounts used. The problems of mortality, health and other problems to the individual, families, the social fabric, including the economy, made Substance misuse a national security issue. The country analysis report by the World Health Organization showed that per capita alcohol consumption in the UAE almost doubled from the period 2003-2005 compared to 2008-2020 (World Health

Organization, 2014). These figures included nationals and expats.

Death from overdose is another statistic that can be added to the picture (Al Ghafri, Osman, Matheson, & Wanigaratne, 2013).

The UAE is a signatory to the international laws on drug demand reduction. There is zero tolerance of use of banned substances and conviction results in a mandatory sentence or treatment and rehabilitation for those first timers. In terms of the legality of alcohol, its consumption is only legal for non-Muslims who are 21 years of age and older within licensed premises. UAE legislation based on Shari’ah law prohibits a Muslim to consume alcohol in the UAE (Sarhan, 1995),

(Department of Drug Control, 2018).

Based on a study conducted by C.M. Doran (2016), the estimated cost of addiction was at US$ 5.47 billion in 2012, which equals 1.4% of the gross domestic product and consisted of lost productivity at US$ 4.79 billion (88%) and criminal behavior at US$ 0.65 billion (12%) (Doran,

2016)

Just like the rest of the region, alcohol and drug abuse is becoming a growing burden on the economy of the United Arab Emirates. This is due to many reasons such the close proximity to opiate-producing countries and the rapid social and economic changes. All of these reasons made the United Arab Emirates an excellent route for substance trafficking (World Health Organization, 2014).

1.3. Social Drift

It is known in the social epidemiology that there is an inverse relationship between mental illness and social class. This means that a person with a mental illness, would have a downward shift in the social class as the mental illness worsens. Most studies linked social drift with mental illnesses, especially schizophrenia (Perry, 1997).

As explained earlier, addiction is a chronic relapsing mental illness. So, it can be claimed that addicted patients might be subject to social drift.

Investigating social drift in the area of substance use disorders and addiction is uncommon. Terms such as social status, social class, social group and socio-economic status are used interchangeably in the literature. Also, social networks or social capital are used in some settings. For this study purpose, Al Ghafri’s (2015) definition of social drift will be used, which is “a downward spiral in an individual’s wealth, educational achievement, employment status, marital status and family relationships, social networks (social capital), accommodation and general status in society”. Furthermore, he included having a criminal record due to addiction whether it was illicit use or illegal activity to get

the substance or resulted from its use such as accidents or murders (Al

Ghaferi, Sayed, & Ali, 2015)

1.4. Study Aims

The aim of this study is to identify the characteristics of substance abusers receiving treatment from the National Rehabilitation Center

(NRC) in Abu Dhabi – UAE and explore the relationship of social drift among this population. The study also aims to compare the characteristics of this clinical population with that of a clinical population in Jordan carried out by Al Ghafri in 2014. In addition, the study will explore the associations between the nursing interactions with the patients at the NRC and the patient satisfaction.

Specific Objectives:

1. To describe the characteristics of a population of substance

abusers in treatment in the National Rehabilitation Center (NRC)

in Abu Dhabi - UAE in terms of demographics, substance use

pattern and history, dependence, relapse history, medical and

psychiatric histories and indicators of social drift (education,

employment, marital, financial and criminal).

2. To assess the current used substance and patterns of behavior

in terms of substance use patterns, dependence and relapse

history.

3. To examine factors associated with relapse from the patient

perspective.

4. To explore patient experiences of treatment. 9

5. To assess in-depth, the association between social drift and

substance use disorders (education, employment, marital,

financial and criminal).

6. To compare the results of this study with a prior study

conducted with a similar population from Jordan results (Al

Ghafri H. , 2014).

7. To examine the relationship between the quality of nursing

interaction and patient satisfaction.

8. And finally, to develop and test a tool for measuring social drift

in the context of drug abuse treatment.

This study will test the following research hypotheses:

1) The characteristics of the clinical population of substance

abusers receiving treatment in the NRC will be similar to the

clinical population of substance abusers studied in Al Ghafri’s

Study (2014).

2) Severity of dependence is associated with:

a. Early initiation of substance use.

b. Longer length of dependence.

c. Presence of a family history of addiction.

d. Lower level of education.

3) Social drift is associated with:

a. Early initiation of substance use.

b. Longer length of dependence.

c. Presence of a family history of addiction.

4) Increased nursing interactions will be associated with higher

level of patient satisfaction with the nursing services.

Given the limited number of studies on substance use disorders and addiction in the UAE, the expected outcomes of this study are to contribute to the substance use disorders’ literature in the UAE and provide a useful data for the policymakers. The results of the study would help in restructuring the existing prevention and treatment interventions and programs that are currently in use in the UAE.

2. CHAPTER TWO: SYSTEMATIC LITERATURE REVIEW

Substance use disorders and addiction are topics that have been comprehensively studied in the West and a large number of publications. In contrast, there is a scarcity of reported research in

Muslim Arab communities. This scarcity may be due to these substances being religiously, socially, and legally prohibited and disapproved. In addition, the social stigma attached to such cases, which views addiction as a disgraceful individual event, is a major barrier to treatment. The same factor may apply to research as obtaining data from a hidden problem has its inherent difficulties, explaining the relative scarcity of research publications. However, as a result of the proximity to opiate-producing countries, globalization and rapid social and economic changes occurring in these countries, the urgency of exploring the field of substance use and addiction has become a necessity in recent years (AlMarri & Oei, 2009).

A systematic comprehensive literature review that was carried out is described in this chapter. The chapter is divided into two sections. The first section aimed to look at a collection of credible articles that describe the characteristics of substance and alcohol users in Arab countries. The second section examined the connection between substance and alcohol use and social drift.

2.1. Search Strategy

The electronic databases used in this literature review were Academic

Search, EMBASE, PubMed, PsycInfo, MEDLINE, and Web of Science.

The inclusion criteria for articles in the literature review were articles published from 2001 to 2016, written in English and addressed topics similar to the research topic. A period of 15 years was chosen because it was anticipated that a shorter period would yield fewer papers.

The literature search was restricted to published articles appearing in the above search engines. ‘Grey literature’ consisting of unpublished reports and articles available on the internet was avoided due to concerns about accuracy and quality.

All results were examined for relevance to the research topic and the irrelevant titles and duplicates were excluded. Then, of the remaining articles abstracts were reviewed and excluded as appropriate. The final list of relevant articles was examined, summarized and tabulated. The

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

(PRISMA) chart was used to illustrate the process and results of the systematic literature review (Moher D, 2009).

In the first section, the key words used were substance; alcohol; use; misuse; abuse; dependence, addiction and specific drug names or groups such as: heroin; narcotics; cocaine; benzodiazepines; cannabis; sedatives; hallucinogenic; inhalants; khat and amphetamines. Also, key words like Arab countries; Arab; Gulf Cooperation Council (GCC)

countries; UAE; Bahrain; Kuwait; Oman; Qatar; Saudi Arabia. They were grouped in the following manner:

1. Substance

2. Alcohol

3. Use

4. Misuse

5. Abuse

6. Dependence

7. Addiction

8. Specific drug groups (heroin, narcotics, cocaine,

benzodiazepines, sedatives, cannabis, hallucinogenic, inhalants,

khat, amphetamines).

9. Specific region or countries (Arab countries; Arab; Gulf

Cooperation Council countries; UAE; Bahrain; Kuwait; Oman;

Qatar; Saudi Arabia).

10. (1 or 2 or 8) and (3 or 4 or 5 or 6 or 7) and 9.

In the second section – social drift, the key words used were social drift; social decline; social migration; social complications; socio-economic status; financial status; employment status; social impairment. Also, other key words were used such as substance; alcohol; abuse; addiction and specific drug names or groups such as: heroin; narcotics; cocaine; benzodiazepines; cannabis; sedatives; hallucinogenic; inhalants; khat and amphetamines. In addition to key words like Arab countries; Arab;

Gulf Cooperation Council (GCC) countries; UAE; Bahrain; Kuwait;

Oman; Qatar; Saudi Arabia. They were grouped in the following manner:

1. Social drift

2. Social decline

3. Social migration

4. Social complications

5. Socio-economic status

6. Financial status

7. Employment status

8. Social impairment

9. Substance

10. Alcohol

11. Use

12. Abuse

13. Addiction

14. Specific drug groups (heroin, narcotics, cocaine,

benzodiazepines, sedatives, cannabis, hallucinogenic, inhalants,

khat, amphetamines).

15. Specific region or countries (Arab countries; Arab; Gulf

Cooperation Council countries; UAE; Bahrain; Kuwait; Oman;

Qatar; Saudi Arabia).

16. (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 14) and (9 or 10)

and (11 or 12 or 13) and 15.

2.2. Overview of Search

Using the search strategy described above, the number of papers that were found under section one in the identified database using substance and Arab countries as the main key words which were combined with use, misuse, abuse, dependence and addiction produced 7,018 articles. After applying the selected period (2001 –

2016), the number of articles was reduced to 5,627 articles. From this total, 263 articles were removed due to duplication, 4,967 articles were excluded based on their title, and 312 were excluded on the basis of their abstract. The total number of articles assessed for eligibility was

85. A further 23 articles were excluded due to non-relevance. 62 articles were included in the final literature review. Three types of papers were included in the review: original research, systematic reviews and non- empirical papers, which include reviews and overviews. The above- mentioned strategy was presented in the Preferred Reporting Items for

Systematic Reviews and Meta-Analysis (PRISMA) chart below (Figure

2.1).

Using the same search strategy described above, the number of papers that were found under section two in the identified database using social drift and substance/alcohol and Arab countries as the main key words which were combined with use, abuse, and addiction produced

6 articles. After applying the selected period (2001 – 2016), the number of articles remained 6 articles. From this total, 4 articles were removed due to duplication, no articles were excluded based on their title, and

no articles were excluded on the basis of their abstract. The total number of articles assessed for eligibility was 2. No articles were excluded due to non-relevance, so 2 articles were included in the final literature review.

The above-mentioned strategy was presented in the Preferred Reporting

Items for Systematic Reviews and Meta-Analysis (PRISMA) chart below

(Figure 2.2).

Figure 2- 1 PRISMA Chart – Section One: Substance/Alcohol Use and Arab

Countries

Number of articles identified through database searching = 7,018

Number of articles identified through database searching (2001 – 2016) = Number of removed 5,627 duplicates = 263

Number of articles Number of articles screened = 5,364 excluded on the basis of title = 4,967

Number of articles Number of articles screened = 397 excluded on the basis of abstract = 312

Number of full-text articles assessed Number of articles for eligibility = 85 excluded on the basis of relevance = 23

Number of studies included in qualitative synthesis = 62

Figure 2- 2 PRISMA Chart – Section Two: Social Drift and Substance/Alcohol

Use and Arab Countries

Number of articles identified through database searching = 6

Number of articles identified through Number of removed database searching (2001 – 2016) = 6 duplicates = 4

Number of articles Number of articles screened = 2 excluded on the basis of title = 0

Number of articles Number of articles screened = 2 excluded on the basis of abstract = 0

Number of full-text articles assessed Number of articles for eligibility = 2 excluded on the basis of relevance = 0

Number of studies included in qualitative synthesis = 2

2.3. Review of Papers

One of the most important review papers found was a bibliometric analysis of publications of Middle Eastern and Arab countries to assess research activity (Sweileh, Zyoud, Al-Jabi, & Sawalha, 2014). The authors found that although research productivity was relatively low, an increasing trend was found in research activity level. In this landmark review that the authors claimed to be the first attempted in the region, spanning a period between 1900 and 2013, using an advanced seven steps search strategy, found only 413 research articles.

Of these, 401 were original research articles and 12 were review articles

(Sweileh, Zyoud, Al-Jabi, & Sawalha, 2014).

The review included 18 countries of which, Kingdom of Saudi Arabia,

Lebanon and Egypt were the top three countries, in terms of research publications, United Arab Emirates being 6th with Somalia, Oman and

Libya being at the bottom of the list. The authors admitted that one of the weaknesses of this review was that some regional journals such as the Arab Journal of Psychiatry and the Eastern Mediterranean Health journal are not included in the Web of Science database they searched.

Nevertheless, it can be concluded that this gives a measure of research activity in the area of substance misuse in the region (Sweileh, Zyoud,

Al-Jabi, & Sawalha, 2014).

The article ‘Mental health research in the Arab world’ was another broader review paper covering mental health research in 21 Arab countries in a 40-year period between 1966 and 2005. The paper found 20

2,213 articles and 11.1% of these covered substance misuse, which approximated to 245 articles. More than two-thirds of the articles from the Arab world were published in international journals. A very important finding of this paper was that there is a huge need for very informative researches in the field of mental health. Other areas such as cross-cultural, and religious comparisons are also needed. In addition, and due to the unique social fabric of the more traditional

Arab countries, genetic studies are highly important and required

(Jaalouk, Okasha, Salamoun, & Karam, 2012).

A more recent publication by Hickey, Pryjmachuk and Waterman

(2016), looked at mental illness research in the GCC countries between

1975 and 2013. The paper found 55 research articles in total and 13

(23%) of which were on substance misuse. Majority of the papers (38%) were from Saudi Arabia, followed by Kuwait (33%), then Qatar, Bahrain and the UAE with 9% each and only 2% from Oman. Their findings highlighted the lack of research into mental health in general and on substance misuse in specific. One of this review’s limitations was that most of the research included were cross-sectional studies which gave only a snapshot of a phenomenon and didn’t not allow for causal implications to be made. Also, under-representation of women limited the generalization of findings to the male population. (Hickey,

Pryjmachuk, & Waterman, 2016).

Papers covered by this review and published within the current study selected period would be included in the below sections under different countries (Hickey, Pryjmachuk, & Waterman, 2016).

The most relevant review to the present study is the Alcohol and substance use in the Arabian Gulf region paper. This comprehensive and methodological sound review covered research publications in the

GCC countries (United Arab Emirates (UAE), Bahrain, Kuwait, Kingdom of Saudi Arabia (KSA), Oman, and Qatar), over a 37- year period between 1975 and 2007. It covered electronic databases such as

Medline and PsychINFO as well as Arab journals such as Arab Journal of Psychiatry, Journal of Gulf and Arabian Peninsula Studies, Annals of Arts and Social Sciences, Dersat Nefseyah, and Annals of Saudi

Medicine. In this comprehensive search of publications spanning 37 years only 60 relevant articles were found (AlMarri & Oei, 2009).

The confidence in this search and the objective of focusing on recent publications was taken as the justification to restrict the literature search in the current paper to 15 years from 2001 to 2016. It was felt that a 10-year period would yield sufficient papers, hence the decision to have a 16 year period, with a 6 year overlap with the AlMarri and Oei sturdy (2009). The yield of 62 papers in the current study also is an indication of the increase in the rate of publications in relation to substance use and abuse. Instead of reviewing the publications country by country as is the case in this paper, the AlMarri and Oei paper (2009) picked out key themes in their review. These themes included,

prevalence data, types of substances used, initiation and relapse issues, treatment protocols, use of standardized instruments in the studies, attitudes towards substance use and barriers to research. The current review follows some of these themes on a country by country basis (AlMarri & Oei, 2009).

Some possible barriers were identified by AlMarri & Qei paper (2009) that might impose some challenges on substance abuse researches in this region. Having individuals seeking treatment from substance use disorders as a pool to recruit from for studies might not be completely representative of the substance abuse problem in this region. This is because many individuals with substance abuse problem might not seek treatment due to of ethical, cultural, social, and legal considerations. Another reason could be the available number of treatment facilities and admission criteria as there is a scarcity in the number of treatment facilities in each country. Most of these facilities; if not all, treat adult patients only which doesn’t provide a sense of the substance abuse problem among the younger population. Lack of female representations in such studies was also highlighted in this review (AlMarri & Oei, 2009).

2.3.1. Substance Abuse Profile in Arab Countries

As mentioned earlier, the literature search was conducted from the years of 2000 to 2016 in Arab countries such as, Jordan, Lebanon, Iraq,

Egypt, Saudi Arabia, Kuwait, United Arab Emirates and Yemen using

the previously mentioned search strategy. Below is an explanation for the relevant researches according to countries.

2.3.1.1. Saudi Arabia:

Reflecting its geographical and population size, Saudi Arabia has produced the largest number of studies on mental health and substance misuse. Most of the published studies have been conducted with clinical populations, hence it does not give accurate prevalence data in the country (AlMarri & Oei, 2009) (Hickey, Pryjmachuk, &

Waterman, 2016).

A study conducted in a hospital in Saudi Arabia to collect basic data on diverse issues related to substance abuse. 799 patients were surveyed during their admission for voluntary detoxification in consecutive years

(1995 and 1996). It was found that 68% were under the age of 35. The youngest age among the sample was 17 and the eldest was 66. 97% were smokers and 55% started smoking before the age of 15. 31.5% started to use drugs before the age of 20, with 10 years being the youngest age to initiate substance use. The study found that 83% of the participants were heroin users and 91% of them were injecting. 21% of the injectors had injection related complications, such as Hepatitis C

Virus (69%) or death (0.40%). 17.5% reported having a substance use problem among their family. 76% of them were siblings, 17% were other relatives such as cousin and 6.4% were parents. This study highlighted the existence of a young population of substance users with complex problems ( Iqbal, 2000). 24

An interesting study conducted by Amir (2001) compared patterns of substance use in Saudi Arabia and United Arab Emirates as both countries are similar in many ways (culture, race, language and religion). 120 male patients receiving treatment at the Damam Hospital in Saudi Arabia were compared with 79 male patients receiving treatment in a corrective institution in Dubai (United Arab Emirates).

Type of the substances abused, age at the onset of abuse, the number of months since the start of abuse, level of education and employment were studied. Despite the assumed similarity, the researchers found marked differences (Amir, 2001).

Age of onset of substance abuse problems was significantly lower in the

UAE (18.7 ± 4.6 years) compared to 22.5 ± 3.9 years in Saudi Arabia.

The percentage of heroin users was higher in Saudi Arabia (85%) than in the UAE (64%). The opposite was true regarding the opium users, there was 44% of opium users in the UAE compared to 0.8% in Saudi

Arabia. The same was found in the other substance groups; hashish

(87% in UAE compared to 25% in KSA), alcohol (55% in UAE compared to 31% in KSA), solvents (3.8% in UAE compared to 1.7% in KSA), sedatives (46.8% in UAE compared to 1.7% in KSA), stimulants (19% in

UAE compared to 8.3% in KSA) and cocaine (20% in UAE compared to

0.8% in KSA). The poly-substance use pattern was also significantly higher in the UAE compared to KSA (85% compared to 35%) (Amir,

2001).

The strength of this study is that the same methodology and same instruments were used in both groups. On the other hand, a major weakness of the study was that a hospital clinical population in the case of KSA was compared with a clinical population in a corrective institution in the case of the UAE where the severity of problems may be higher. However, this is an important study showing how substance using patterns and profiles can vary from country to country, even when there is geographic proximity and other similarities such as race, culture and religion, which provides a strong argument for country- specific profile studies (Amir, 2001).

A study by Abu Madini and his colleagues (2008) examined substance use patterns and trends among patients admitted at Al Amal Hospital in Dammam over a period of two decades (between 1986 and 2006).

This study is of particular interest as it gives an indication of the size of the problem and compares trends (AbuMadini, Rahima, Al-Zahrani, &

Al-Johi, 2008).

In the first decade, the majority were between the ages of 20 to 29 (83%), never married (60%) and with a low level of education (81%). The study reported that the relative percentage of amphetamine users increased from 12% to 48% and cannabis users from 17% to 46%. At the same time, the study reported a decrease in heroin users from 51% to 22%, sedative users from 15% to 7% and solvent users from 6% to 2%. The study also reported an increasing trend in poly-substance use from a

mean number of substances per person of 1.32 to 1.56 (AbuMadini,

Rahima, Al-Zahrani, & Al-Johi, 2008).

The weakness of this study is that it only used male subjects and it only recruited patients from one hospital. If data from the other hospital were studied with the same methodology, a more accurate picture of the prevalence rates and profile of drug users in the country could be obtained. A weakness of any retrospective study is the issues of accuracy and coding of data (AbuMadini, Rahima, Al-Zahrani, & Al-

Johi, 2008). Patient’s medical records were not created initially for research purposes. Also, data are coded to meet the needs of insurance and other third party companies. This creates biases based on the intended use of the data.

Another study by Al-Haqwi (2010) looked at the magnitude of the substance abuse problem from the perceptions of 215 medical students in Riyadh and examined their views of its possible predisposing causes.

75% of the participants identified alcohol and substance abuse as a real problem in the community, and it is more common among young adults. The majority of the students believed that males are more prone to be alcohol and substance abusers then females as only 1.4% think that substance abuse problem might affect females. Friends, life stressors, smoking and curiosity were listed as the most important predisposing factors for abuse (Al-Haqwi, 2010).

An interesting view was highlighted which was the beneficial effect of alcohol and substance abuse as stress alleviation (Al-Haqwi, 2010).

University life and study in general are among the general life stresses that should be treated carefully because they could disturb the students’ well-being of and their academic performance, which eventually would lead to alcohol or substance abuse. Therefore, it is highly important to teach students stressors’ safe and effective coping strategies.

3% of the students indicated that they may use alcohol or some other substance in the future. The study concluded that there is a serious need for different preventions and awareness programs that target medical students and younger adults. These programs must focus on the risks of alcohol and other substances abuse, stress coping strategies and counseling (Al-Haqwi, 2010).

A recent cross-sectional study was conducted on male secondary students in Abha City in Saudi Arabia. The aim was to examine the history of substance abuse problems among this population. The study used a self-administered pencil-and-paper questionnaire. It was found that 38.3% of the students were cigarette smokers and 41.2% of them started smoking before the age of 16. Alcohol was consumed by 9.3% of the total during the last month. 56.8% of those who used alcohol, took alcohol once during the last month and 64.1% got in troubles due to their alcohol intake. 8.8% of the students were substance users. The

main used substance was cannabis (51.4%) followed by glue/solvents

(48.6%) and amphetamine (45.7%) (Al Musa & Al-Montashri, 2016).

Although the study had a small sample of 350 of a potential 3852 student population in the area, it painted a picture of the extent of substance misuse among students. The results indicated that students with substance abuse problem showed significantly lower academic achievements, which requires teachers to take any drop in the student's academic achievement seriously. Families with working mothers have a higher probability of substance abuse problem among their children.

The same applies to families with high monthly income. This requires parents to be more engaged with their children (Al Musa & Al-

Montashri, 2016).

2.3.1.2. Kuwait:

Al-Kandhari et al., (2007) conducted a study on a clinical population of

237 patients receiving treatment at a Psychological Medicine Hospital.

A questionnaire was developed to explore sociodemographic variables, drug addiction habits, types of drugs, favorite drugs, effect of substance abuse on self, relationships with others and work performance. The questionnaire was self-administered by volunteers recruited for the project (Al-Kandari, Yacoub, & Omu, 2007).

As is usual in studies from Arabic countries, there were a very low number of female participants (2 out of a total of 237). The average age of participants was 33 years ranging from 18 to 67, with 50% were

currently married, 38% were single and 20% were divorced or widowed.

Educationally, 6% had elementary education and 22% were college or university graduates. The majority, 76%, received income from work,

12% received income form their families and 8% from the government

(Al-Kandari, Yacoub, & Omu, 2007).

The results show that 78% reported using heroin, 64% cannabis, 60% alcohol, 32% cocaine and crack and 23% hypnotics. Half of the sample reported being addicted for more than 10 years and 23% from five to ten years. Approximately 75% of the sample reported injecting drugs. A weakness in this study is that it did not use translated standard instruments that would have enabled direct comparison with other studies. However, the study gave a picture of the situation in Kuwait from the substance abuse perspective (Al-Kandari, Yacoub, & Omu,

2007).

A cross-sectional study was conducted among 1587 male university students from both private and public universities in Kuwait to examine the prevalence of substance use and identify the factors associated with this use among the study sample. The study used a self-administered survey that was adapted from WHO guidelines titled ‘A Methodology for

Student Drug Use Surveys’ (Bajwa, Al-Turki, Daw, Behbehani, & Al-

Mutairi, 2013).

It was found that there was a total lifetime prevalence of substance use of 14.4% and the most frequently used substance was cannabis

(marijuana/hashish) (11%). Even though, the age of first use varied depending on the substances the age group of 14–16 years was the youngest age of initiation of any substance use. The study highlighted that tobacco smoking is the access to alcohol and substance use.

Multivariate logistic regression model revealed that drug use was positively associated with age, poor academic performance, high family income, being an only child, divorced parents, and graduation from a private high school (Bajwa, Al-Turki, Daw, Behbehani, & Al-Mutairi,

2013).

Through the study, it was clear that alcohol and substance use in general varied significantly between private university students and public Kuwait university students. The difference in social and economic status of the two groups was offered as an explanation

(Bajwa, Al-Turki, Daw, Behbehani, & Al-Mutairi, 2013).

2.3.1.3. United Arab Emirates

UAE is a fast growing country due to discovery of oil, with a rapidly changing society in keeping with its rapid development. Ghubash and her colleges conducted a cross-sectional community survey of adult population in Al Ain to assess the prevalence of mental disorders in the general population in an attempt to linking it to the socio-cultural changes that are taking place in the country. The total sample was 1394 adults (Ghubash, Daradkeh, A.A, Al-Manssori, & Abou-Saleh, 2001).

The study found that adhering to traditional values was a protective factor in relation to psychiatric morbidity. Less traditional people in general were found to have a significantly increased rate of psychiatric disorder and higher scores on psychopathology measures. Females in specific, were found to have higher rates of psychopathology the less traditional they were. In this study, the authors did not report on substance misuse or specific disorders (Ghubash, Daradkeh, A.A, Al-

Manssori, & Abou-Saleh, 2001).

Data in general on substance abuse from the United Arab Emirates region is limited. A base-line profile of a UAE clinical population was provided by Elkashef et al (2013) who published a 10-year retrospective study of the patients who had received treatment at the National

Rehabilitation Center (NRC) Abu Dhabi. The aim of the study was to examine the socio-demographic characteristics, patterns of substance use disorder and the related co-morbid conditions (Elkashef, et al.,

2013).

In their sample of 591 patients, they found that the average age at first admission was 32.4 (9.6) years. 44% were single, 42% were married, and 13% were divorced. 60% were unemployed and 33% were either employed or were students. In their sample 51% did not have a secondary education, 33% had secondary education and 16% had post- secondary education. In relation to family history, 30% of patients were from families with a history of alcohol abuse and 16% were from a

family with a history of drug abuse, which is a surprising and interesting finding given the cultural context (Elkashef, et al., 2013).

The sample that Elkashef et al (2013) studied comprised of 77% voluntary patients and 23% involuntary (ordered by courts and not free to leave) and there were some significant differences in demographics between the groups. These were in respect to education level where 67% of the voluntary patients compared to 47% of the involuntary group having intermediate or secondary education on the other hand only

14% of the voluntary group had post-secondary education compared to

22% of the involuntary group (p=0.02). There were no other significant differences in demographics between the two groups (Elkashef, et al.,

2013).

In relation to substance use patterns, the main substance used was alcohol 41%, cannabis, benzodiazepines, amphetamines and inhalants accounted for 22%, heroin 16% and a range of prescription drugs such as tramadol, methadone, codeine, and Xanax, and psychoactive substance such as kemadrine, artane and khat accounted for 21%.

Since 2009, a dramatic increase in prescription drugs and other psychoactive substances (polysubstance use) was reported. Elkashef et al (2013) also found that younger patients (aged 16-26) preferred heroin use while older patients (aged 37-66) preferred alcohol (Elkashef, et al.,

2013).

In relation to blood borne viruses 3% were positive for Hepatitis B and

15% were found to be positive for Hepatitis C and among intravenous drug users the Hepatitis C prevalence rate was 44%. In relation to comorbidity with psychiatric disorders, the paper reported amalgamated results of prevalence (presence or absence) of three categories of disorders (anxiety disorders, mood disorders and psychotic disorders) in relation to the type of substance used. Alcohol users (25%) and polysubstance users (16%) recorded the highest prevalence. Elkashef et al (2013) reported relapse rates using an admittedly crude method based on a calculation of re-admission to treatment. Using this method, they reported a 27% relapse rate. They also reported a progressive reduction of relapse rates at 60% in 2002 to 20% in 2010 (Elkashef, et al., 2013).

The main criticism of this study is that it is a retrospective study based on case note analysis, hence reliant on what was written in the case notes. Case notes are detailed notes in a story telling format which makes it a time and effort consuming tool to be used for research purposes, which is different from extracting data from an electronic information system (EMR) or a cross-sectional survey. As data in EMR is easily retrieved and it reduces redundant data capturing.

Nevertheless, it provides a baseline for future comparisons (Elkashef, et al., 2013).

In 2015, a cohort study was conducted to study the pattern of substance use in the United Arab Emirates. A total of 250 patients

receiving their treatment at the National Rehabilitation Centre (NRC) were recruited for this study. The mean age was 29.6 years, 58.4% were singles and 95.6% were current smokers. 56.8% had a family history of substance use disorder, who were mainly from first degree family members ( Alblooshi, et al., 2016).

The study also found that substance use disorders correlated with smoking and marital status. Polysubstance users represented 84.4% of the study population with the majority of them being among the youngest age group (19 – 29 years old). The majority of the polysubstance users used four or more substances. The most common combination used was alcohol, opioid, cannabis, tranquilizers and one of three prescribed medications especially among the youngest age group. Opioid and alcohol were the most commonly used substances.

Correlating substance used with age, the study found that tramadol use was higher among the youngest age group patients, while heroin was more commonly used by the older age group patients ( Alblooshi, et al., 2016).

The results of this study sharply contrasts with the previous Elkashef et al (2013) study which is from the same center, Polysubstance use has become established as the dominant pattern of substance misuse.

More than 60% of the polysubstance users use prescribed medication for non-medical use such as Pregabalin, Procyclidine and Carisoprodol.

Pregabalin was the most common one among the three medications.

One of the documented limitations of this study was lack of female 35

involvement, which calls for other studies that assess the characteristics of female patients and their pattern of use. The highlighted conclusion of Alblooshi’s study was that there is a sharp increase in the use of pharmaceutical opioid and prescribed medications as mixture which imposes a major health threat. This is due to the overdose and death that could result from the potential toxicity risk of these mixtures, which requires the local authorities to take serious actions ( Alblooshi, et al., 2016)

According to AlMarri and his colleagues study (2009), the community study of prevalence of psychiatric symptomatology in the general public by Abou-Saleh, Ghubash and Daradkeh in Al Ain Abu Dhabi was one of the most important and what is described as regionally unique study as a general population prevalence study in psychiatry had not been attempted in the region. This study reported a prevalence of substance use or abuse among men of approximately 9%. No females were diagnosed with substance abuse. This study does not describe other characteristics of the respondents (Abou-Saleh, Ghubash, & Daradkeh,

2001).

In Amir study that compared patterns of substance use in Saudi Arabia and United Arab Emirates as mentioned earlier (2001), it was found that the age of onset of substance abuse problems in the UAE was 18.7 years. About 42.3% of users in the UAE were addicted to more than one substance (Amir, 2001).

In AlMarri’ study, one of the UAE psychiatric hospitals stated that within a two-year period (1990-1991), 9.5% of its patients were admitted for SUD (AlMarri & Oei, 2009).

2.3.1.4. Lebanon

Lebanon is an Arabic speaking county with a population of different religious groups which is unique in the region.

A study conducted by Karam and his colleges to examine the comorbidity of substance abuse and psychiatric disorders in acute general psychiatric admissions. It was considered to be the first published study from an Arab Near Eastern country to examine this topic. The study took place in a 22-bed psychiatry and psychology

Inpatient Unit, that treats patients with various psychiatric disorders, including substance use. The majority of beds are self-paid. The referral sources could be self- or family members but never by the legal system

(Karam, Yabroudi, & Melhem, 2002).

The mean age was 34.5 ± 11.8 years with no difference in age between genders and the mean age of abuse initiation was 25.9 ± 10.5 years.

The mean duration of abuse was 8.1 ± 8.5 years. The study found that out of 1,643 case notes analyzed, 222 (13%) had a history of substance misuse, 64% of whom had a comorbid condition. The substances that were abused fell into three categories, which were prescribed medication (tranquilizers, barbiturates, medicinal opiates and stimulants), illicit substances (cannabis, cocaine, heroin); and alcohol.

Alcohol was the most commonly used substance (55%), followed by heroin (29%), cannabis (28%), cocaine (27%) and tranquilizers (13%).

Only 2% reported using stimulants. Poly-drug abuse was found in 44% of the sample. 18% to 80% of the psychiatric populations had addictive disorders, compared to nearly 80% of the substance-abusing populations having psychiatric disorders (Karam, Yabroudi, & Melhem,

2002).

The authors concluded that the prevalence rates discovered were comparable with those in the West and that cultural factors and the war in Lebanon seemed to have no effect on the rates (Karam, Yabroudi,

& Melhem, 2002).

Another study of alcohol use among university students was conducted in two universities with different socio-demographic characteristics.

The study was carried out in two phases (1991 and 1999). A self-report anonymous questionnaire was used as a tool to collect information on the lifetime use and pattern of substances use. The mean age of the phase I sample was 20.51 ± 1.78 years and the mean age of the phase

II sample was 20.18 ± 1.69 years. It was found that there was a significant increase in the number of those who tried of alcohol from phase I to phase II (Karama, Maalouf, & Ghandour, 2004).

The number of males who have tried alcohol were more than females in both phases. When looking at the age, in phase I older students were more likely to have ever tried alcohol, whereas in phase II there was no

significant age differences observed. The 1999 alcohol lifetime use rates were comparable with those of Western countries. While in phase II,

Christians were more likely to drink alcohol (87%), compared to the

Druze (67%) and Muslims (43%), there was no significant difference in alcohol ever use rates across different religions in phase I. The mean age of onset of drinking was 16.12 ± 2.69 years and it was significantly earlier in males. Belief in God and practice of religion seemed to reduce consumption regardless of religion. The study also, found a strong association between the frequency of physical fights and shoplifting and the prevalence of use (Karama, Maalouf, & Ghandour, 2004).

As part of the WHO World Mental Health (WMH) Survey Initiative,

Karam and colleagues studied the prevalence of mental illness in

Lebanon including substance misuse. The survey was conducted between September 2002 and September 2003. 2,857 individuals were interviewed in a household population survey using the WHO

Composite International Diagnostic Interview (CIDI) version 3. The results showed that 17% of the respondents met criteria for a DSM-IV disorder in the last 12 months and 1.3% met criteria for Substance Use

Disorder. Of the population that met case criteria, 32% met criteria for substance use. The study concluded as they have done previously that these figures were comparable with Western countries (Karam, et al.,

2006).

Using the Drug Abuse Rapid Situation Assessment and Responses methodology developed by the United Nations Office for Drug Control

and Crime Prevention, Karam and his colleges (2010) conducted a

Rapid Situation Assessment (RAS) study to examine the use of multiple substances in diverse segments of the Lebanese population. Both quantitative and qualitative data were collected from high school and university students, substance users in treatment or in prison or detention and “street” users (Karam, Ghandour, Maalouf, Yamout, &

Salamoun, 2010).

The study found that the age of first use of substances started as early as 9 years in the youth sample. 12% of the high school students stated that they smoke one or more packs of cigarettes per day and 9% of the university students met criteria for DSM-IV alcohol abuse. Cannabis represented the most commonly used illicit drug in both high school and university students, and tranquilizers were the most frequently misused pharmaceutical substance. Heroin was accountable for 50% of the admissions for treatment and the most common substance of arrest. Unperceived need for treatment was the most common reason for not seeking treatment in non-institutionalized drug users. Around

50% of substance users in treatment and street users were injectors with a high rate of needle sharing practices. Interestingly about half of patients in treatment had a history of police arrests, and around one- third of those in prison had ever received prior treatment (Karam,

Ghandour, Maalouf, Yamout, & Salamoun, 2010).

A study that examined the differences between Lebanese adolescents living in two different countries Lebanon (Muslims) and USA (Christian)

in alcohol and substance abuse. There was no association between age and substance abuse. The study also found that 52% of Christians reported drinking alcohol compared to 27% of Muslims and 15.5% of

Christians compared to 9.3% of Muslims using illegal substances (Badr,

Taha, & Dee, 2014).

These figures are lower than what was reported by Karam et al., (2004) study. This might be because Karam et al.’s (2004) study sample were university students, while in this study, the sample were high school students. Another reason could be that this study measured alcohol use in the last year only compared to life time use in Karam et al.’s

(2004). Factors such as religion that forbids alcohol and drugs, close relationship with the immediate family and less time spent with friends outside the home are considered protective factor for adolescents (Badr,

Taha, & Dee, 2014)

2.3.1.5. Iraq

An article written by Aqrawi and Humphreys (2009) describes the substance use problem in Iraq. The authors believed that substance misuse situation is getting worse in Iraq. Many factors exist that provide a fertile ground for substance misuse such as violence and the poorly monitored boarders. Inflation and unemployment resulted in economic insecurity that feed the increase of misuse of drugs. The fragile pharmaceutical system in Iraq contributed to illegal sale and distribution of drugs. In return, many initiatives are in process to fight this epidemic. For example, the program of substance misuse control 41

under the umbrella of the National Mental Health and Substance Abuse

Council to structure the applicable legislation, and to prioritize substance misuse in public health programs (Aqrawi & Humphreys,

2009).

From the Inaugural Community Epidemiological Workgroup held in

2012 (Al-Hemiary, Al-Diwan, Hasson, & Rawson, 2014), it was reported that there is an increasing trend in drug and alcohol use in Iraq, particularly among females and youth. The report presented a survey conducted in 2009 that it was reported that lifetime prevalence of alcohol use in Bagdad was 17.8% and drug use 7.02%. The most commonly used drugs across the country were sedatives, hypnotics and benzhexol. This is confirmed in an article by Al Hasnawi et al (2009) who surveyed 70 psychiatrists with an 83% response rate, regarding the patients they see and found that benzhexol and anxiolytic medication including benzodiazepines were the main drugs abused. Al

Hemiary et al. (2014) reported the recent appearance of amphetamine type substances (Captagon and “crystal” (methamphetamine)). They noted that the Captagon is the same type of drug that is used in large quantities in Saudi Arabia. The painkiller tramadol is also a new substance in Iraq together with Afghan opium (Al-Hemiary, Al-Diwan,

Hasson, & Rawson, 2014).

2.3.1.6. Morocco

A national epidemiological study was conducted to assess the prevalence of mental disorders in 2009 with a sample of 5498. The 42

study found a prevalence of 5.8% of disorders related to substance use and 3.4% disorders related alcohol use. There was a highly significant difference between men for substance use disorders 10% to 0.4% and alcohol use disorder 5.8% to 0.4%. Overall there was significantly a higher degree of mental disorders in the female population compared to males (34% to 20%) (Kadri, et al., 2010).

In a rare study of adolescent drug use in the region and its association with their academic performance, El Omari et al (2015) examined the drug use among both male and female high school students. They surveyed 2139 students in 36 high schools in two Moroccan cities. The participants were in 10th, 11th and 12th grades with an average age of

15.5 years (SD=2.4) with approximately half the sample female. They reported that 16% of the females and 40% of the males reported ever using alcohol, hashish or psychotropic drugs. Unfortunately, the paper does not report a more detailed breakdown of substances used and patterns of use. It does however reports that academic performance is affected according to substance use. Substance use in the past 30 days was significantly associated with average or below average grades in both male and female students with males being more affected (El

Omari, et al., 2015).

2.3.1.7. Yemen

There is a long history of Khat (Catha edulis) use in Yemen. There are records of its use since the 13th century (AlMarri & Oei, 2009). The use of Khat is widespread in Yemen and its use is often accompanied by 43

smoking (cigarettes and Shisha) and a positive association between the two substances have been reported (Nakajima, Dokam, Khalil, Alsoofi,

& al'Absi, 2016).

Hence it has been questioned whether Khat acts as a gateway drug to tobacco smoking. Nakajima et al (2016) found that for concurrent users, Khat chewing did start before tobacco smoking and that there were gender differences in the choice of tobacco products, with men smoking more cigarettes and women showing higher rate of Shisha smoking. Shisha smoking is also called hookah, waterpipe, or hubble bubble smoking. It’s a way of smoking tobacco, through a bowl and tube. The study supported the hypothesis that Khat acts as an entry point to tobacco smoking, whether it is a gateway for abuse of other substances is yet to be reported (Nakajima, Dokam, Khalil, Alsoofi, & al'Absi, 2016).

2.3.1.8. Palestine

A study by Massad et al., (2016) provided insights into perceived prevalence of alcohol and drug use among Palestinian youth. Their target sample (n=83) was aged 16–24 years. Although a qualitative study, they employed 10 focus groups and 17 individual interviews to arrive at their findings. They reported that almost all participants confirmed that alcohol use was common and is widely available.

Participants reported that they drank alcohol for many reasons such as coping with stress, for fun, and out of curiosity. Others drank as a way to challenge their society or they were influenced by media. They also 44

reported knowledge of use of illicit drugs such as marijuana, cocaine and heroin. Almost for the same reasons youth used alcohol they used illicit drugs. In addition to these reasons, some highlighted reasons such as poor parental control and lack of awareness or sadness

(Massad, et al., 2016).

2.3.1.9. Jordan

Mu’men et al., 2009 conducted a study in Jordan over a five-year period

(2000-2004) reviewing post mortem forensic pathology results for all autopsies conducted in the National Institute for Forensic Medicine.

Out of a total of 5,789 autopsies, 44 were attributed to drug abuse.

More than 80% were Jordanian males aged from 20 to 60 years (mean

± S.D. = 32.7 ± 7.2). The substances of abuse included alcohol (56.8% of cases), morphine (36.4%), heroin (15.9%), benzodiazepines (11.4%) and one case of cocaine. For 75% of the cases, the cause of death was recorded as accidental and 52.3% death occurred at home. When looking in specific to drug overdose death, it was found in 50% of cases.

Linking substances to deaths, alcohol was mainly associated with accidental death, while morphine and heroin were associated with drug overdose. 56.8% of cases were having injection marks. This study is the first study that addresses such topic in Jordan (Hadidi, Ibrahim,

Abdallat, & Hadidi, 2009).

A study was conducted to investigate the abuse of prescription and nonprescription drugs in community pharmacies in Jordan. They distributed using a random method a structured questionnaire to 405 45

pharmacists in the country. 94.1% of the respondents suspected abuse of decongestants, cough/cold preparations and benzodiazepines. It was believed that the majority of abusers were males, who were in the age group of 26 to 50 years (Younes, Wazaify, Yousef, & Tahaineh, 2010).

A cross-sectional, descriptive study was conducted to assess the mental health consequences of abuse among Jordanian women. The sample was 95 women who were experiencing intimate partner abuse. Age of the participants ranged from 15 to

54 years, with a mean age of 32.4 (SD 8.3) years. The professional and legal services provided for those women included support in relation to abuse, depression, coping, suicidal ideation, substance use, social support and self-efficacy (Hamdan-Mansour, Constantino, Shishani,

Safadi, & Banimustafa, 2012).

The most commonly reported form of abuse was psychological abuse.

Applying the Beck Depression Inventory showed that 38.7% of the abused women had moderate to severe levels of depression. Although half the women had a low level of perceived social support, abused

Jordanian women reported moderate to very high levels of self-efficacy and used approach coping strategies more frequently than avoidance coping. Using the Modified Scale for Suicide Ideation, 15.7% of the women reported that the desire for death was stronger than the desire for life (Hamdan-Mansour, Constantino, Shishani, Safadi, &

Banimustafa, 2012).

Results showed that the substances most commonly used were caffeine

(82.8%), painkillers (61.3%) and nicotine (26.9%). In addition, alcohol was used by three women, stimulants were used by five women and 10 took tranquillizers. None had used cocaine, marijuana or hallucinogens in the past 12 months. Abused women in Jordan face mental health and psychosocial risks that could compromise their quality of life

(Hamdan-Mansour, Constantino, Shishani, Safadi, & Banimustafa,

2012).

2.3.1.10. Egypt

A case-control study examined the link between alexithymia and substance misuse. Alexithymia can be defined as dimensional personality trait which includes dysfunction in emotional consciousness, social attachment, and interpersonal connecting. It also, thought to be a trait that it is affected by drug abuse. In this study,

200 randomly selected substance users were compared with matched controls. The demographic profile of substance users was not reported in the results as it was not the aim of the study, but the substance use picture was reported after stratifying according to levels of alexithymia.

95% of the substance misusing group were polysubstance users, 2% abused anticholinergics and 2% only benzodiazepines. Looking at the marital status, 70% of the sample were single, 17% married and 13% divorced. Only 12% were employed (El Rasheed, 2001).

The study reported that alexithymia was significantly more dominant in the substance use group as compared to healthy controls. 47

Alexithymia was statistically significant with benzodiazepine abuse and no persistence in treatment. The study recommended that medical teams should focus on alexithymia when treating from substance use disorders. (El Rasheed, 2001).

The characteristics of patients admitted for treatment of substance use disorders in a private hospital in Egypt was examined by Hasan and his colleges. The sample was of 324 patients, of whom 91% were male. It was found that 93% used cannabis, 89% used alcohol, 80% used prescribed medication, 78% used heroin, 23% used amphetamines,

19% used cocaine and 15% used hallucinogens (Hasan, et al., 2009).

25% of the sample used more than one substance but the study did not give a detailed breakdown. 21% of the women stated using ecstasy during the past 30 days and were more likely to be poly-drug users.

84% of the heroin users were injecting it (Hasan, et al., 2009).

Another study looked at the prevalence of substance use and addiction in Egypt and its sociodemographic correlates. There was a total of

44,000 subjects interviewed from 8 governorates by stratified sampling.

It was found that lifetime prevalence of any substance use varies between 7.25% and 14.5%. 9.6% of the total subjects were illicit substances users. This included 3.3% experimental and social use,

4.64% regular use 1.6% substance dependence. In males, the prevalence of substance use was 13.2% and 1.1% in females. It was found that the prevalence of substance abuse increases significantly in

males with lower financial status, with lower education levels, and in certain occupations. The onset of substance use was associated with the 15–19 age group. Cannabis is the most commonly misused drug in

Egypt (Hamdi, et al., 2013).

2.3.2. Substance/Alcohol Abuse and Social Drift

According to what was mentioned above, alcohol and substance use disorders could lead to disturbing socio-economic consequences which in return could lead to social drift. Social drift is “defined as an individual drifting down the socio-economic scale as a result of a mental illness” (Fox, 1990). Social drift assumption proposes that disability, disgrace, decreased productivity and increased health expenditure cause an individual with mental illness to drift into poverty (Fox, 1990).

It was highlighted through few studies that individuals with increased substance use disorders status are more likely to travel to deprived neighborhoods due to chronic poverty or to have accessibility to more alcohol and drugs to test this hypothesis a study was conducted by Buu and her colleagues (2007) to assess the long term consequence of individual alcohol use on social migration using a quasi-experimental residential mobility study of alcoholics in the USA. Their sample consisted of 206 white alcoholic men who were recruited mainly through courts records. The residential address at baseline and at a 12- year follow-up was studied (Buu, et al., 2007).

The study findings showed that individual has greater probability of remaining or migrating into a poor neighborhood, the greater his/her alcohol problem is. This showed a strong evidence that social drift is associated with alcoholism just like the case in psychiatric disorders.

On the other hand, the study also, provided that recovery safeguards against downward social drift. A number of limitations of the study prevented it from being generalized such as being carried out with no women in the sample (Buu, et al., 2007).

Social drift and substance use disorders are not a common topic of research in general and in Arab countries or the Gulf region. Most of the studies provided indirect information on social drift in relation to substance misuse. Others explored the association between substance use disorders and one form of social drift such as unemployment and disrupted family relationships.

In Al-Kandari’s study (2007) indirect evidence to support social drift was found in the form of disrupted family relationships and negative impact on employment. The study results revealed that more than 50% of the participants had frequently affected family relationships. 21% reported that their job performance was negatively affected by their addiction. This study provided an obvious indirect evidence for some aspects of social drift in Kuwait ( (Al-Kandari, Yacoub, & Omu, 2007).

Another study in Saudi Arabia examined the impact of heroin on the social, nutritional and health status of People who are addicted to

heroin compared to other drugs of abuse addicts compared to other drugs of abuse. The study compared 243 heroin addicts with 66 non heroin addicts who are using other substances. In the social side, the heroin-addicted group was found to have poor education (53%), a higher level of unemployment (52%) and broken marriages (8%) compared to the non-heroin addicted group. However, these differences did not reach statistical significance (Abalkhail, 2001).

2.4. Conclusion

A systematic comprehensive literature review was carried out into two sections, the first section looked at a collection of credible articles that describe the characteristics of substance and alcohol users in the Arab countries and the second section examined the connection between substance and alcohol use and social drift.

The available research on alcohol and substance use in Arab countries is relatively limited. Due to cultural and religious causes, it is difficult to carry out community-based surveys to estimate the real prevalence rates of substance use disorders. This is why most of the existing researches relay on clinical settings or treatment centers to assess the prevalence, demographics and pattern of use. Despite the benefits gained from such method, it has some drawbacks.

The same situation applied to substance use disorders and social drift.

There is limited existing published literature on social drift relating to substance use disorders in general and in Arab countries in specific.

3. CHAPTER THREE: METHODLOGY

The research methodology used will be described in this chapter in detail. The discussion in this chapter will include an explanation of the study aims and hypothesis and the steps taken to ensure the protection of human subjects. This will be followed by a detailed description of the study design including the study population and study sample. The next section will discuss the source of data and the study instrument and its development. Finally, the data analyses method and processes, including data cleaning, creation of a data set, creation of variables and types of statistical analyses done will be presented.

3.1. Study Aims and Hypotheses

In common with many other places, substance use disorder is an important public health problem in the Middle East, although this area remains less explored. In Abu Dhabi the situation is the same with very little published research on substance use disorders and characteristics of the people who have drug problems. However, examining the characteristics of a clinical population may be the only approach researchers and policy makers use to gather data about a health related question and the magnitude of the problem such as substance use disorders.

The principal focus of the present study is to describe substance use disorders in Abu Dhabi using a clinical sample receiving treatment at a well-established center (The National Rehabilitation Center - NRC) as

representative of the wider substance abuse population and to explore the concept of social drift in its relation to addiction in this population.

Further, the study aims to compare its results with the results of a similar study (Al Ghafri H. , 2014) conducted in Jordan using a similar methodology.

This study will test the following research hypotheses:

5) The characteristics of the clinical population of substance

abusers receiving treatment in the NRC (UAE) will be similar to

the clinical population of substance abusers studied in Al

Ghafri’s Study (2014) in Jordan, another Arab country.

6) Severity of dependence will be associated with the following – as

found in the literature:

a. Early initiation of substance use,

b. Longer length of dependence,

c. Presence of a family history of addiction, and

d. Lower level of education.

7) Social drift will be associated with the following:

a. Early initiation of substance use,

b. Longer length of dependence, and

c. Presence of a family history of addiction.

8) Increased nursing interactions will be associated with higher

level of patient satisfaction with the nursing services.

3.2. Protection of Human Subjects

The research protocol and plan was submitted to the Director General of the NRC to get his permission on conducting the study. Once the permission was granted, the proposal was submitted to the NRC IRB for ethical approval. On the IRB committee meeting, some clarifications were requested. For example, it was requested to highlight where and why Dr. Hamad’s questionnaire was modified. Also, the committee recommended to increase the data collection time to ensure capturing quality data and reducing the probability of errors occurring. After completing all requested items, the IRB committee’s final approval was received on May 2014.

In regard to the participants as discussed earlier, informed consent was obtained from them prior to enrollment and assurances were made in the study information sheet provided to all potential study participants that taking part in the study was voluntary. The study information sheet stated clearly that all the information would be treated anonymously and be used only for research purposes. Also, that the participants’ identity will not be revealed in any publication resulting from this study. Withdrawal from the study could be at any point of time during the study with no implications for their treatment process.

Furthermore, contact information for the researcher was provided in case any of the participants had questions about the study. All of this information was explained to the participants before starting the

process. Only those who volunteered and signed the consent form were included in the study. The study presented no risks to the participants.

All communication with participants was in the Arabic language. The face to face interview (questionnaire) took place in a private office in which suitable room temperature and good lighting was maintained.

The study records and raw data were stored in a locked-cabinet at the researcher’s home, to which only the researcher has access. Completed questionnaires and electronic data and all findings will be destroyed five years after completion of the study.

3.3. Study Design, Including Study Population,

Controls, and Design

3.3.1. Study Population

The participants in this study are volunteers from the National

Rehabilitation Center (NRC) in Abu Dhabi – UAE who were receiving treatment as inpatients or outpatients in the center. The study population is considered a volunteer sample since respondents self- select themselves into the study. The selection was based on the following criteria:

3.3.1.1. Inclusion Criteria

a) In-patients, including detoxification patients and rehabilitation

patients,

b) Patients who agree to participate in the study during their

admission to the NRC,

c) Patients above 15 years of age,

d) Patients from both genders,

e) Patients who are admitted either voluntarily or non-voluntarily,

f) Inpatients who are already admitted to the NRC, and

g) Outpatients who came to the outpatient clinic for follow up

during the data collection period.

3.3.1.2. Exclusion Criteria

a) Patients who refuse to be in the study,

b) Patients who are re-admitted and were previously interviewed,

c) Patients with severe mental illness, and

d) Patients with severe medical illness.

3.3.2. Sample Size

To determine the sample size for this study to provide sufficient power to detect statistically significant differences, the below formula was used. I set the confidence level at 90% and assumed a standard deviation of 0.5. and a margin of error (confidence interval) of +/- 5%:

Sample Size = (Z-score)2 *standard deviation*(1- standard deviation) /

(margin of error)2

= ((1.645)2 x .5(.5)) / (.05)2

= (2.71 x 0.25) / 0.0025 = 0.6775 / 0.0025 = 271

This means 271 respondents are needed. (Smith, 2013).

Out of 261 patients invited to participate in the Al Ghafri’s study, 250 patients participated (Al Ghafri H. , 2014). So, in order to have an

equivalent sample size as Al Ghafri’s study as the main aim of this study is to compare the characteristics of this clinical population with that of the clinical population in Jordan in Al Ghafri’s study. Therefore, the sample size was decided to be 250 patients for the current study.

3.3.3. Study Design

Generally, quantitative descriptive studies are the best techniques to collect information that demonstrates relationships and describes the existing situation at a specific point in time. They are convenient for defined description as they use numbers and for comparison purposes

(Barker, Pistrang, & Elliott, 2016). So, a cross-sectional descriptive design was used in this study in the form of a questionnaire. Cross- sectional studies allow the comparison of many different variables at the same time, but they may not offer a complete picture about cause- and-effect relationships which is not the aim of this study (Institute for

Work & Health, 2015).

In this study, it was expected that the questionnaire approach will offer a broader and deeper perspective of substance use disorders and addiction in the UAE from the patient point of view. It was expected that it would help to gain a comprehensive understanding of the addiction situation and one of its associated problems which is social drift. The questionnaire relied on a large sample of NRC patients who meet the inclusion criteria and voluntarily accept to participate in the study

3.4. Source of Data

3.4.1. The National Rehabilitation Centre (NRC):

The National Rehabilitation Center (NRC) was established in 2002 under the direction of the late President of the United Arab Emirates

(UAE) Sheikh Zayed Bin Sultan Al Nahyan. It provides the principal source of treatment and rehabilitation for individuals who have various types of substance use disorders. NRC endeavors to develop its services to better cater for the community needs following the latest evidence based methods of drug addiction treatment (National Rehabilitation

Center, 2013).

The NRC has established partnerships with world’s leading academic institutions, local institutions and international organizations, including McLean-Harvard and NIDA in the US, Maudsley Hospital,

King’s College London and Aberdeen University in the UK, United Arab

Emirates University, Abu Dhabi University and Khalifa University in the

UAE, United Nations Office on Drug & Crime, World Health

Organization, the Colombo Plan and the International Society for

Addiction Medicine (National Rehabilitation Center, 2013).

As the only specialized center in addiction treatment across the UAE,

NRC provides its patients with understanding, care, confidentiality, medical and psychiatric treatment as well as rehabilitation in order to reintegrate them back into society and, to be active persons in their community and to enjoy their normal lives (National Rehabilitation

Center, 2013). 58

At present, the NRC comprises 78 beds for residential treatment and rehabilitation. The inpatient program provides its services to both male and female patients with each program being tailored to the specific gender it treats (National Rehabilitation Center, 2013)

The NRC also has a very active outpatient program that takes care of patients whose health conditions are not so severe to be inpatients and it also provides post-treatment services to individuals’ who were formally inpatients. The medical team in the outpatient program follows a treatment method called ‘The Way to Recovery’ or internationally known as ‘Matrix Model’ (Hazelden Betty Ford Foundation, 2017), after being adapted to UAE cultural context. Over 16 consecutive weeks, the patient is treated and supervised by a medical team with integrated specialties (National Rehabilitation Center, 2013).

Based on the NRC monthly report for the month of April 2018, 49.9% of its patients were younger than 30 years of old. 58.5% were single and 33.2% were married. Looking at education, the report showed that

37.5% of all patients had a secondary level and 13.9% had a university degree. The majority of the patients (46.9%) were unemployed. Self- referral represented the most common source of intake for patients (The

National Rehabilitation Center, 2018).

3.4.2. The Questionnaire

The study used the same questionnaire instrument developed by Al

Ghafri (2014) which is based on validated scales and questionnaire instruments such as CAGE (Ewing, 1984), and Addiction Severity Index 59

– ASI (McLellan, 1980). This instrument was translated into Arabic using standard procedures and tested/used on a Jordanian population.

In the paragraphs below, the questionnaire development and its contents will be explained in more detail (AlGhafri, 2014).

3.4.2.1. Original Questionnaire Development

In Al Ghafri study (2014), the questionnaire instrument was developed for the purpose to collect data from a clinical population receiving treatment at the National Addiction Centre (NACT) in Amman – Jordan.

Validated scales were integrated within the questionnaire instrument such as Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, &

O‟Br, 1980), Maudsley Addiction Profile (MAP) (Marsden, Gossop,

Stewart, & Best, 1998) and CAGE (Ewing, 1984). The final version of the Al Ghafri questionnaire (2014) was revised and discussed with a local professor of public health to ensure that all the main areas of interest were included. The questionnaire was completed in English and translated into Arabic.

Below is a brief description of the validated scales used to develop the

Al Ghafri questionnaire (2014):

3.4.2.1.1. Addiction severity index (ASI)

The ASI is a semi-structured clinical interview tool which is widely used in alcohol and drug abuse assessment and treatment planning because it is simple to use and is cost effective. It is intended to identify factors contributing to the patient’s substance abuse problems through collecting information about specific areas of a patient’s life. The ASI 60

focus on seven possible problem areas which are medical problems, employment and support, drug use, alcohol use, legal problems, family/social issues, and psychiatric problems. It was used effectively to explore problems with adults seeking treatment for substance use disorders. The ASI has been used widely for treatment planning and outcome evaluation (McLellan, Luborsky, Woody, & O‟Br, 1980).

In Al Ghafri’s study (2014), questions related to medical status, employment, financial status, the drug or alcohol use in the past 30 days and route of administrations were included (Al Ghafri H. , 2014).

3.4.2.1.2. Maudsley Addiction Profile (MAP)

The MAP is a short questionnaire used by an interviewer for treatment outcome and research applications. It was first developed and validated in a UK clinical population. It examines the problem from four domains: substance use, health risk behavior, health symptoms (including physical health, psychological health), and the fourth domain focus on personal and social functioning. The original measure has 60 items and takes on average 12 minutes to complete. It provides a comprehensive picture of the substance user. There are many similarities between MAP and the Addiction Severity Index (ASI) and the Opiate Treatment Index

(OTI) (Marsden, Gossop, Stewart, & Best, 1998) . The MAP has not been used in the Arabian region nor translated into Arabic.

3.4.2.1.3. CAGE Questionnaire (Ewing, 1984)

CAGE Questionnaire is a simple, easy to administer and easy to remember alcohol screening tool. It is the most widely used tool because 61

of its effectiveness and efficiency. The acronym “CAGE” reminds the physician of the four questions which are Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers. All of the CAGE questions were used in Al Ghafri questionnaire (2014).

3.4.2.1.4. Questionnaire Content:

The questionnaire used in the study has 3 main parts and 93 items. Its format included fixed choices and open-ended questions as appropriate. The three parts of the questionnaire are detailed below.

3.4.2.1.4.1. Part 1: Demographic information

This section includes items on age, gender, nationality, religion,

marital status, education, and accommodation. Psychiatric and

medical histories are also included.

3.4.2.1.4.2. Part 2: Substance use and addiction

history

This section includes questions regarding the use of alcohol and

different types of substances such as heroin, benzodiazepines,

narcotics and cannabis. Other information such as the age of first

use, period of use, frequency of use, current usage, and criteria of

dependence were also collected. Questions from Addiction severity

index (ASI), Maudsley Addiction Profile (MAP), and CAGE

Questionnaire have been incorporated in this section of the

questionnaire.

3.4.2.1.4.3. Part 3: Social drift

Due to lack of literature on social drift, questions related to the

social drift in this study were developed by the research team and

based on the mental health literature. Under this section, questions

focused on social characteristics such as employment history,

accommodation status history, family relationships, and financial

status.

3.4.2.2. Current Questionnaire Development

For the purpose of this study and to fit the UAE culture, the questionnaire items were revised and some modifications were made ensuring that there were no analysis implications for the comparison of the data. For example, under the demographic section – patient background, the following modifications were made:

Table 3- 1 Examples of modifications made in the questionnaire

Original Current Item Justifications Questionnaire Questionnaire

1. Jordanian Only Emiratis are Nationality 2. Other Arab 1. UAE 2. Others treated in the NRC 3. Non-Arab 1. Moslem 2. Christian 1. Muslim Linked to previous Religion 3. Jewish 2. Others question 4. Other

1. Primary 1. Illiterate To capture all 2. Preparatory 2. Primary Educational levels of education. 3. Secondary 3. Preparatory Background University = BSc, 4. University 4. Secondary Mater, PhD 5. Above university 5. University 1. Unemployed 2. Student 3. Self- To be written by For statistical Occupation employed researcher reasons. 4. Employed 5. Retired 1. Abu Dhabi 2. Dubai 3. Sharjah State Name: Town, Address 4. Ajman To fit the UAE Village, Camp 5. Fujairah 6. Ras al-Khaimah 7. Umm al-Quwain Not needed as it Contact To be written by Deleted doesn’t add any Person researcher statistical value

In addition to the main three parts, some nursing related questions are added to assess the status of nursing services in the National

Rehabilitation Center and how nursing is viewed by the substance abuse patients in order to help improve the nursing role and contribute to the development of the nursing profession in the addiction field.

3.5. Piloting

The pilot was designed to test the questionnaire in a like sample of substance abuse patients to assess its validity and feasibility, to simplify complicated or compound questions, and to provide the

researcher with data on issues arising from the questionnaire questions in order to refine and clarify the final questionnaire.

In Al Ghafri study (2014), a full pilot on ten patients drawn from the same population as the main sample was conducted. The pilot included testing all processes starting from patient approach, recruitment, acceptability of documents, and finally administering the questionnaire. Feedback was collected from the pilot patients on both content and administration. As a result, questions regarding sexual habits were removed as these were found to be embarrassing to participants. Other questions related to the family relationship were made more formal and rephrased to avoid ambiguity. The final study questionnaire was modified accordingly. An additional step was done which is entering the collected data from the pilot sample in SPSS and simple descriptive frequencies were run to check for outliers (Al Ghafri

H. , 2014).

In the current study, and after modifying the questionnaire to fit the

UAE culture, the questionnaire was piloted on five patients drawn from the same population. Pilot patients were asked for their feedback on both content and administration. The same methodology used in the study was applied in the pilot for testing purposes. No major changes were made to the final questionnaire. All data are to be destroyed five years after the completion of this study.

3.6. Procedure

The data collection was conducted between October 2014 till October

2015. During this time face-to-face structured interviews were done by the researcher (SM) and by a research assistant (FA), who had been trained on the study protocol and on how to fill out the questionnaire.

Training was provided by the creator of the questionnaire; Al Ghafri.

The structured interviews were conducted in Arabic in a private meeting room in the center.

Participants were provided with a written patient information sheet in

Arabic, reassuring them of confidentiality and that no effect on their treatment will take place if they withdraw from the study at any time.

Those who agreed to participate were asked to sign an informed consent form and then they were asked to sit for the interview to answer the questionnaire which the researcher or researcher assistant administered. The completed answered questionnaires were collected and stored securely. The procedure is outlined in the diagram below.

(Figure 3-1).

Figure 3- 1 Data Collection Procedure

Patient who meets the inclusion criteria

Patient information Not included sheet No

Yes

Consent Not included form No

Yes

Questionnaire

3.7. Data Entry and Quality Assurance

Data were entered by the researcher. After every 50 questionnaires were entered, data were checked for any errors such as coding, incorrect entries, and missing entries. In the first two groups of data

(100 questionnaires), several errors were found due to errors in coding and incorrect entries. All entries were rechecked and errors were corrected. In the last 150 questionnaires, there were only two coding errors that were corrected immediately. After completing all data entry, 67

a systematic sample of 25 questionnaires (the fourth questionnaire in every 10 questionnaires) were checked for errors against the entered data and no more errors were found. At the same time, data were randomly checked by the local supervisor as second level of assurance.

Data were stored on a password-protected laptop and the hard copies of the questionnaires were kept in the researcher’s home office in a locked cabinet.

3.8. Data Management and Analysis

The data were analyzed using the Statistical Package for Social

Sciences (SPSS) package. The entered data were cleaned before analysis. The following sections describe the hypothesis variables, and how the study hypotheses were tested including a detailed explanation of the analysis plan.

3.8.1. Variables and Measures – operational indicators

The table (Table 3.2) below lists the study hypothesis and their variables (independent and dependent):

Table 3- 2 The Study Hypothesis and their Variables

(independent and dependent)

Independent Dependent Hypothesis Type Data source variables variables

Group of Depends on H1 Group of variables variables variable

H2 Age of first use Categorical

H3 Education Level Continuous Severity of Length of dependence H4 Binary dependence

H5 Family History Binary Questionnaire

H6 Age of first use Categorical

H7 Education Level Continuous

Social Drift Length of H8 Binary dependence

H9 Family History Binary

Patient H10 Nursing interaction Binary satisfaction

3.8.2. Analysis plan

The data were analyzed using an SPSS software package for analysis.

Simple descriptive statistics such as frequencies, percentages, means

(SD) and medians were calculated. Regression analysis was conducted to explore links between socio-demographic variables and addiction and treatment variables. The data were compared with the results from

Al Ghafri’s study in Jordan (AlGhafri, 2014).

Associations were assessed for statistical significance using appropriate statistical methods such as multivariate logistic regression. For example, one of the hypotheses that was tested in this study is the association between nursing interaction with substance abuse patients and patient satisfaction with the nursing services. In other words, when the nurses’ interaction with the substance abuse patients increases, the patient satisfaction with the nursing services will increase. Statistically, if there is a significant linear relationship between the independent variable X (nursing interaction) and the dependent variable Y (patient satisfaction) the slope will not equal zero.

The null hypothesis states that the slope is equal to zero H0:Β=0.

This means that there is no relationship between nursing interaction and patient satisfaction.

The alternative hypothesis states that the slope is not equal to zero

Ha: Β1 ≠ 0. This means that there is a correlation between nursing interaction and patient satisfaction.

The following logistic regression model will be used to test this hypothesis:

Y = b0 + b1X1 + b2X2 + ……… bnXn

Y = “patient satisfaction” as the outcome or the dependent variable

X1 is “nursing interaction” as the independent variable

X2 to Xn are potential confounders, such as, health status, socio- demographics, health behaviors, etc.

b1 is the log odds ratio of “patient satisfaction” for “nursing interaction” after controlling for potential confounding variables.

The significance level in this study will be 0.05. Using sample data, we will conduct a linear regression t-test to determine whether the slope of the regression line differs significantly from zero.

3.8.3. Detailed analysis plan to address research

questions

A. To describe the characteristics of a population of substance

abusers in treatment in the National Rehabilitation Center (NRC) in

Abu Dhabi – UAE.

Frequency distribution of the following variables was carried out to describe the participants: Age, gender, marital status, educational background, current occupation, address, referral source, medical history, psychiatric history, smoking, type of substance, age of first use for all the substances, length of use and family history, employment

status and indicators of social drift (education, employment, marital,

financial and criminal).

Analyses: Summary statistics (n, %, mean).

B. To assess the current user substance and patterns of behavior.

Frequency distributions were carried out for all participants and by subgroups according to substance of abuse for the following variables to describe current substance abuse and its severity: Drug taking history over the past month, (frequency of use, importance, satisfaction with life, time spent in activities, increasing usage over a long period of time); persistent desire to cut down, continue to use despite its problems, trial to stop, withdrawal symptoms, including the CAGE score for alcohol and severity score for alcohol and drug use. Severity scores were computed for both alcohol and drug use, from questions around: time spent in activities, increasing usage over a long period of time, persistent desire to cut down, continue to use despite its problems and attempts to stop.

Analyses: Summary statistics (n, %, mean, (SD) or median).

C. To examine factors associated with relapse from the patient

perspective.

Frequency distributions were conducted for all participants and by

subgroups according to substance of abuse for the following variables:

Perceived dependence, peer pressure, poor attitude, family problems,

role model, unemployment, place, time.

Analyses: Summary statistics (n, %, mean (SD), or median)

A new variable was computed for relapse, which was defined as “1=Yes‟ or “0=No” if answered to ‘Is this the first time in treatment?’. A score was created based on number of previous treatments for those who had relapsed (1=1 previous treatment, 2=2 previous treatments, 3=3 previous treatments, 4=4 or more previous treatments).

D. To explore patient experiences of treatment.

Frequency distributions were created for all participants and by subgroups according to substance of abuse for the following variables: received a treatment, received rehabilitation, number of treatments, follow up program, number of detoxification courses, number of rehabilitation courses, services responsive to your needs, care coordinated, choosing this facility again.

Analyses: Summary statistics (n, %)

E. To assess the association between severity of dependence and

substance abuse (initiation age, length of dependence, presence of

a family history of addiction and level of education.).

Frequency distributions were carried out for all participants and by subgroups according to substance of abuse for the following variables to define severity of dependence for both alcohol and substance. Based on research, the Severity of Dependence Scale is a 5-item questionnaire that provides a score indicating the severity of dependence. The total score is obtained through the addition of the 5- item ratings. The higher the score, the higher the level of dependence

(Gossop, 1995).

This was done by answering the following five questions first; do you spend time in activities searching for the drugs/alcohol?, do you use large amount of drugs/ alcohol over a long period?, do you have a persistent desire to cut down or to control taking drugs/ alcohol yet you have not succeeded?, do you continue to use drugs/ alcohol despite the fact that it causes you many problems? and have you tried to stop your habits?. The initial answer for these questions was Yes =

1 or No =2.

To investigate the association between the severity of dependence and alcohol and substance use, a new variable “severity of dependence score‟ was computed based on the answers to the above mentioned five questions. The five questions were recoded as 0 if the answered was No and 1 if the answer was Yes. A new severity of dependence score was computed by summing the five answers to give a value ranging from zero to five. Five indicated the highest level of severity of dependence.

Then the total severity of dependence for al substance and alcohol was computed by combining both the alcohol severity of dependence and substance severity of dependence. To have the final total score of severity of dependence in a binary format the previous 5- scale score was recoded in to 0 = low severity (by merging total severity of dependence score of 1 and 2) and 1 = high severity (by merging total severity of dependence score of 3, 4 and 5).

Dependent variable: severity of dependence score.

Independent variables: Time spent searching for drugs/alcohol, use of large amount over time, persistent desire to cut down without success, continue to use despite the problems and trial to stop.

Analyses: Association of the dependent variable with the independent variable was carried out using the Chi squared test and logistic regression analyses.

F. To assess the association between social drift and substance abuse

(education, employment, marital, financial and criminal).

Frequency distributions were carried out for all participants and by subgroups according to substance of abuse for the following variables to describe social circumstances and social drift: employment status, type of employment, history of employment, losing job because of addiction, job affected by addiction, loss of promotion, type of accommodation, education finished before addiction, education not finished because of addiction, number of current marriages, number of previous marriages, income change after addiction.

To consider associations of different factors with social drift a new variable “social drift score‟ was computed based on the answers to three questions: losing job because of addiction, education not finished because of addiction, and income changed after addiction. The score was developed from these three questions, which might indicate adverse changes in a person’s social status. The three questions were recoded as 0 if the answered was No and 1 if the answer was Yes. A new Social drift score was computed by summing the three answers to

give a value ranging from zero to three. Three indicated the highest level of social drift. To have the final social score in a binary format the previous 3- scale score was recoded in to 0 = low social drift (by merging the social drift score of 0 and 1) and 1 = high social drift (by merging total severity of dependence score of 2, 3 and 4).

Dependent variable: Social drift score.

Independent variables: Type of drug by subgroup, severity of addiction for drugs and alcohol, and the new variable relapse.

Analyses: Association of the dependent variable with each of the independent variables was carried out using the Chi squared test and logistic regression analyses.

3.9. Conclusion

The study aimed at providing a detailed picture of the characteristics of substance users whom attending the national Rehabilitation Center for treatment and exploring the notion of social drift among this population. Therefore, a quantitative methodology using a questionnaire instrument was used. The questionnaire was developed by Al Ghafri (2014) and was based on internationally validated scales.

4. CHAPTER FOUR: RESULTS

The main findings of the study, which will be broadly structured by the study hypotheses, will be presented in this chapter. This chapter will include four main sections. The discussion in the first section will include a detailed analysis of the characteristics of the clinical population of substance abusers receiving treatment in the NRC (UAE).

As mentioned earlier, the total sample of the clinical population in this study is 250 patients including 242 males and 8 females.

This will be followed in the second section by a detailed comparison of the current study clinical population of substance abusers’ characteristics with the characteristics of the clinical population of substance abusers from another study conducted in Jordan on 2014.

Because the Jordan study included a male only sample, the comparison will be with male sample subset from the current study which is 242 males.

The third section will explore the association between severity of dependence and substance use initiation age, length of dependence, presence of a family history of addiction and level of education. The other association that will be explored in this section will be between social drift and age of first initiation, length of dependence, and presence of a family history of addiction. Finally, the association between the nursing interactions and patient satisfaction with the nursing services will examined in the fourth section.

4.1. Response Rate

Of the 266 subjects invited to participate in this study, 250 (94%) consented and completed the questionnaire. The reason given by the 16 who did not consent to participate was fear of information leakage to the police.

4.2. SECTION ONE: The characteristics of the clinical

population of substance abusers receiving treatment in

the NRC (UAE):

4.2.1. Part 1: Demographic Data:

4.2.1.1. Patient Background:

Of the 250 patients, there were 242 (96.8%) males and 8 (3.2%) females.

The youngest among the males was 16, while the youngest age among the females was 20. The mean (SD) age of subjects was 28.52 (8.87) years, with the majority of the patients being under the age of 31 years

(71.5%). Only seven were over the age of 50 years. At the time the data were collected, all of the patients who volunteered to participate in the study were UAE nationals and were all Muslim. (Table 4.1)

149 (59.6%) of the total sample were single, 82 (32.8%) were married,

18 (7.2%) were divorced, only one (0.4%) reported that he was not living with his wife and none were widows or widowers. Among the males, 144

(59.5%) were single, 80 (33.06%) were married, 17 (7.02%) were divorced and one (0.4%) was separated. Out of the 8 females, 5 (62.5%)

were single, 2 (25%) were married and one (12.5%) was divorced. (Table

4.1).

98.8% (274/250) of the total sample were educated and only 1.2%

(3/250) didn’t know how to read or write. The majority of the educated sample were at the secondary level (128 - 51.2%) followed by the preparatory level (58 - 23.2%), the university level (39 - 15.6%) and last was the primary level (22 - 8.8%). The same scenario applied to the male sample, with 127 (52.5%) at the secondary level, 54 (22.3%) at the preparatory level, 38 (15.75%) at the university level and 20 (8.3%) at the primary level. 3 (1.2%) out of the 242 males were illiterate. The female sample were all educated; 4 (50%) at preparatory level, 2 (25%) at primary level, one (12.5%) at secondary level and one (12.5%) at university level. (Table 4.1)

49.6% (124) of the total sample were unemployed compared to 36% (91) who were employed. Of the 91 employed, 11 were self-employed. Almost all the females were unemployed (87.5%) except one (12.5%) who was employed. The majority of the males were unemployed (118 – 48.8%).

90 (37.2%) out of the 242 males were employed, with 11 (12%) who were self-employed. 31 (12.8%) were students and 3 (1.2%) were retired.

(Table 4.1)

Table 4- 1 Frequency Distribution of the participants'

Demographic Data

Total Male Female N (%) 250 (100%) 242 (96.8%) 8 (3.2%)

16-20 yrs. 37 (14.7%) 37 (15.3%) 0 (0%) 21-25 yrs. 88 (35.2%) 85 (35.1%) 3 (37.5%) 26-30 yrs. 54 (21.6%) 51 (21.1%) 3 (37.5%) 31-35 yrs. 18 (7.2%) 17 (7%) 1 (12.5%) Age Group 36-40 yrs. 23 (9.2%) 22 (9.1%) 1 (12.5%) 41-45 yrs. 16 (6.4%) 16 (6.6%) 0 (0%) 46-50 yrs. 7 (2.8%) 7 (2.9%) 0 (0%) Above 51 yrs. 7 (2.8%) 7 (2.9%) 0 (0%)

Single 149 (59.6%) 144 (59.5%) 5 (62.5%) Married 82 (32.8%) 80 (33.06%) 2 (25%) Marital Status Divorce 18 (7.2%) 17 (7.02%) 1 (12.5%) Widower 0 (0%) 0 (0%) 0 (0%) Separated 1 (0.4%) 1 (04%) 0 (0%)

Illiterate 3 (1.2%) 3 (1.2%) 0 (0%) Primary 22 (8.8%) 20 (8.3%) 2 (25%) Educational Preparatory 58 (23.2%) 54 (22.3%) 4 (50%) Background Secondary 128 (51.2%) 127 (52.5%) 1 (12.5%) University 39 (15.6%) 38 (15.75) 1 (12.5%)

Unemployed 124 (49.6%) 117 (48.3%) 7 (87.5%) Student 32 (12.8%) 32 (13.2%) 0 (0%) Current Occupation Self-employed 11 (4.4%) 11 (5%) 0 (0%) Employed 80 (32%) 79 (4.5%) 1 (12.5%) Retired 3 (1.2%) 3 (1.2%) 0 (0%)

Abu Dhabi 155 (62%) 151 (62.4%) 4 (50%) Dubai 30 (12%) 27 (11.2%) 3 (37.5%) Sharjah 32 (12.8%) 31 (12.8%) 1 (12.5%) Address or State of Ajman 13 (5.2%) 13 (5.4%) 0 (0%) residence Fujairah 14 (5.6%) 14 (5.8%) 0 (0% Ras Al-Khaimah 5 (2%) 5 (2.1%) 0 (0% Umm Al- 1 (04%) 1 (0.4%) 0 (0% Quwain

Self 129 (51.6%) 124 (51.2%) 5 (62.5%)

Referral Source Family 30 (12%) 29 (12%) 1 (12.5%) Justice System 91 (36.4%) 89 (36.8%) 2 (25%)

Compared to the other emirates, Abu Dhabi had the largest number of patients with 155 (62%). Followed by 65 (26%) were from the northern emirates and 30 (12%) from Dubai. Analyzing the patients’ distribution around the emirates based on gender resulted in the majority of patients coming from Abu Dhabi with 151 (62.4%) males and 4 (50%) females. More male patients (64 - 26.4%) come from northern emirates males compared to only one (12.5%) female. On the other hand, more females (3 - 37.5%) come from Dubai compared to 27 (11.2%) of males.

(Table 4.1)

The common source of referral was self-referred with a total of 129

(51.6%), of whom 124 were males and 5 were females. Referrals from the justice system came next, with a total of 91 (36.4%), of whom 89 were males and 2 were females. 30 (12%) out of the total referred by their families to seek treatment; 29 out of the 30 were males with only one female. (Table 4.1).

4.2.1.2. Psychiatric & Medical Data:

Mood disorders were most frequently reported (129 – 51.5%) as a psychiatric illness among the total sample, followed by depression (109

– 43.6%). While anxiety disorders were the least reported (106 – 42.4%).

None of the sample was reported as being diagnosed with schizophrenia. (Table 4.2).

Similar to the psychiatric illnesses distribution among the total sample, mood disorders were reported by the majority of the male sample (126

– 52.1%). The second most reported psychiatric illness was depression

(106 – 43.8%) and the least frequently reported were anxiety disorders

(102 – 42.1%). (Table 4.2).

The picture was different among the female sample. Among females, anxiety disorders were reported n half of the sample (4 – 50%).

Depression and mood disorders were both reported by 3 females

(37.5%). (Table 4.2).

Looking at the medical history of the total sample, it was found that hypertension and gastritis were the most common medical problems that were reported by the same number of participants (31 – 12.4%).

Only 25 (10%) of the 250 reported to have hepatitis. Further breakdown of the types of hepatitis revealed that hepatitis C (19 – 7.6%) was the most common type of hepatitis among the total sample. Five (2%) reported having hepatitis A and only one (0.4%) had hepatitis B.

Diabetes was reported by 13 (5.2%) participants and none mentioned that they had AIDS. (Table 4.2).

Among the females group, gastritis was the most common medical problem (3 – 37.5%), followed by hypertension (2 – 25%) and only one

(12.5%) stated that she was diagnosed with diabetes. Hepatitis and

AIDS were not among the medical problems that were reported by females. (Table 4.2).

Hypertension was identified by 29 (12%) of the male sample which made it the most common medical problem. Gastritis came next with 28

(11.6%) male participants believed to have it. While hepatitis came in third place with 25 (10.3%) male participants reported that they were diagnosed with a type of hepatitis. Hepatitis C is the most common type of hepatitis (19 – 7.9%) among males, while hepatitis B was the least reported (1 – 0.4%). Five of the 25 male participants who have hepatitis, have hepatitis A. (Table 4.2).

Table 4- 2 Frequency Distribution of the participants' Psychiatric

& Medical Data

Total Male Female

250 (100%) 242 (96.8%) 8 (3.2%)

Yes (%) No (%) Yes (%) No (%) Yes (%) No (%)

109 141 106 136 3 5 Depression (43.6%) (56.4%) (43.8%) (56.2%) (37.5%) (62.5%) 250 242 8 Schizophrenia Psychiatric 0 0 0 (100%) (100%) (100%) History 106 144 102 140 4 Anxiety disorders 4 (50%) (42.4%) (57.6%) (42.1%) (57.9%) (50%) 129 121 126 116 3 5 Mood disorders (51.6%) (48.4%) (52.1%) (47.9%) (37.5%) (62.5%)

5 5 0 Hep (A) (2%) (2.1%) (100%) 1 225 1 217 0 8 Hepatitis Hep (B) (0.4%) (90%) (0.4%) (89.7%) (100%) (100%) 19 19 0 Hep (C) (7.6%) (7.9%) (100%) Medical 250 242 8 AIDS 0 0 0 History (100%) (100%) (100%)

Hypertension 31 219 29 213 2 6 (12.4%) (87.6%) (12%) (88%) (25%) (75%) 13 237 12 230 1 7 Diabetes (5.2%) (94.8%) (5%) (95%) (12.5%) (87.5%) 31 219 28 214 3 5 Gastritis (12.4%) (87.6%) (11.6%) (88.4%) (37.5%) (62.5%)

4.2.2. Part 2: Addiction History

4.2.2.1. Substance Abuse and Smoking History:

4.2.2.1.1. Substance of Use:

Table 4.3 shows the distribution of the sample by type of substance of abuse. A total of 73% of the sample are polysubstance and alcohol users, 18% used drugs only, and 9% used alcohol only. The same distribution applies to both genders. Polysubstance and alcohol users represent 73% of the male group and 63% of the female group. 17% of the males reported drugs only and 10% alcohol only. On the other hand, none of the females reported using alcohol only and the remaining 38% are drugs users only. (Table 4.3).

Table 4- 3 Frequency Distribution of the participants by

Substance of Use

Gender Total Male Female

Alcohol only 23 10% 0 0% 23 9%

Drugs only 42 17% 3 38% 45 18%

Alcohol + Drugs 177 73% 5 63% 182 73%

Total 242 100% 8 100% 250 100%

4.2.2.1.2. Age of First Use:

The youngest age of first use of most of substance was 11 years with a mean (SD) of 17. 8 and oldest age of first use range between 27 and 46.

82% (205) of the total sample used alcohol for the first time in their life between the ages of 11 and 41. The age of first use among the heroin 84

users was 14 years with a mean (SD) of 20.4. The users of other types of narcotics also started their first use at the age of 14 with a mean (SD) of 21.0. Cocaine users started to use at the age of 13 with a mean of

21.1. Both benzodiazepine and other sedatives users reported their first use before they reach their twelfth birthday. The same pattern was observed among hallucinogenic and amphetamines users. The youngest age of first use of cannabis, inhalants and khat was 11 years old. (Table 4.4).

Table 4- 4 Frequency Distribution of Substance of Use by age of

1st Use

Addiction

History Benz Khat

Hallu

Other Other

Heroin

Alcohol

Amphet

Cocaine

Sedative

Cannabis

Narcotics

Inhalants

205 149 119 84 201 193 188 114 34 35 156 Total (%) (82%) (60%) (48%) (34%) (80%) (77%) (75%) (46%) (14%) (14%) (62%) Youngest 11 14 14 13 11 11 12 11 12 12 11 reported age

Meanof 1st (SD)use 17.78 20.4 20.96 21.12 18.99 18.97 17.86 18.17 15.44 18.97 20.5

(yrs)st age at 1 use (4.1) (4.4) (4.7) (4.3) (4.9) (4.9) (3.4) (4.1) (2.9) (6.1) (5.3)

11-20 yrs 168 83 63 43 158 149 155 86 33 25 104

21-30 yrs 33 63 54 37 38 39 31 27 1 7 42

31-40 yrs 2 3 1 4 4 4 2 1 0 3 9

> 41 yrs 2 0 1 0 1 1 0 0 0 0 1

4.2.2.1.3. Nicotine Smoking History:

Table 4.5 illustrates the current smoking status and when the participants started smoking in relation to their addiction onset. 247

(98.8%) of the total sample reported that they were currently smoking. 85

Of the 247 who are smoking, 223 (90.3%) reported starting smoking

before their addiction. (Table 4.5). 239 (98.8%) of the male sample

reported that they are currently smoking, of whom 216 (90.4%)

mentioned that they were smoking before their addiction. All the

females were smokers at the time of the study with seven (87.5%)

started to smoke before they became addicts. (Table 4.5).

Table 4- 5 Frequency Distribution of Current smoking status and

smoking history categorized by gender

Total Male Female

250 (100%) 242 (96.8%) 8 (3.2%) Yes (%) No (%) Yes (%) No (%) Yes (%) No (%) Do you smoke? 247 239 3 (1.2%) 3 (1.2%) 8 (100%) 0 (0%) (98.8%) (98.8%)

Was it ...... Before After Before After Before After 223 24 216 your addiction 23 (9.6%) 7 (87.5%) 1 (12.5%) (90.3%) (9.7%) (90.4%) 4.2.2.1.4. Current Use

The frequency of use for both substances and alcohol during the over

the past 1-2 months was divided into four categories, which were

abstinent, light use, moderate use and heavy. More than 50% of the

total substance users sample (122/227) reported that they had not

been using drugs in the last 1-2 months preceding their admission,

while 23.3% (53/227) reported a heavy use. (Table 4.6).

For alcohol, more than 75% of the participants (157/205) who used

alcohol stated that they didn’t use alcohol during the past 1-2 months,

whereas, 9.3% (19/205) described their use as a light use. (Table 4.6).

Table 4- 6 Frequency Distribution of Current Use of Substance &

Alcohol Over the Past 1-2 Months

Current Use Substance Alcohol (Past 1-2 Frequency % Frequency % months) Abstinent 122 53.7 157 76.6 Light 24 10.6 19 9.3 Moderate 28 12.3 13 6.3

Heavy 53 23.3 16 7.8 Total 227 100 205 100 Participants were also asked about the overall importance of substance and alcohol use in their life during the past month. The majority of participants described the use of substances (55.1%) and alcohol

(84.9%) as not so important. This result goes along with what they reported as their current use during the past 1 - 2 months. Only 27.3%

(62/227) of substance users and 9.3% (19/205) of alcohol users described their use as very important. (Table 4.7).

Table 4- 7 Frequency Distribution of the Participants' View of the

Importance of Use of Substance & alcohol

Importance of Substance Alcohol Use Frequency % Frequency % Very important 62 27.3 19 9.3 Important 40 17.6 12 5.9 Not so 125 55.1 174 84.9 important Total 227 100 205 100

Table 4- 8 Frequency Distribution of the Participants'

Satisfaction of their Use

Substance Alcohol

Frequency % Frequency %

Very satisfied 74 32.6 44 21.5 Reasonably 36 15.9 34 16.6 satisfied A bit satisfied 115 50.7 124 60.5

Not satisfied 2 0.9 3 1.5 Total 227 100 205 100

The last question on current history of use highlighted how satisfied the participants with substance use in their life were. 50.7% (115/227) of substance users and 60.5% (124/205) of alcohol users stated that they were a bit satisfied. 32.6% (74/227) of the substance users and 21.5%

(44/205) of the alcohol users were very satisfied. (Table 4.8).

4.2.2.1.5. Criteria of Dependence

Dependency criteria for substance and alcohol use were assessed in the questionnaire using five questions. These questions were asking about the time spent searching for the addicted substance, using large amounts of substance or alcohol over a long period, having a persistent desire to cut down taking without succeeding, continuing to use despite having many problems, and whether the participant tried to stop or not.

Both substance users (81%, 184/227) and alcohol users (96%,

197/205) stated that they didn’t spend time searching for either

substances or alcohol. Most substance users (158%, 31/227) admitted that they were using large amounts of drugs over a long period of time, whereas only 31% (64/205) of the alcohol users used large amounts of alcohol over a long period of time. The vast majority of participants in both groups had a persistent desire to cut down on their use (79%,

180/227 of the substance users and 59%, 120/205 of the alcohol users). However, they still continued to use despite many problems caused by their addiction (88%, 180/227 of the substance users and

64%, 132/205 of the alcohol users), even though they had tried to stop using (76%, 173/227 of the substance users and 66%,135/205 of the alcohol users). (Table 4.9).

To measure the severity of dependence among participants, the answers to the five above questions (yes = 1, no = 0) were calculated. The total severity of dependence ranged between 0 which means no dependency and 5 which means high severity of dependence as shown in Table 4.12 below. The majority of both groups had moderate severity of dependence (50%, 114/227 of substance users and 61.5%, 126/205 of alcohol users). Followed by high severity of dependence (40%, 93/227) among substance users and low severity of dependence (26.3%,

54/205) among alcohol users. (Table 4.10).

Table 4- 9 Frequency Distribution of Dependency Criteria for

Substance & Alcohol Users

Substance Alcohol

Male Female Total Male Female Total 41 2 43 8 0 8 Do you spend time in Yes (19%) (25%) (19%) (4%) (0%) (4%) activities searching for 178 6 184 192 5 197 …….. No (81%) (75%) (81%) (96%) (100%) (96%) 124 7 131 64 0 64 Yes Do you use large amount of (57%) (87.5%) (58%) (32%) (0%) (31%) …. over a long period 95 1 96 136 5 141 No (43%) (12.5%) (42%) (68%) (100%) (69%)

Do you have a persistent 173 7 180 117 3 120 Yes desire to cut down taking (97%) (87.5%) (79%) (59%) (60%) (59%) ….. yet have not 46 1 47 83 2 85 No succeeded? (21%) (12.5%) (21%) (42%) (40%) (41%)

191 8 180 128 4 132 Do you continue to use ….. Yes (87%) (100%) (88%) (64%) (80%) (64%) despite it causes you many 28 0 47 72 1 73 problems? No (13%) (0%) (12%) (36%) (20%) (36%)

167 6 173 131 4 135 Yes Have you tried to stop your (76%) (75%) (76%) (65.5%) (80%) (66%) habits? 52 2 54 69 1 70 No (24%) (25%) (24%) (34.5%) (20%) (34%)

Table 4- 10 Frequency Distribution of Severity of Dependency

Severity of Substance Alcohol Dependence Male Female Total Male Female Total 20 0 20 52 2 54 0, 1 (9%) (100%) (9%) (26%) (40%) (26.3%) 112 2 114 123 3 126 2, 3 (51%) (25%) (51%) (61.5%) (60%) (61.5%) 87 6 93 25 0 25 4, 5 (40%) (75%) (40%) (12.5%) (0%) (12.2%) Total 219 8 227 200 5 205

4.2.2.1.6. CAGE Questionnaire: Alcohol.

Most of the alcohol users (64%, 131/205) felt they had to cut down their drinking and 55% (112/205) were annoyed by people who criticized their drinking. Feeling guilty about drinking was commonly reported among 70% (144/205) of the alcohol users. On the other hand, only

28% (58/205) admitted that they had a drink first thing in the morning.

(Table 4.11). 29% had a CAGE score of 2 or 3. (Table 4.12).

Table 4- 11 Frequency Distribution of CAGE Criteria

Male Female Total 128 3 131 Have you ever felt you should Yes (64%) (60%) (64%) cut down on your drinking 72 2 74 No (36%) (40%) (36%)

Have you been annoyed by 111 1 112 Yes (55.5%) (20%) (55%) people who criticizing your 89 4 93 drinking No (44.5%) (80%) (45%)

141 3 144 Have you ever felt guilty about Yes (70.5%) (60%) (70%) your drinking 59 2 61 No (29.5%) (40%) (30%)

55 3 58 Have you ever had a drink first Yes (27.5%) (60%) (28%) thing in the morning 145 2 147 No (72.5%) (40%) (72%)

Table 4- 12 Frequency Distribution of CAGE Score

Male Female Total

15 0 15 0 (8%) (0%) (7%) 39 2 41 1 (20%) (40%) (20%) 64 2 66 2 (32%) (40%) (32%) 60 0 60 3 (30%) (0%) (29%) 22 1 23 4 (11%) (20%) (11%) Total 200 5 205

4.2.2.1.7. Withdrawal Symptoms

Withdrawal symptoms were reported by the majority of the participants and they varied based on the addicted substance. Insomnia was the most common withdrawal symptom reported by 93% (210/227) of the substance users, followed by sweating with 91% (206/227), and body weakness was the third most commonly reported symptom with 90%

(204/227). On the other hand, headache was the most common withdrawal symptom reported by 13% (27/204) of the alcohol users, followed by body weakness with 12% (25/205). Both tremor and insomnia were reported by 11% of alcohol users (22/205). (Table 4.13).

The same scenario applies to the male substance users and male alcohol users. Among the male substance users, insomnia was the most commonly reported symptom by 92% (202/219), then sweating with

90% (198/219) and the third most common symptom was body

weakness with 89% (196/219). Looking at the male alcohol users, the picture didn’t differ from the general one. Headache was reported by

13.5% (27/200) of the male alcohol users, followed by body weakness with 12% (25/200). 11% of the males who used alcohol experienced both tremor and insomnia (22/200). (Table 4.13).

The female users had a different withdrawal experience. All eight female substance users suffered from tremor, nausea, sweating, insomnia and body weakness. None of the five female alcohol users went through any withdrawal symptoms. (Table 4.13).

Table 4- 13 Frequency Distribution of withdrawal Symptoms

Substance Alcohol

Yes No Yes No 171 48 27 173 Male (78%) (22%) (13.5%) (86.5%) 7 1 0 5 Headache Female (87.5%) (12.5%) (0%) (100%) 178 49 27 178 Total (87%) (22%) (13%) (87%) 172 47 22 178 Male (79%) (21%) (11%) (89%) 8 0 0 5 Tremor Female (100%) (0%) (0%) (100%) 180 47 22 183 Total (79%) (21%) (11%) (89%) 170 49 15 185 Male (78%) (22%) (7.5%) (92.5%) 8 0 0 5 Nausea Female (100%) (0%) (0%) (100%) 178 49 190 Total 15 (7%) (78%) (22%) ((3%) 139 80 9 191 Male (63%) (37%) (4.5%) (95.5%) 6 2 0 5 Vomiting Female (75%) (25%) (0%) (100%) 145 82 9 196 Total (64%) (36%) (9%) (91%)

198 21 18 182 Male (90%) (10%) (9%) (91%) 8 0 5 Sweating Female 0 (0%) (100%) (0%) (100%) 206 21 18 187 Total (91%) (9%) (9%) (91%) 202 17 22 178 Male (92%) (8%) (11%) (89%) 8 0 0 5 Insomnia Female (100%) (0%) (0%) (100%) 210 17 22 183 Total (93%) (7%) (11%) (89%) 196 23 25 175 Male (89%) (11%) (12.5%) (87.5%) 8 0 0 5 Weakness Female (100%) (0%) (0%) (100%) 204 23 25 180 Total (90%) (10%) (12%) (88%) 174 45 21 179 Male (79%) (21%) (10.5%) (89.5%) 7 1 0 5 Anxiety Female (87.5%) (12.5%) (0%) (100%) 181 46 21 184 Total (80%) (20%) (10%) (90%) 168 51 20 180 Male (77%) (23%) (10%) (90%) 7 1 0 5 Depression Female (87.5%) (12.5%) (0%) (100%) 174 52 20 185 Total (43%) (57%) (8%) (92%) 4.2.2.2. Treatment Experiences.

4.2.2.2.1. Previous Treatment Experiences

Participants were asked to report any previous drug and alcohol treatment and follow up experiences they went through prior to this treatment encounter. Patient’s treatment experiences were assessed in the bases if the participant went into inpatient, outpatient or if he went through both experiences. 72% (180/250) of the participants stated that they had received some type of treatment before. Of those who being in a type of treatment before this treatment encounter, 22%

(39/180) received inpatient treatment, 24% (43/180) had been to outpatient services and 54% (98/180) went through both inpatient and outpatient treatment services. (Table 4.14).

Follow ups and after care programs after discharge were another aspect of treatment experiences participants were asked about. Of the 180 who received some sort of treatment previously, 60% (108) indicated that they had engaged in a type of follow up programs. Follow up programs were sorted into outpatient follow ups, the matrix program and

Emirates House (Halfway house). Most (94%) of the 108 had follow ups in an outpatient clinic (101/108), 18% (19/108) were enrolled in the matrix program and only 3% (3/108) were part of the Emirates House.

(Table 4.14).

The number of times a participant received a type of a treatment was also examined. The maximum number of admissions to inpatient units was 12 times, whereas the maximum number of outpatient admissions and readmissions reached 30 times. However, most of the participants

(120/136) were admitted to inpatient program between 1 to 5 times and the same applied for participants who received outpatient treatments

(89/142). (Table 4.15).

Table 4- 14 Frequency Distribution of Previous Treatment

Experiences and Follow ups

Male Female Total

176 4 180 Yes (73%) (50%) (72%) Have you ever received a treatment 66 4 70 No before this visit (27%) (50%) (28%)

Total 242 8 250

38 1 39 Inpatient (22%) (25%) (22%)

43 0 43 Was it ..... Outpatient (24%) (0%) (24%)

95 3 98 Both (54%) (75%) (54%) 105 3 108 Yes Did you have a follow up (after care (60%) (75%) (60%) program) after your discharge 71 1 72 No (40%) (25%) (40%)

98 3 101 Yes What sort of follow up you receives (56%) (100%) (94%) (OPD)? 7 0 7 No (4%) (0%) (6%)

19 0 19 Yes What sort of follow up you receives (18%) (0%) (18%) (Matrix)? 86 3 89 No (82%) (100%) (82%)

3 0 3 Yes What sort of follow up you receives (3%) (0%) (3%) (Emirates House)? 102 3 105 No (97%) (100%) (97%)

Table 4- 15 Frequency Distribution of Numbers of Previous

Inpatient and Outpatient Treatment Encounter

4.2.2.2.2. Current Treatment Experiences No. of Male Female Total Admission

1 41 0 41 2 33 2 35

3 19 0 19

4 10 0 10

5 13 2 15

6 5 0 5 How many times 7 3 0 3 inpatient? 8 1 0 1

9 1 0 1

10 4 0 4

11 1 0 1

12 1 0 1

Total 132 4 136

1 35 /1 36

2 21 0 21

3 12 0 12 4 11 0 11

5 9 0 9 How many times 6 5 0 5 outpatient? 7 9 0 9

8 5 0 5 9 7 0 7

10 6 1 7

< 10 19 1 20

Total 139 3 142

Participants were asked to assess their current experience at the NRC from three aspects; how responsive is the NRC to their needs, how well is the care is coordinated in-between different services at the NRC and finally will the participants come back to the NRC for treatment.

In regard to the first question, 91% (227/250) of the participants stated that the NRC was responsive enough to their needs, while 9% (23/250) thought that the NRC was not responsive. (Table 4.16). A similar situation was witnessed in regard to coordination of care in-between services. 97% (242/250) of the sample indicated that the care in- between services were well coordinated. A small number of participants

(3%, 8/250) viewed the NRC service as unresponsive to their needs and poorly coordinated. (Table 4.17). The majority (80%, 199/250) of the total sample stated that they would choose the NRC again to receive treatment, while 20% (51/250) said they wouldn’t. (Table 4.18).

Table 4- 16 Frequency Distribution of Participants' Views on how

NRC Respond to their Needs

Male Female Total 39 2 41 Very responsive (16%) (25%) (16%) 116 4 120 Responsive How responsive is (48%) (50%) (48%) 65 1 66 NRC service to your OK (27%) (12.5%) (26%) needs 16 1 17 Unresponsive (7%) (12.5%) (7%) 6 0 6 Very Unresponsive (2%) (0%) (2%) Total 242 8 250

Table 4- 17 Frequency Distribution of Participants' Views on the Coordination in-between Different NRC Services

Male Female Total 44 3 47 Very well (18%) (37.5%) (19%) 126 4 130 How well is your care Well (52%) (50%) (52%) being coordinated in- 65 0 65 Ok between different (27%) (0%) (26%) 5 1 6 services Poorly (3%) (12.5%) (2%) 2 0 2 Very poorly (1%) (0%) (1%) Total 242 8 250 Table 4- 18 Frequency Distribution of Participants' Respond to coming back to NRC

Male Female Total 192 7 199 Yes Will you come back again to (79%) (87.5%) (80%) this center 50 1 51 No (21%) (12.5%) (20%) Total 242 8 250

4.2.2.2.3. Patient Satisfaction with NRC Nursing

Services

Patient satisfaction with the nursing staff was assessed in the questionnaire. A total of four questions were asked, three of which focused on nursing tasks and the fourth asked about patient satisfaction about nursing care during the admission or OPD visit. 87%

(217/250) of the total sample were able to identify the nursing staff,

66% (165/250) mentioned that they had received counselling therapy

from the nursing staff and the nurses where available whenever they were needed as stated by 92% (229/250) of the participants. Only 5%

(12/250) were unsatisfied by the care received from the nursing staff.

(Table 4.19).

Table 4- 19 Frequency Distribution of Participants' Satisfaction with NRC Nursing Services

Male Female Total 210 7 217 Yes Were you able to identify nursing (87%) (87.5%) (87%) staff? 32 1 33 No (13%) (12.5%) (13%) 158 7 165 Yes Did you receive any counselling from (65%) (87.5%) (66%) the nursing? 84 1 85 No (35%) (12.5%) (34%) 221 8 229 Yes Were the nurses available when you (91%) (100%) (92%) needed them? 21 0 21 No (9%) (0%) (8%) 85 6 91 Strongly satisfied (35%) (75%) (36%) How satisfied are you with the care 145 2 147 Satisfied you received from the nursing staff? (60%) (25%) (59%) 12 0 12 Not satisfied (5%) (0%) (5%)

4.2.2.3. Family History

Table 4.22 represents the family history of psychiatric, addiction, suicide and the current health status of each family member as reported by the participants. A small number of participants stated having a family history of psychiatric problems. The same applies to

100

family history of addiction and suicide. When asked about the current

health status of their family members, 53% (133/250) mentioned that

their mothers are ill and 54% (136/250) described their fathers as ill.

In regard to the rest of the family members (sisters, brother, spouses

and children), the majority were healthy as stated by the most of the

participants. (Table 4.20).

Table 4- 20 Frequency Distribution of Family History of

psychiatric problem, addiction problem, suicide problem and the

current health status

Mother Father Brother Sister Spouse Children

(n=250) (n=250) (n=250) (n=250) (n=97) (n=90)

11 1 1 Yes 7 (3%) 19 (8%) 5 (2%) Psychiatric (4%) (1%) (1%) problem 239 243 231 245 96 No 89 (99%) (96%) (97%) (92%) (98%) (99%)

0 0 0 Yes 11 (4%) 68 (27%) 2 (1%) (0%) (0%) (0%) Addiction problem 250 239 182 248 97 No 90 (100%) (100%) (96%) (83%) (99%) (100%)

3 0 0 Yes 0 (0%) 3 (1%) 0 (0%) (1%) (0%) (0%) Suicide problem 247 250 247 250 97 No 90 (100%) (99%) (100%) (99%) (100%) (100%)

117 114 209 214 86 83 Healthy Current health (47%) (46%) (84%) (86%) (89%) (92%) status 133 136 11 7 Ill 41 (16%) 36 (14%) (53%) (54%) (11%) (8%) 4.2.2.4. Factors associated with relapse

Of the 250 participants, 72% (180/250) have been in one or more

treatment experiences prior to this interview which means they have

been through relapse. 98% (176) of the 180 were males and 2% (4) were 101

females. Craving was reported as the highest factor associated with relapse by 91% (163/180) of the participants. Peer pressure ranked second among all factors by 89% (161/180) of the participants. 86%

(154/180) mentioned unemployment as a reason for relapse. The same scenario found among the male sample (craving 90%-159, peer pressure 89%-157 and unemployment 86%-152). On the other hand, all the four females identified family problems as one of the most contributing factors to relapse after craving and peer pressure. (Table

4.21).

Table 4- 21 Frequency Distribution of Participants' View of

Factors associated with relapse

Male Female Total Factors (n=176) (n=4) (n=180)

159 4 163 Yes (90%) (100%) (91%) Craving 17 0 17 No (10%) (0%) (9%) 157 4 161 Yes (89%) (100%) (89%) Peer pressure 19 0 19 No (11%) (0%) (11%) 94 2 96 Yes (53%) (50%) (53%) Poor attitude 82 2 84 No (47%) (50%) (47%) 145 4 149 Yes Family (82%) (100%) (83%) problems 31 0 31 No (18%) (0%) (17%)

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107 2 109 Yes (61%) (50%) (61%) Roll modelling 69 2 71 No (39%) (50%) (39%) 152 2 154 Yes (86%) (50%) (86%) Unemployment 24 2 26 No (14%) (50%) (14%)

118 3 121 Yes (67%) (75%) (67%) Place 58 1 59 No (33%) (25%) (33%) 111 3 114 Yes (63%) (75%) (63%) Time 65 1 66 No (37%) (25%) (37%) 4.2.3. Part 3: Social

4.2.3.1. Employment:

The sample was divided into 4 categories in regard to employment: employed, not employed, never employed and others. From the total, there were 32% (80/250) of the participants employed (33%-79 males and 12.5%-one female). Half (49.6% - 124/250) of the total were not employed at the time of the interview. 12.8% (32/124) of those were never employed (11%-27 males and 62.5%-5 females), while 19%

(46/250) were under “others” and were all males. Those 46 were further divided into students, retired and having their own private business.

69.6% (32/46) were students, 23.9% (11/46) were self-employed or having a private business and 6.5% (3/46) retired. (Table 4.22).

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Table 4- 22 Frequency Distribution of Participants' Employment

Status

Male Female Total

79 1 80 Employed (33%) (12.5%) (32%)

90 2 92 Not Employed (37%) (25%) (36.8%)

27 5 32 Never Employed Employment (11%) (62.5%) (12.8%) status Private 11 0 11 (23.9%) (0%) (23.9%) Retired 3 0 3 Others (6.5%) (0%) (6.5%) Student 32 0 32 (69.6%) (0%) (69.6%) Total 242 8 250

The 80 (32%) participants who were employed, were asked to describe the type of employment they do. 11% (9/80) of them described their daily work as manual and 38% (30/80) said they were having a professional job, while 51% (40/80) males and one female were doing administrative jobs. (Table 4.23).

Table 4- 23 Frequency Distribution of Participants' Employment

Type

Male Female Total

9 0 9 Manual (11%) (0%) (11%) Employment 30 0 30 Professional type (38%) (0%) (38%) 40 1 41 Administrative (51%) (100%) (51%) Total 79 1 80

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73% (138/190) of the total who were employed at any point in their life reported that they lost their job because of their addiction. 73%

(137/138) of them were males and 33% (1/3) were females. The same percent of participants (73%, 139/190) stated that their job was affected by their addiction. Only 4% (7/139) out of them described this affect as positive while it was negative affect for the others 69%

(132/139) and 3 females). 41% (77/190) lost a chance of promotion because of their dependence. (Table 4.24).

Table 4- 24 Frequency Distribution of perceived effect of addiction on employment as reported by participants

Male Female Total (n=187) (n=3) (n=190) Did you lose your job in any of 137 138 Yes 1 (33%) the above because of (73%) (73%) dependence No 50 (27%) 2 (67%) 52 (27%)

No 51 (27%) 0 (0%) 51 (27%) Since start taking Yes, 7 (4%) 0 (0%) 7 (4%) drugs/drinking alcohol, has positive your job ever been affected Yes, 129 132 3 (100%) negative (69%) (69%)

77 Did you lose a chance of Yes 76 (41%) 1 (33%) (41%) promotion because of 111 113 dependence No 2 (67%) (59%) (59%)

4.2.3.2. Accommodations

More than 87% (218/250) of the total sample reported that they owned their own house and 12% (31/250) were living in rented houses. Only one male participant was homeless. The same picture applied to both 105

gender. 88% (213/242) of the male sample and 62.5% (5/8) of the females owned the accommodation they are living in. Living in a rented house was reported by 11.6% (28/242) of the male sample and 37.5%

(3/8) of the females. (Table 4.25).

The majority of the participants were living with their parents (74% -

184/250) and their siblings (68% - 169/250). Half (126/250) of the participants have domestic help living in their homes. The same situation was found in the male and female sample. Only 18% (45/250) of the participants lived with others who used drugs or alcohol. When asked about the importance of maintaining one’s own accommodation, the majority of the participants viewed it as an important item (94% -

234/250). (Table 4.25).

91% (41/45) of the participants who lived with others who used drugs or alcohol were males and 9% (4/45) were females. The majority lived with an addict brother (76% - 34/45) and 11% (5/45) of the participants lived with an addict father. The male sample illustrated the same results; 76% (31/41) lived with an addicted brother and 12% (5/45) lived with an addicted father. With the female sample, there was a slight difference. 75% (3/4) lived with an addicted brother and 25% (1/4) of lived with an addicted uncle. (Table 4.26).

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Table 4- 25 Frequency Distribution of perceived effect of addiction on employment as reported by participants

Male Female Total 218 Owned 213 (88%) 5 (62.5%) Accommodation (87.2%) type Rented 28 (11.6%) 3 (37.5%) 31 (12.4%) Homeless 1 (0.4%) 0 (0%) 1 (0.4%) Spouse 79 (33%) 1 (13%) 80 (32%) Parents 178 (74%) 6 (75%) 184 (74%) Dependent 68 (28%) 1 (13%) 69 (28%) Children Friends 5 (2%) 0 (0%) 5 (2%)

Who lives with you? Alone 11 (2%) 1 (13%) 12 (5%) Step Parents 12 (5%) 1 (13%) 13 (5%) Siblings 163 (67%) 6 (75%) 169 (68%) Half Siblings 22 (9%) 2 (25%) 24 (10%) Domestic Help 122 (50%) 4 (50%) 126 (50%) Others 53 (22%) 3 (38%) 56 (22%)

Does any who is Yes 41 (17%) 4 (50%) 45 (18%) living with you use No 201 (83%) 4 (50%) 205 (82%) drugs or alcohol? How do you feel Important issues 227 (94%) 7 (87.5%) 234 (94%) about maintaining your Not important 15 (6%) 1 (12.5%) 16 (6%) accommodation?

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Table 4- 26 Frequency Distribution of the Substance Users living with the participants as reported by participants

Male Female Total

(n=41) (n=4) (n=45)

31 Brother 3 (75%) 34 (76%) 76%) Does any who is living Father 5 (12%) 0 (0%) 5 (11%) with you use drugs or Friends 4 (10%) 0 (0%) 4 (9%) alcohol? Mention? Son 1 (2%) 0 (0%) 1 (2%) Uncle 0 (0%) 1 (25%) 1 (2%)

4.2.3.3. Education

The table below illustrates the perceived effect of drug and alcohol abuse on the participants’ education status. 43% (108/250) completed their studies either before their addiction (12% - 31/250) or despite their addiction (31% - 77/250). More than 56% (142/250) did not complete their studies of whom 68% (97/142) didn’t complete their studies because of their addiction, while 32% (45/142) did not complete their studies because of reasons other than addictions. (Table 4.27).

The total sample, the male sample presented with the same figures.

44% of the participants completed their studies either before their addiction (13% - 31/242) or despite their addiction (31% - 76/242), and

56% (135/242) did not complete their studies. Two-third (91/135) didn’t complete their studies because of their addiction, while 33%

(44/135) did not complete their studies because of reasons other than addiction. None of the female participants completed their studies before their addiction and only one completed her studies despite her addiction. 87.5% (7/8) did not complete their studies. 86% (6/7) didn’t 108

complete their studies because of their addiction, and only one did not

complete her studies because of reasons other than her addiction.

(Table 4.27).

Table 4- 27 Frequency Distribution of the Participants’

Education Status

Male Female Total Before 31 (13%) 0 (0%) 31 (12%) I finished my studies ...... Despite 76 (31%) 1 (12.5%) 77 (31%) my addiction Not Applicable 135 (56%) 7 (87.5%) 142 (57%) I did not complete my studies Yes 91 (67%) 6 (86%) 97 (68%) because of my addiction No 44 (33%) 1 (14%) 45 (32%)

4.2.3.4. Marital Status

42% (106/250) of participants had been married at least once. 23%

(57/250) had married once, 13% (33/250) had married twice, 5%

(13/250) had married three times and only 1% (3/250) had married

four times. 58% of the total (144/250) were never married. The same

percentages were seen in the male sample. Among the females, 38%

(3/8) were married once and 13% (1/8) was married three times. 58%

(140/242) of the males and 50% (4/8) of the females were never

married. (Table 4.28).

One-quarter (26/106) had ended their marriage due to their addiction.

The same percentage was in both male (25/102) and female (1/4)

participants. Around one-third (34/106) of the married participants

were involved in relationships outside their marriage. 78% (83/106) had

dependent children and 82% (68/83) of them were involved in caring

109

for their children; 13% (11/83) of those who had children, used drugs

or drink alcohol in front of their children. (Table 4.28).

Table 4- 28 Frequency Distribution of the Participants’ Marital Status

Male Female Total

One 54 (22%) 3 (38%) 57 (23%)

Two 33 (14%) 0 (0%) 33 (13%) How many times did you get Three 12 (5%) 1 (13%) 13 (5%) married? Four 3 (1%) 0 (0%) 3 (1%)

Not married 140 (58%) 4 (50%) 144 (58%)

Did any of the previous marriages Yes 25 (25%) 1 (25%) 26 (25%) ended because of addiction? No 77 (75%) 3 (75%) 80 (75%)

Do you have another partner Yes 33 (32%) 1 (25%) 34 (32%) other than your wife, such as a No 69 (68%) 3 (75%) 72 (68%) girlfriend?

No 20 (20%) 3 (75%) 23 (22%)

Yes (1) 12 (12%) 0 (0%) 12 (11%) Do you have dependent children? (2-5) children 51 (50%) 1 (25%) 52 (49%)

>5 19 (19%) 0 (0%) 19 (18%)

Are you involved in caring for Yes 67 (82%) 1 (100%) 68 (82%) your children? No 15 (18%) 0 (0%) 15 (18%)

Do you use drugs or drink alcohol Yes 10 (12%) 1 (100%) 11 (13%) in front of your children? No 72 (88%) 0 (0%) 72 (87%)

4.2.3.5. Financial Status

The table below shows the source of income for the 250 participants.

Other sources of income represented the highest source on income with

56.4% (141/250), followed by employer (32.4%, 81/250) and the least

was social support (11.2%, 28/250). The other sources of income as

mentioned by the participants were family (80% - 113/141), private

business (11% - 16/141) and financial support given by the NRC (7% -

110

10/141). Two participants didn’t have any source of income. (Table

4.29).

Two-thirds (159/250) of the participants reported a change in their income after their initial usage of drugs/alcohol. The majority of the participants (48% - 121/250) preferred to spend their money on their children and family even if it was only 1000 Dirham (US $ 273), while

31% (78/250) of the total would chose to spend it on drug and alcohol.

Food (12% - 29/250) and accommodation (9% - 22/250) were mentioned by a small number of the participants as a choice to spend money on. (Table 4.30).

Table 4- 29 Frequency Distribution of the Participants’ Source of

Income

Male Female Total

Employer 80 (33%) 1 (13%) 81 (32%)

What is your Social support 28 (12%) 0 (0%) 28 (11%) Business 16 (12%) 0 (0%) 16 (11%) source of Family 107 (80%) 6 (86%) 113 (80%) income? Others No income 2 (1%) 0 (0%) 2 (1%)

NRC 9 (7%) 1 (14%) 10 (7%)

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Table 4- 30 Frequency Distribution of the Participants’ Financial

Status

Male Female Total Did your income change 159 Yes 152 (63%) 7 (88%) after your initial usage of (64%) drugs/alcohol? No 90 (37%) 1 (13%) 91 (36%)

Food 29 (12%) 0 (0%) 29 (12%)

Drug and If you have only Dhs 74 (31%) 4 (50%) 78 (31%) alcohol 1000 how would you Accommodation 20 (8%) 2 (25%) 22 (9%) spend it? Children & 121 119 (49%) 2 (25%) Family (48%)

If there is anything else Fun 4 (9%) 0 (0%) 4 (9%) you would rather spend Dhs 1000 on (apart from Self 41 (91%) 0 (0%) 41 (91%) drugs or alcohol), what is it?

4.3. SECTION TWO: Hypothesis # 1: The

characteristics of the clinical population of substance

abusers receiving treatment in the NRC will be similar

as the clinical population of substance abusers studied

in Al Ghafri - 2014.

As Al Ghafri’s study has only male participants, therefore, the female participants in the current sample will be excluded from the comparison. Also, as the raw data for Al Ghafri’s sample was not available. It was not possible to carry out any comparative analysis from means and standard deviation with the available statistical programs.

112

An alternative chi-square online calculator was used (iCalcu.com,

2018).

4.3.1. Patient Background:

In Al Ghafri’s study the 250 participants were all male (100%) and the youngest age was 18. The mean (SD) age of the participants was 32.28

(8.18) years. 68% of the total were under the age of 36 years (170/250) and only four were over the age of 50 years. Out of the 250 participants,

Jordanians accounted for 94.4% (236/250) and the remaining 5.6%

(14/250) were of other nationalities. A total of 98% (245/250) of the participants were Muslim and 2% (5/250) were Christian. 48.8%

(122/250) were married at the time of the study and 38.4% (96/250) had never been married. A total of 12.8% (32/250) were separated, widowed, or divorced. In regard to education level, 52% (130/250) were above preparatory education and only one was illiterate. 80% (200/250) were employed, of whom 60.1% (121/200) were manual laborers, 26.0%

(52/200) worked as administrators, and 13.5% (27/200) had professional job. When it comes to referral sources, 66.8% (167/250) were referred by their families, and 30.8% (77/250) were self-referred.

Only one subject had been referred by the police.

In the current study, there were 96.8% (242/250) male participants.

The youngest age was 16 years. The mean (SD) age was 28.52 (8.87) years, with the majority of the participants being under the age of 31 years (71% -173/242). Only seven were over the age of 50 years. All the participants were UAE nationals and were all Muslim. 59.5% (144/242) 113

were single, 33.1% (80/242) were married, 7.0% (17/242) were divorce,

0.4% (1/242) were separated and none was widower. The majority of the sample completed secondary education (52.5% - 127/242) followed by preparatory level (22.3% - 54/250), university level (15.7% - 38/242) and last was primary level (8.3% - 20/242). Only 1.2% (3/242) didn’t know how to read or write. 48.3% (117/242) of the participants were unemployed and 32.6% (79/242) were employed. Out of the 79 employed, 51% (40/79) were doing an administrative job, 38% (30/79) had a professional job and 11% (9/97) had a manual job. Looking at source of referral, self-referred was the most common with 51.6%

(129/242), followed by the justice system with 36.4%(91/242), and 12%

(30/242) were referred by their families. (Table 4.31).

Table 4- 31 Frequency Distribution of the Comparison of Patient

Demographic between Al Ghafri’s study and the current study.

Al Ghafri’s Study Current Study Sample 250 242 Unit n (%) n (%) Gender Males 250 242 Age Mean (SD) 32.3 (8.1) 28.52 (8.87) 17-20 years 8 (3.2) 37 (15.3) 21-25 years 50 (20) 85 (35.1) 26-30 years 64 (25.6) 51 (21.1) 31-35 years 48 (19.2) 17 (7.0) 36-40 years 36 (14.4) 22 (9.1) 41-45 years 26 10.4) 16 (6.6) 46-50 years 14 (5.6) 7 (2.9)

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≤51 years 4 (1.6) 7 (2.9) Nationality National (Jordanian - 236 (94.4) 242 (100) UAE) Others 14 (5.6) 0 (0) Religion Muslim 245 (98) 242 (100) Others 5 (2) 0 (0) Marital Status Single 96 (38.4) 144 (59.5) Married 122 (48.8) 80 (33.1) Divorced 29 (11.6) 17 (7.0) Widower 2 (0.8) 0 (0) Separated 1 (0.4) 1 (0.4) Educational Background Illiterate 1 (0.4) 3 (1.2) Primary 38 (15.2) 20 (8.3) Preparatory 81 (32.4) 54 (22.3) Secondary 96 (38.4) 127 (52.5) University and above 34 (13.6) 38 (15.7) Employment Not Employed 50 (20) 152 (63) Employed 200 (80) 90 (37) Source of referral Family 167 (66.8) 29 (12) Self 77 (30.8) 124 (51) Hospital/Clinic 3 (1.2) 0 (0) Police/Justice 1 (0.4) 89 (37) SystemOthers 2 (0.8) 0 (0)

Using chi-square test in the comparison between the two clinical populations characteristics, it was found that there is a statistically significant association between the two populations in material status, educational background and employment as their p<0.05. with age and source of referral there was not enough evidence to conclude that the variables are associated. (Table 4.32).

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Table 4- 32 Chi-square test between the two clinical populations characteristics

Marital Educational Source of Age Employment Status Background referral

Chi-square 52.81 23.34 16.39 93.12 55.60 DF 7 24 4 1 4 P-value 4.04E-09 0.00011 0.0025 0 2.40E-11 4.3.2. Psychiatric & Medical Data:

In Al Ghafri’s study, anxiety was the most common psychiatric symptom that was reported by 43.6% of the participants (109/250), followed by depression as reported by 27.2% (68/250). Only 5.2%

(13/250) reported having schizophrenic symptoms. Regarding medical history, gastritis was the most commonly reported illness by 17.6%

(44/250) of the total sample. 5% of the participants stated being diagnosed with a type of hepatitis. Hepatitis C was more prevalent (2.4%

- 6/250) than the other hepatitis types. Hypertension was the third most commonly reported medical illness as it was mentioned by 3.6%

(9/250) of the sample. 0.8% (2/250) of the total reported having diabetes. Only one participant revealed having HIV. (Table 4.33).

In the current study, mood disorders were the most commonly reported by 52.1% (126/242). Depression was mentioned by 43.8% of the sample

(106/242), and 42.1% (102/242) stated that they had anxiety symptoms. Schizophrenia was not reported by anyone. When assessing the medical history of the participants, hypertension (12.0% -29/242) and gastritis (11.6% -28/242) were reported by most of the sample.

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Only 10% (25/250) stated having one type of hepatitis. Mostly hepatitis

C was the most common type of hepatitis among the total sample with

7.9% (19/242). Diabetes was reported by 5% (12/242) of the sample and none reported having AIDS. (Table 4.33).

Table 4- 33 Frequency Distribution of the Comparison of

Psychiatric & Medical Data between Al Ghafri’s study and the current study.

Al Ghafri’s Study Current Study

250 (100%) 242 (100%) Yes (%) No (%) Yes (%) No (%) Depression 68 (27.2) 182 (72.8) 106 (43.8) 136 (56.2) Psychiatric Schizophrenia 13 (5.2) 237 (94.8) 0 242 (100) History Anxiety disorders 109 (43.6) 141 (56.4) 102 (42.1) 140 (57.9)

Mood disorders 0 (0) 0 (0) 126 (52.1) 116 (47.9)

Hep (A) 2 (0.8) 5 (2.1) Hepatitis Hep (B) 4 (1.6) 238 (95.2) 1 (0.4) 217 (89.7)

Medical Hep (C) 6 (2.4) 19 (7.9) AIDS 1 (0.4) 249 (99.6) 0 (0) 242 (100) History Hypertension 9 (3.6) 241 (96.4) 29 (12) 213 (88) Diabetes 2 (0.8) 248 (99.2) 12 (5) 230 (95) Gastritis 44 (17.6) 206 (82.4) 28 (11.6) 214 (88.4) 4.3.3. Substance Abuse and Smoking History:

4.3.3.1. Substance of Use

Looking at the sample distribution based on substance of abuse, the majority of Al Ghafri’s study (41.2% - 103/250) used alcohol only, while

18.8% (47/250) used drugs only. A small number of the total (3.6% -

9/250) were alcohol and drugs abusers. (Table 4.34).

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In the current study, 73% (177/242) of the sample were alcohol and drugs users, 17% (42/242) used drugs only, and 10% (23/242) used alcohol only. (Table 4.34).

Table 4- 34 Comparison of Substance of Use between Al Ghafri’s study and the current study

Al Ghafri’s Study Current Study Alcohol only 103 (41.2) 23 (10) Drugs only 47 (18.8) 42 (17) Alcohol + Drugs 9 (3.6) 177 (73)

4.3.3.2. Smoking History

Table 4.33 shows the current smoking status and the smoking history,

98% (245/250) of Al Ghafri’s sample were currently smoking, of whom

89.7% (220/245) stated that they started smoking prior to their addiction. (Table 4.35).

In the current study, 98.8% (239/242) of the total reported that they were currently smoking, of whom 90.4% (216/242) started smoking before their addiction. (Table 4.35).

Table 4- 35 Comparison of current smoking status and smoking history between Al Ghafri’s study and the current study

Dr. Al Ghafri’s Current Study Study Yes (%) No (%) Yes (%) No (%) Do you smoke? 245 (98) 5 (2) 239 (98.8) 3 (1.2)

Was it ...... your Before After Before After addiction 220 (89.7) 25 (4.0) 216 (90.4) 23 (9.6)

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4.3.3.3. Age of First Use:

The age of first use varied in Al Ghafri’s study according to the

substance used. The youngest age of first use reported was among the

hallucinogenic drugs users and it was 11 years,while the oldest age of

first use was 17 for both heroin users and cocaine users. (Table 4.36).

In the current study, the youngest age of first use of most of substance

was 11 years and oldest age of first use was 14 for both heroin and

other narcotics. (Table 4.36).

Table 4- 36 Comparison of substance by age of 1st use between

Al Ghafri’s study and the current study

Khat

Benz

Hallu

Other Other Other

Heroin

Alcohol

Amphet

Cocaine

Sedative

Cannabis

Narcotics Inhalants

Substances

Al Ghafri’s 12 17 13 17 15 15 16 11 13 0 0 Study Current 11 14 14 13 11 11 12 11 12 12 11 Study 4.3.3.4. Current Use

In Al Ghafri’s study, there were 147 participants who used drugs only.

68.7% (101/147) of this group were moderate or heavy users. Only 6

(4.1%) were abstinent in the last 1-2 months prior to their admission.

The same results were found among alcohol users group as 76.2%

(103/135) of the participants were moderate or heavy users and 5.9%

(8/135) were abstinent in the last 1-2 months prior to their admission.

(Table 4.37).

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In the current study, 219 participants used drugs only. 49.2%

(119/219) of whom stated they were abstinent in the last 1-2 months prior to their admission, while 31.8% (77/219) of the participants were moderate or heavy users. For alcohol, the majority (76.6% - 157/205) of the participants reported being abstinent during the past 1-2 months. (Table 4.37).

Table 4- 37 Comparison of current use of substance and alcohol between Al Ghafri’s study and the current study.

Current Use Substance Alcohol (Past 1-2 Abstinent Light Moderate Heavy Abstinent Light Moderate Heavy months)

39 55 23 74 Al Ghafri’s Study 6 (4.1) 46 (31.3) 8 (5.9) 29 (21.4) (26.5) (37.4) (17.0) (54.8) 119 52 Current Study 23 (9.5) 25 (10.3) 152 (76) 19 (10) 13 (7) 16 (8) (49.2) (21.5)

The above section presented the comparison between two clinical populations; one from Jordan (Al Ghafri, 2014) and one from the UAE.

The assumption was that the characteristics of the two clinical populations are similar due to the assumed cultural and religious similarities. The descriptive analysis of both clinical populations’ profile revealed the presence of some similarities and differences. (Chapter 5).

4.4. SECTION THREE: Hypothesis #2: Severity of

Dependence Associations

The second hypothesis is testing the association between severity of dependence and substance use initiation age, length of dependence,

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presence of a family history of addiction and level of education as follows:

Severity of dependence will be associated with:

a. Early initiation of substance use,

b. Longer length of dependence,

c. Presence of a family history of addiction, and

d. Lower level of education.

Logistic regression analysis was carried out to test the association between the severity of dependence (dichotomous) and the above mentioned variables. (n=250). In both unadjusted and adjusted logistic regression, there were no significant associations found between severity of dependence and the variables studied as all p-values are larger than the critical p<0.05.

Table 4- 38 Unadjusted and adjusted Regression analysis of Severity of Dependence

Unadjusted Adjusted Characteristics 95.0% CI p- 95.0% CI p- measured Odds ratio value Odds ratio (Lower, value (Lower, Upper) Upper) Initial age (young 0.86 (0.42, 1.76) 0.68 0.90 (0.44, 1.85) 0.77 age) Education (below 1.14 (0.58, 2.24) 0.71 1.2 (0.6, 2.4) 0.61 Secondary) Family history 1.31 (0.63, 2.69) 0.47 1.30 (0.63, 2.70) 0.48 (present) Length of use 1.29 (0.61, 2.77) 0.51 1.30 (0.60, 2.83) 0.51 (<5years)

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4.5. SECTION THREE: Hypothesis #3: Social Drift

Associations

The third hypothesis tested the association between social drift and age of first initiation, length of dependence, and presence of a family history of addiction as follows:

Social drift will be associated with the following:

a. Early initiation of substance use,

b. Longer length of dependence, and

c. Presence of a family history of addiction.

Logistic regression analysis was carried out test the association between social drift (dichotomous) and the above mentioned variables

(n=250). In both unadjusted and adjusted logistic regression, there were no significant associations found between social drift and the variables studied as all p-values are larger than the critical p<0.05.

Table 4- 39 Unadjusted and adjusted Regression analysis of

Social Drift

Unadjusted Adjusted Characteristics 95.0% CI p- 95.0% CI p- measured Odds ratio (Lower, value Odds ratio value Upper) (Lower, Upper) Initial age 1.35 (0.75, 2.43) 0.33 1.45 (0.80, 2.66) 0.22 (young age) Family history 1.62 (0.92, 2.86) 0.10 1.60 (0.90, 2.85) 0.11 (present) Length of use 1.83 (0.99, 3.39) 0.60 1.84 (0.98, 3.43) 0.57 (<5years)

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4.6. SECTION FOUR: Hypothesis #4: Increased nursing

interactions will be associated with higher level of

patient satisfaction with the nursing services

The association between the nursing interactions and patient satisfaction was examined using linear regression analysis. Highly significant association was found between patient satisfaction and the combined variable of nursing interaction. The table below shows that beta value of 0.82 indicates that a change of one standard deviation in the nursing interaction results in a 0.82 standard deviations increase in the patient satisfaction.

Table 4- 40 Unstandardized and Standardized Coefficients analysis of Patient Satisfaction

Unstandardized Standardized 95.0% Confidence Coefficients Coefficients Interval for B Model t Sig. Std. Lower Upper B Beta Error Bound Bound

1 (Constant) -0.019 0.042 -0.46 0.65 -0.10 0.06

Nursing 0.36 0.016 0.82 22.21 .000 0.33 0.39 Interaction

4.7. Conclusion

The main objective of the study was to build up a profile of substance users who are attending NRC for treatment, which can be used to shape treatment and prevention and policies and practices. The study findings showed that the substance user is single, educated, smoker and

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unemployed who requested the treatment by himself or herself. The youngest age of first use of most of substance was 11 years. The majority of the participants were polysubstance users who are having moderate severity of dependence. Family history of substance use disorders was present with 27% of participants reported having an addicted brother living with them.

The study also, looked at the characteristics of two clinical populations, one from Jordan and the other one was the substance users who are receiving treatment at the NRC. The assumption was that they are similar as they share the same racial origins, the same language, the same religion and, to some extent, the same cultural background. The results of the study confirmed the proposed hypothesis and the characteristics of the two populations were found to be generally similar.

The second hypothesis examined the association between severity of dependence and substance use initiation age, length of dependence, presence of a family history of addiction and level of educational attainment. No significant associations were found between severity of dependence and the variables studied. The same was found with the third hypothesis which tested the association between social drift and age of first initiation, length of dependence, and presence of a family history of addiction. The association between the nursing interactions and patient satisfaction was highly significant.

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5. CHAPTER FIVE: DISCUSSION

This chapter consists of three main sections. Section one summarizes the key findings and presents these findings considering the existing literature. The second section provides a description of the study’s strengths and limitations and the third section explores the implications of the study findings on health policy in the UAE and future research.

5.1. Main Findings

The study aims to identify and examine the characteristics of the clinical population of substance users in the UAE and explores the concept of social drift with respect to substance use disorder. The main findings were drawn from a questionnaire and summarized under the original objectives.

5.1.1. The characteristics of the clinical population of

substance abusers receiving treatment in the NRC

(UAE):

The mean age of the participants in the current study was 28.5 years which is similar to the mean age in Amir’s study (2001) which was 27.6 years despite the 14 years difference between the two studies. The majority of the current study participants were under the age of 30 years and only seven were over the age of 50 years. This is an indicator of the presence of a younger generation of substance abusers in the community who require more attention. Seeking treatment at a younger

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age could be an indication of a better accessibility to treatment or it could reflect the increase in the community awareness of substance abuse problems. The same was reported in Abu Madini study (2008) and Amir’s study (2001). This was supported by the low age of first initiation of use among the same sample, which was 11 years for most substances. This was lower than Amir study (Amir, 2001) which was

18.7 years, perhaps indicative of the growth of the substance use problem in the region.

The majority of the current sample were single, which is consistent with

Elkashef study (2013). This could be explained by having the majority of study sample younger than 30 years. 98.8% of the current sample were educated, with the majority being at the secondary level. This finding is different from Elkashef study (2013) as the majority in that sample did not have a secondary education. This also is consistent with the age distribution among the UAE population as more than 80% of

UAE population is aged between 15 and 64 years. (Statista, 2018).

Half (49.6%) of the current sample were unemployed compared to 36% who were employed. This is another different finding from Elkashef study (2013) which had 60% of its sample being unemployed and 33% were either employed or were students. This decrease in the unemployment rate between the two studies is consistent with the change in the level of education from the majority being below secondary level in Elkashef study to the majority having a secondary level of education in the current study. Also, the current finding can be

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explained by the decrease in the unemployment rate in the UAE to 3.7% in 2016 from 4.2% in 2009. This was a result of many government initiatives that targeted unemployment status in the country (Trading

Economics, 2018).

The most common source of referral was self-referred (51.6%), and referrals from the justice system came next (36.4%). The same finding was highlighted by Elkashef et al. (2013). This can be seen as a result of the NRC’s interventions in awareness raising and prevention. The

National Rehabilitation Centre has a comprehensive prevention strategy that includes structured and systematized evidence-based curricula and targeted awareness activities. The strategy is aimed to reaching sustainable outcomes to reduce social stigma and support recovery. (The National Rehabilitation Center, 2018).

In relation to co-morbidity illnesses in the population treated at the

NRC, the results showed that the majority of the sample reported having a psychiatric condition or symptoms. 52.1% reported having mood disorders, 43.8% reported having depression and 42.1% had anxiety symptoms. The same was reported by Elkashef et al., (2013) with minor differences in the illness’ distribution. This finding is consistent with other studies from the region; e.g., Karam (2002) found that 64% of those with substance abuse problems had a co-morbid condition. It must be noted that these are self-reported findings and not formal diagnoses or case note records.

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Virtually all (98.8%) of the sample reported that they were currently smokers, with 90.3% reported starting smoking before their drug addiction. The same was reported in the Alblooshi study (2016) in the

UAE and by the Iqbal study (2000) in Saudi Arabia. According to the

WHO report on the global tobacco epidemic in 2017, the prevalence of cigarette smoking among adults was more than 28% and more than

12% among the youth population. (World health Organization, 2017).

In the UAE, the youth tobacco use prevalence was 12.2%, while the adult tobacco smoking prevalence among male was 28% and 0.9% among females (World Health Orgnaization, 2017).

Nicotine smoking could be considered as the first acceptable addictive substance in this region and could act as a gateway for use of other substances. This is an area that requires serious intervention by policy makers.

The youngest age of first use of most of substance was 11 years. 82% of the sample used alcohol for the first time in their life between the ages of 11 and 41. The same age of initiation was reported for benzodiazepines, sedatives, cannabis, inhalants and khat use. For heroin and other types of narcotics, the youngest age of first use was

14 years.

These findings are close to the Iqbal study (2000) findings where 10 years was the youngest age to initiate substance use. In Amir’s study

(2001) the age of first use in the UAE was 18.7 years which is older than

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the current sample age of first use. The age of initial use being very young is a red flag that must be taken seriously. According to the

National Institute on Drug Abuse, the use of tobacco, alcohol, and illegal and prescription drugs is common during adolescence due to many reasons. These reasons may include the need to experience something new, assuming that drugs are harmless, as an attempt to do better in school, as a solution to deal with a problem and, most importantly, peer pressure (National Institute on Drug Abuse, 2018).

In the current sample 73% were polysubstance users, 18% used drugs only, and 9 % used alcohol only. This is consistent with other studies from the region such as Amir (2001), AbuMadini (2008) and Elkashef et al. (2013). The reason behind polysubstance abuse is the intent to experience greater effects from multiple substances. However, this will increase the possible negative effects of each drug which could result in unpredictable consequences.

When reporting the current use of alcohol and substance, the majority of the sample reported that they had not been using in the last 1-2 months preceding their admission. This can be related to the fact that more than 70% of the sample were engaged in treatment prior to their entering inpatient treatment. This could be the reason the participants rated the overall importance of substance and alcohol use in their life during the past month as “not so important.”

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In assessing dependency for substance and alcohol use, it was found that more than 80% of both alcohol and substance users stated that they didn’t spend much time searching for either drugs or alcohol. This is an indication of the ease of access of such substances in the UAE.

Clearly more data needs to be collected and the current efforts of Drugs and Alcohol Demand Reduction in the UAE needs to be carefully studied and measures taken to address any weaknesses. Policy makers and law enforcing agencies as well as treatment and rehabilitation centers must constantly work together to more effectively reduce drug and alcohol demand. Most of the substance users admitted that they were using large amounts of drugs over a long period of time, compared to only 31% of the alcohol users. This could be due to increased tolerance and complexities of poly-drug use with drug interactions and use of different drugs for different effects.

When measuring the severity of dependence among participants, it was found that the majority of both groups had moderate severity of dependence (50% of substance users and 61.5% of alcohol users). This could be explained in terms of better access to treatment and patients seeking treatment early in their careers. However, 40% of the substance users were rated as being at high severity of dependence compared to 26.3% of the alcohol users. This may be an indication that individuals switch to drugs as they become more severely addicted or that drugs are more available to users. The religious prohibition of

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alcohol may also mean that patients are more likely to justify use of drugs.

The CAGE results were consistent with the severity of dependence as most of the alcohol users had a CAGE score of 2, which is expected as the majority of the participants were engaged in treatment.

Withdrawal symptoms varied based on the addicted substance.

Insomnia, sweating and body weakness were the most common withdrawal symptoms reported by substance users. Headache, body weakness, tremor and insomnia were the most commonly reported by alcohol users.

72% of the participants went through previous treatments prior to the current inpatient treatment episode, with the majority giving a history of both inpatient and outpatient treatment services. Follow ups and after care programs after discharge were another aspect of treatment experience participants had engaged in. This is a strong indicator of treatment accessibility, availability and affordability. UAE nationals receive treatment for free regardless of the number of admissions, simply because addiction is viewed as a relapsing disease and the best solution to combat this problem is treatment. The antinarcotic law in the UAE states clearly that “No criminal proceedings shall be instituted against any abuser of narcotic drugs or psychotropic substances who voluntarily presents either to the Addiction Treatment Unit referred to in article 4 or to the Public Prosecution, requesting treatment”

(Department of Drug Control, 2018). Another encouraging step was

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adding the option of treatment for those reported by their first-degree relatives without any criminal proceedings being instituted

(Department of Drug Control, 2018).

When assessing the NRC services in terms of responsiveness and coordination, 91% stated that the NRC was responsive enough to their needs and 97% indicated that the care in-between services were well coordinated. The majority stated that they would choose the NRC again to receive treatment. This is a result of the NRC higher management commitment to provide the best treatment and rehabilitation services that meet its patients’ needs. To be able to do this, the NRC regularly evaluates the programs and the services it provides to its customers

(Elkashef, et al., 2017).

On the other hand, 20% of the participants mentioned that they would not choose the NRC again to receive treatment. Because this was a questionnaire-based study, it was difficult to capture in details the reasons behind this response. Most of the reasons were related to participants being unsatisfied with ancillary services provided, such as opportunities for telephone calling and the visitation system. The NRC policy is that only first-degree relatives are allowed to call and visit after completing the successful completion of the detoxification program.

This was viewed by participants as freedom restriction. More patients’ awareness and orientation to treatment sessions may be required to improve patients’ understanding and expectations during their treatment journey at the NRC.

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Looking at the family history of psychiatric, addiction, suicide and the current health status of each family member, it was found that these problems exist but at a smaller scale. One of the interesting results of this study was in relation to family history, where 27% of participants reported having an addicted brother. This also was highlighted under the accommodation section below. Studies suggested that family environment contributes to the risk for addiction (Kendler, Ohlsson,

Sundquist, & Sundquist, 2013).

Craving was reported as the highest factor associated with relapse, followed by peer pressure and unemployment. According to the literature, urges and cravings to use are the most common factors for relapse, which was also found in this study (AlMarri & Oei, 2009).

In general, many studies described the demographic profiles a substance abuser as a young male with limited education who is often unemployed (AlMarri & Oei, 2009). The findings of this study are consistent with this general finding. The results in terms of employment status were discussed earlier.

Further questions were asked to assess the effect of substance use disorders on employment. 73% of those who were employed reported losing their job because of their addiction. 69% stated that their job was affected by their addiction. 41% lost a chance of promotion because of their dependence. This finding can be considered as strong evidence for social drift due to their substance use disorders history.

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More than 87% reported that they owned their own house and 12% were living in rented houses. The majority of the participants were living with their parents and their siblings. Maintaining one’s own accommodation was an important priority in their life. From its inception, the vision of its founding father H.H. the late Sheik Zayed

Bin Sultan Al Nahyan was to channel the countries resources to build a world class infrastructure, provide the best of its citizens and strengthen culture of its society of family cohesion and solidarity among society members, based on Islamic principles. An outcome of this is a high level of home ownership but also extended families living together.

UAE nationals enjoy open access to good free education, health services, housing and other vital infrastructures. The UAE Government distributes land or offers free housing or housing loans, residential facilities and maintenance to deserving UAE nationals. In such a context, it is very difficult to assess the effect of substance use disorders on accommodation (Government.ae, 2018).

Despite all of this, one participant was homeless which strongly contradicts what the UAE culture stands for, which are cohesiveness bound by religious and familial relations and traditional values of cooperating and sharing.

Out of the 18% who had an addict family member living with them, 76% lived with an addicted brother and around 11% of the participants lived with an addicted father, which could explain the low amount of time

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spent in searching for substance or alcohol as it is already available in the house.

As explained above, the majority had had a secondary school education.

This can be explained as a result of the free education that the UAE government provides. Around 56% did not complete their studies for different reasons, of whom 68% of them did not complete their studies because of their addiction. This also lends further support to the concept of social drift as a result of substance use disorders in the UAE.

The consequences of addiction on marital status are very clear in the results. 25% had ended their marriage due to addiction and around

32% of the married participants were involved in relationships outside their marriage. This can be taken as further evidence for social drift.

Shockingly, in the UAE context, 13% of those who had children, used drugs or consumed alcohol in front of their children.

The main source of income identified was the family which is also another translation of the family unity and cohesiveness. Some 7% received financial support from the NRC as a tool used in contingency management to support patients during their treatment journey. Some two-thirds (64%) of the participants reported a change in their income after their initial usage of drugs/alcohol, which is a normal consequence of addiction and an indication of social drift.

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5.1.2. Hypothesis # 1: The characteristics of the clinical

population of substance abusers receiving treatment in

the NRC will be similar as the clinical population of

substance abusers studied in Al Ghaferi’s 2014.

One of the study aims is to compare Jordanian clinical population from

Al Ghaferi’s study and Emirati clinical population from the current study. The assumption was that given the cultural similarities between

Abu Dhabi and Jordan the results of the characteristics of the two populations will be very similar.

UAE and Jordan are both part of the Middle East region. The two countries are similar in many ways. They share the same racial origins, the same language, the same religion and, to some extent, the same cultural background. This suggested that the characteristics of substance abusers may be similar. Also, the location of both countries makes them susceptible to similar geographic patterns of drug trafficking. Both are multinational countries, which expose them both to new norms and traditions that the citizens of each country can be influenced by. On the other hand, the two countries differ in terms of individual income and the standards of living.

The two clinical populations, who were all males, were comparable in terms of age distribution, educational background, smoking history and age of first use but differ in terms of material status, employment and source of referral to treatment. Substance abusers in the UAE were single, unemployed and they sought treatment by themselves compared 136

to substance abusers in Jordan who were married, employed and sought treatment under their families’ request.

There is a larger percentage of polysubstance abusers in the UAE, while there is a larger percentage of alcohol users in Jordan. Comparing the current use of alcohol and substance use, the UAE sample described it as being abstinent as they were more engaged into treatment, while the

Jordanian sample described their use as heavy use.

Chi-square test results suggested that there is a statistically significant difference between the two populations in marital status, educational background and employment (p<0.05), while, age and source of referral were not significantly different.

Based on the cultural, religious and geographical location, similarities in the characteristics of the two clinical populations were expected. Age and education in the two populations were similar. The typical substance abuser in both countries is a male younger than 30 years of age who has secondary education. Based on previous studies, substance abusers would be less able to find and keep a job, which is true about the UAE sample. However, the Jordanian data do not support this hypothesis. Therefore, the proposed hypothesis is accepted and the characteristics of the two populations are generally similar.

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5.1.3. Hypothesis #2: Severity of Dependence

Associations

Severity of dependence was measured by the participants’ response to five questions that addressed the time spent in searching for the substance, use of large amounts over an extended period of time, the presence of a persistent desire to cut down or to control drug/alcohol use without succeeding, and continuing to use despite the problems that may exist and attempts to stop using.

The second hypothesis addresses the association between severity of dependence and substance use initiation age, length of dependence, presence of a family history of addiction and level of educational attainment. Logistic regression analysis was carried out to test the association between the severity of dependence (dichotomous) and the above mentioned variables (n=250). No significant associations were found between severity of dependence and the variables studied.

These findings are not consistent with the literature, which could be due to sample size or unique cultural factors of drug users in the UAE.

Alcohol use is prohibited in Islam. Since there are no explicit references to drug use, some take it is culturally acceptable, although, it is generally understood that intoxicants are prohibited. In UAE law there is a mandatory 4 years’ prison sentence if caught using intoxicants

(alcohol or illegal drugs), seeking treatment or opting for treatment mitigates this sentence. The impact of this on the culture and

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particularly on young people could be considered unique (Department of Drug Control, 2018).

5.1.4. Hypothesis #3: Social Drift Associations

Social drift was based on the following variables: losing one’s job because of addiction, job performance affected by addiction, loss of promotion opportunities, education not completed because of addiction, and a change in income after addiction.

The third hypothesis tested the association between social drift and age of first initiation, length of dependence, and presence of a family history of addiction. Logistic regression analysis was carried out to test the association between social drift (dichotomous) and the above mentioned variables (n=250). In both unadjusted and adjusted logistic regression, there were no significant associations found between social drift and the variables studied as all p-values are larger than the critical p<0.05.

5.1.5. Hypothesis #4: Increased nursing interactions will

be associated with higher level of patient satisfaction

with the nursing services

Patients’ satisfaction with the nursing staff at the NRC was assessed in the questionnaire using four direct questions. Three of the questions focused on specific nursing tasks and the fourth question directly inquired about the patients’ satisfaction with nursing care during their time at the NRC.

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The majority were able to identify the nursing staff, had received counselling therapy from the nursing staff and the nurses were available whenever they were needed. Overall, 95% were satisfied with the care received from the nursing staff. Looking at the association between the nursing interactions and patient satisfaction using correlational and linear regression analysis, a highly significant association between patient satisfaction and nursing interaction was found. Given the link between patient satisfaction in treatment outcome in mental health (e.g., Chue, (2006)) and addictions treatment (e.g.,

Carlson and Gabriel, (2001)), this can be considered an important finding. This has implications for service development as well as enhancing the role of the nurse at the NRC.

Addiction is a subspecialty area within the nursing career framework.

It is defined by the service users and the specialized clinical tasks carried out. Nurses can make positive impacts in the patient’s treatment journey through accomplishing a range of healthcare outcomes. They can achieve these outcomes by delivering interventions that start with conducting the physical and mental assessment, throughout the treatment trip reaching to the comprehensive recovery plan. Nurses can add value across a range of public health priorities for individuals, families and the community. Mental health nurses have an advanced knowledge of psychosocial practices and the skills to implement of these practices (Royal College of Nursing, 2017). Whilst the nurses at the NRC are not mental health nurses, they have had

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significant in-service training input at the NRC. The finding also strengthens the case to develop specialized courses such as Diplomas in mental health and Addiction nursing which are not currently available in the UAE.

Many studies have linked good nursing care with increased patient satisfaction. Some studies demonstrated that nurse burnout is a significant factor influencing how patients’ satisfaction is associated with their care. Others recognized adjustable changes in the nurses' work environments, such as, adequate staffing, administrative support, and better nurses-physician relations that improve nurses' work environments and eventually reduce patient dissatisfaction (Vahey,

Aiken, Sloane, Clarke, & Vargas, 2004). These factors should be constantly monitored in order to maintain good nursing conditions.

There are no specialized mental health or addictions nurse training courses in the UAE or region. Hence, the nurses who work at the NRC are general nurses. The unique feature is that they have received considerable amount of training in the form of regular workshops on counselling skills and psychosocial interventions in addictions. As a result, they have become skilled in these areas and it is demonstrated in their interactions with patients. Motivational interventions and conversations as a result of their training in Motivational Interviewing can be given as an example.

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5.2. Strengths and Limitations

5.2.1. Strengths

In research a questionnaire is considered to be a practical method to collect standardized data from large samples in a fashion that allows the use of statistics and is relatively cost effective. The questionnaire is very comprehensive as it studies multiple aspects including patterns, demographic information and behavior, which enable multiple comparisons at one point in time. The questionnaire used in this study was based on internationally validated questionnaires focusing on aspects of addiction that are universally recognized.

The main strength of this research is that it is one of few studies that has looked at addiction and the characteristics of substance users in the UAE, using current data rather than retrospective data. This will provide a baseline for future comparisons using the same measures.

The results capture the characteristics of a clinical population over a period of one year which could be generalized, particularly the results of the male sample. Despite having a small number of female participants, the results gave a snapshot of the characteristics of female addicts that can be used as a baseline for future researches. The inclusion of a female sample however small can be taken as a major strength as there are very few studies from the region that have reported on the characteristics of female participants.

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5.2.2. Limitations

The lack of published studies on the internationally validated questionnaires, which were used to develop the current questionnaire being used in an Islamic country could be a considered a potential weakness as questions of validity could be raised. Another weakness of this questionnaire is that the participants’ feedback is mainly based on self-reports of their addictive behaviors, where there is a common tendency for under-reporting. The questionnaire included many variables which could be viewed as a possible drawback. (Setia, 2016).

Using only one method approach, a questionnaire, limited gathering in- depth information and the elaboration of many aspects of the participants’ addiction journey, as well as the effect of addiction on their lives. It also limited a comprehensive exploration of social drift in association to drug use in this population. A qualitative component would have greatly enhanced the study and revealed information that could not be obtained by the questionnaire alone. This will be of particular relevance to the cultural aspects. This was a weakness of the study and it is recommended that future studies include a cultural component.

Assessing the availability of infectious disease such as hepatitis C in this group was also limited as the answers were not based on trusted medical evidence. They were based on a self-report approach which depends on what the participants understood and wanted to report.

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The predominant Islamic culture, spirituality is very important in the

UAE. Due to their addiction some patients have drifted away from religion and spirituality. Reconnecting with religion and spirituality is seen as part of recovery and is integral to the therapeutic program based on the biopsychosocial model which is used in the study as its conceptual framework. However, the spiritual domain was not covered by the questionnaire which narrowed the scope of the outcomes.

Despite the structured method used in translation and validating the questionnaire, some questions were confusing and were subjected to cultural understandings. For example, in the accommodations section the participant was asked about the type of the accommodation he or she lives in; “owned” was one of the selections. In Western logic, owned means owning one’s own house, but culturally, in UAE as in most Arab countries, living in the parental home could be understood as “own house.”

An initial aim of the study and one of the hypotheses was to compare the UAE data with that of Jordan. This was an important aspect of the study. On the other hand, it also created a weakness in that some of the structural and linguistic problems like the example above carried over to this study. With hindsight it may have been better to develop a questionnaire based on international standard questionnaires for the purpose of this study, that was more precise and based on the standard clinical assessment. This way there could be ongoing data collection for regular comparison.

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The main limitation of the study was the small number of female participants and the lack of non-nationals in the study sample, which could raise a question about generalizing the results.

5.3. Implications for Practice

One of the main findings in this study was the early age of initiation.

Currently, there is no structured addiction treatment program for adolescents in the UAE, if not in the region. Targeting the early age of use opens the door for variety of interventions for the adolescent population that are available. This could include prevention initiatives and development of specialized and culturally adapted treatment programs. Early interventions targeting younger adolescents who are at high risk could improve the cost-effectiveness of investments in substance use disorders treatment.

School based prevention programs should be considered that are research-based that positively modify the balance between risk and protective factors for drug abuse in families, schools, and communities.

Such programs have proved that they can significantly decrease early use of tobacco, alcohol, and illicit drugs among youth. They support teachers, parents, and health care professionals and shape youths’ perceptions about the risks of substance use (National Institute on

Drug Abuse, 2018). These prevention programs must be developed in collaboration with different entities and stakeholders as adolescent addiction is a problem for the whole country. Parents, schools, media,

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healthcare facilities and the criminal justice system should all be involved in developing such programs.

Another practice implication on the emergence of adolescent substance use disorders is developing evidence-based treatment programs for those who already substance users. The current treatment rates propose that most adolescents with substance use disorders receive no treatment whatsoever which makes it difficult to estimate the treatment costs. Additionally, the consequences of adolescents’ substance use disorders costs may stretch across multiple entities that could include criminal justice system resources, mental health and general medical care services and the education system (Slade, 2008).

The study highlighted another problematic side which is smoking. A typical substance abuser is first a smoker. Smoking was mentioned by different studies as the gateway to addiction especially among adolescents. In the UAE, the WHO report stated that the prevalence of smoking among the youth for both sexes was 12.5% in 2015 and it is on the rise (World Health Organization, 2015).

The direct action to this problem is to include smoking cessation modalities in addiction treatment facilities as a crucial part of the treatment, not supplementary. Another action is to make all addiction treatment facilities smoke-free facilities. On the other side, a mass general smoking prevention program at the level of the whole community may be more effective as a public health strategy. Again, such programs must start as early as preparatory school if not at the 146

elementary level. Anti-tobacco messages in the media and education campaigns should be directed to parents and adolescents to raise awareness about the risks of tobacco use. Moreover, and to have effective preventive programs, messages should be focused on changing social norms around smoking and provide knowledge and skills to resist smoking. Research is also needed on smoking patterns of the population which will be discussed in the next section.

5.4. Implications for Policy

There are a number of implications from the present study for the continuing process of policy development. Policies regarding substance misuse in the UAE have been changing and in recent times the NRC has contributed to this process. Studies such as the present one provide valuable data to help support policy change. The finding that despite the laws, enforcement, restrictions and cultural attitudes, the easy access to drugs and alcohol that the majority of the patients reported is alarming. This has to be discussed among all the stakeholders including policymakers, law enforcement agencies, the criminal justice system, prevention organizations and treatment and rehabilitation facilities to identify the gaps or weaknesses in the system with the view of developing policies and interventions to address this issue. The policies have to be multidimensional and should use information from all stakeholders as well as research findings. This is the work of a surveillance center or body, perhaps by the Department of Health.

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The findings that the severity of dependence among the participants is moderate and the trend in the average age of patients is downwards is an indication that addiction services are becoming more accessible and that it may be capturing people earlier in their addiction. If this is the case, further review of policies in the direction of easing access to treatment and raising awareness should be carried out.

The headline finding of age of first use showing a downward trend is an alarming finding and should be taken very seriously by policymakers.

Policies that put a greater emphasis on school-based prevention work is urgently needed.

The comparison with similar data collected from a treatment sample from Jordan, although not in the same timeframe, revealed some similarities as well as differences. This indicates that even when the cultural and geographical contexts are similar, patterns of use and profiles of substance users could be quite different. There is an argument to work towards policy synchronization in a given region with similar cultural contexts. A regional forum to discuss each country’s policies and to learn from each other might lead to joint work towards synchronization of prevention and treatment efforts. The WHO is a good vehicle to facilitate this. The NRC as WHO Regional Collaborating

Centre could take a lead in this and call for such a meeting and facilitate presenting these findings and studies from regional countries.

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5.5. Further Research

There are a few indications for further research that come out of this study. Future studies of this nature should include a qualitative component so that more information on context and culture-related factors could be gathered. This type of information is helpful to develop more appropriate and user sensitive treatment programs as well as reviewing and developing policies. Qualitative data, particularly on female substance users, are lacking in the literature. This information is urgently needed for service development as well as policy development.

The finding that most patients smoked tobacco is an important one.

There is a general lack of studies into smoking in the UAE. The

“Midwakh”, a small pipelike implement that delivers a high dose of nicotine in a short period of time, is a particular invention of the UAE.

It appears that this is very popular among young people and most of our patients seem to use it. Yet there are no studies on “Midwakh” use and substance use in clinical populations. It is recommended that a study on smoking patterns of the patients at the NRC be carried out as a matter of priority which includes a measure of their attitude towards being treated for tobacco use while they are at the NRC. Findings from such a study will give valuable information to affect prevention programs and develop interventions for smoking cessation.

The finding that nursing interaction was highly significantly associated with patient satisfaction indicated that further research into nursing

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interaction would yield particularly useful information to develop the much-needed specialization in addiction nursing.

5.6. Overall Conclusions

This is one of the first concurrent studies of clinical population of substance users in the UAE. The findings provide useful information on the profile of the current patient population that could be used for developing and improving services as well as developing policies and conducting research. It also provides us with a baseline that could be used to monitor trends in the future. The study also enabled a comparison with a regional country with similar culture and demographics. The findings that nursing interaction is strongly associated with patient satisfaction has major implications for developing addiction nursing.

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APPENDIX – 1: PATIENT INFORMATION SHEET

PATIENT INFORMATION SHEET A STUDY OF THE CHARACTERISTICS OF A CLINICAL POPULATION OF SUBSTANCE MISUSERS IN THE UAE AND AN EXPLORATION OF SOCIAL DRIFT IN THIS POPULATION

INTRODUCTION You are being invited to participate in a research study. Before you decide to take part in this, kindly take time to read the following information carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to participate.

Thank you for reading this. WHAT IS THE AIM OF THIS PROJECT? To examine the characteristics of known illegal substance users in treatment in the National Rehabilitation Center – Abu Dhabi and to explore the concept of social drift in this group

WHY HAVE I BEEN CHOSEN? The sample size of the study will be all the patients (in - out) of National Rehabilitation Center – Abu Dhabi.

DO I HAVE TO TAKE PART? It is up to you to decide whether or not to take part. If you decide to take part you are still free to change your mind without giving a reason. A decision not to take part, will not affect the standard of care you receive.

WHAT DO I HAVE TO DO IF I TAKE PART? The procedure involves filling a questionnaire that will take approximately 30 minutes. You might be also asked to be interviewed by researcher or researcher assistants.

WILL MY TAKING PART IN THE STUDY BE KEPT CONFIDENTIAL? Yes. All the information will be treated anonymously and will be used only for research purposes only. Your identity will not be revealed in any publication resulting from this study.

CONTACT FOR FURTHER INFORMATION If you have any questions or concerns about the study, please contact Mrs. Samya Al Mamari – 02 4467777 We would be pleased to answer any queries you might have.

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APPENDIX – 2: CONSENT FORM

RESEARCH PARTICIPATION CONSENT FORM

INTRODUCTION

You are being invited to participate in a research study. Your participation in this research study is voluntary.

You may choose not to participate and you may withdraw your consent to participate at any time. You will not be penalized in any way should you decide not to participate or to withdraw from this study.

There are no known risks associated with this research.

All the information will be treated anonymously and will be use only for research purposes only. Your identity will not be revealed in any publication resulting from this study

If you have any questions or concerns about the research study, please contact Samya Al Mamari – 02 4467777

I read the Patient Information Sheet and I understand that my participation in the study is voluntary and that I am free to withdraw from the study at any time without giving any reason, without any effect on the standard of care I receive.

I agree to take part in the study  I don’t agree to take part in the study 

Date ……………….. Patient Signature………………………

Name of person taking consent………………………………………….. Date ……………….. Signature………………………

Researcher ………………………………………………………………………... Date ……………….. Signature………………………

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APPENDIX – 3: QUESTIONNAIRE

000 STRUCTURED QUESTIONNAIRE

Date: … /….. / …… Time: ………..

NRC #: ………………

PART 1: DEMOGRAPHIC

Patient Background

1. Gender: a. Male b. Female 2. Age: ………………….. 3. Nationality: a. UAE b. Other ………………….. 4. Religion: a. Muslim b. Other ………………….. 5. Material Status: a. Single b. Married c. Divorce d. Widower e. Separated 6. Educational Background: a. Illiterate b. Primary c. Preparatory d. Secondary e. University 7. Current Occupation: a. Unemployed b. Student c. Self-employed d. Employed e. Retired 8. Address: a. Abu Dhabi b. Dubai c. Sharjah d. Ajman e. Fujairah f. Ras al-Khaimah g. Umm al-Quwain

Referral Source

9. Voluntary: a. Self b. Family c. Hospital d. Others ………. 10. Non-voluntary: a. Justice System b. Others …………………………

Psychiatric History

11. Depression: a. Yes b. No c. Don’t know 12. Schizophrenia: a. Yes b. No c. Don’t know 13. Anxiety disorders: a. Yes b. No c. Don’t know 14. Mood disorders: a. Yes b. No c. Don’t know Medical History

15. Hepatitis: a. No b. Yes (A) c. Yes (B) d. Yes (C) e. Don’t know 16. AIDS: a. Yes b. No c. Don’t know 17. Hypertension: a. Yes b. No c. Don’t know 18. Diabetes: a. Yes b. No c. Don’t know 19. Gastritis: a. Yes b. No c. Don’t know 153

PART 2: ADDICTION HISTORY A. History of Substance Abuse / Nicotine Smoking

A.1 Substance Abuse

Route Age Use in Period Freq. of Substance First last 28 of use use 1. Yes uses days 2. No IV SM SN O Alcohol Heroin Other Narcotics Cocaine/Crack Benzodiazepines Other Sedatives/ Hypnotics Cannabis Hallucinogenic Inhalants/ Solvents Khat Amphetamines Others ……………..

Code to (Route): IV = intravenous injections. SM= smoked, SN = snorted, O = Oral

If you answer yes for Others, please mention ------

A.2 Nicotine Smoking

20. Do you smoke? a. Yes b. No If Yes, go to question No. 21. If No, go to question No. 23, 21. Was it before your addiction? a. Yes b. No 22. Was it after your addiction? a. Yes b. No

B. Current Use B.1 Substance Abuse

23. How would you describe your drug taking over the past 1-2 months? a. Abstinent b. Light c. Moderate d. Heavy 24. In the past month over all, how important were drugs in your life?

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a .Very important b .Important c. Not so important d. Do not know 25. How do you describe your satisfactions with this aspect in your life? a .Very satisfied b .Reasonably satisfied c. A bit satisfied d. Not satisfied B.2 Alcohol

26. How would you describe your alcohol intake over the past 1-2 months? a. Abstinent b. Light c. Moderate d. Heavy 27. In the past month over all, how important were alcohol your life? a .Very important b .Important c. Not so important d. Do not know 28. How do describe your satisfactions with this aspect in your life? a .Very satisfied b .Reasonably satisfied c. A bit satisfied d. Not satisfied

C. Criteria of dependence

C.1 Substance Abuse Dependence 29. Do you spend time in activities searching for the drugs? a. Yes b. No 30. Do you use large amount of drugs over a long period? a. Yes b. No 31. Do you have a persistent desire to cut down or to control taking drugs yet you have not succeeded? a. Yes b. No 32. Do you continue to use drugs despite the fact that it causes you many problems? a. Yes b. No 33. Have you tried to stop your habits? a. Yes b. No 34. If your answer is yes, mention the withdrawal symptoms that appear in you: Symptoms a. Yes b. No Symptoms a. Yes b. No Headache Insomnia Tremor Weakness Nausea Anxiety Vomiting Depression Sweating Others

If you answer yes for Others, please mention ------

35. Do you feel that you want to increase the amount of drugs you are using to reach the same feeling that you used to have in a small amount (with your current amount)? a. Yes b. No

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C.2 Alcohol Dependence 36. Do you spend time in activities searching for alcohol? a. Yes b. No 37. Do you use large amount of alcohol over a long period? a. Yes b. No 38. Do you have a persistent desire to cut down or to control taking alcohol yet you have not succeeded? a. Yes b. No 39. Do you continue to use alcohol despite the fact that it causes you many problems? a. Yes b. No 40. Have you tried to stop your habits? a. Yes b. No 41. If your answer is yes, mention the withdrawal symptoms that appear in you: Symptoms a. Yes b. No Symptoms a. Yes b. No Headache Insomnia Tremor Weakness Nausea Anxiety Vomiting Depression Sweating Others

If you answer yes for Others, please mention ------

42. Do you feel that you want to increase the amount of alcohol you are consuming to reach the same feeling that you used to have in a small amount (with your current amount)? a. Yes b. No D. CAGE Questionnaire: ALCOHOL

43. Have you ever felt you should cut down on your drinking? a. Yes b. No 44. Have you been annoyed by people who criticizing your drinking? a. Yes b. No 45. Have you ever felt bad or guilty about your drinking? a. Yes b. No 46. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye- Opener)? a. Yes b. No

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E. Control Measure History

47. Have you ever been received a treatment in a Detoxification and \or Rehabilitation center before this visit? a. Yes b. No If Yes, go to question No. 48. If No, go to question No. 53, 48. Was it: a. Inpatient b. Out Patient c. both 49. How many times: a. Inpatient b. Out Patient

50. Where and how long did you stay inpatient? …………………………………....

51. Did you have a follow up after your discharge? a. Yes b. No 52. Describe what sort of follow up you receives? a. OPD b. Matrix c. HWH 53. Do you feel the NRC service is responsive to your need? a. Very responsive b. Responsive c. Ok d. Unresponsive e. Very Unresponsive 54. What you like and what you don’t like in your treatment? ………………………………………………………………………………………………… …………………………………………………………………………………………………. 55. How well is your care being coordinated in-between different services? a. Very well b. Well c. Ok d. Poorly e. Very poorly 56. Were you able to identify nursing staff? a. Yes b. No 57. Did you receive any counselling from the nursing? a. Yes b. No 58. Were the nurses available when you needed them? a. Yes b. No 59. During your stay or attendance (outpatient) at the NRC how satisfied are you with the care you received from the Nursing staff? a. Strongly satisfied b. satisfied c. not satisfied 60. If you have the chance to choose your treatment facility will you come back again to this center? a. Yes b. No

F. Family history

61. Does any of your family have any psychiatric problems? 157

a. No b. Mother c. Father d. Brothers e. Sisters f. Spouse/partner g. Children 62. Does any of your family have alcoholism or have a drug addiction problem? a. No b. Mother c. Father d. Brothers e. Sisters f. Spouse/partner g. Children 63. Has any of your family attempted suicide? a. No b. Mother c. Father d. Brothers e. Sisters f. Spouse/partner g. Children 64. What is the current health status of your family members? I. Healthy : a. No b. Mother c. Father d. Brothers e. Sisters f. Spouse/partner g. Children II. Ill : a. No b. Mother c. Father d. Brothers e. Sisters f. Spouse/partnerG. Factors Associated g. Children with Relapse

65. Is this your first time for treatment? a. Yes b. No If Yes, go to question No. 67. If No, go to question No. 66, 66. What are your views of relapse? Why you get relapse? Dependence a. b. a. b. Dependence effect effect Yes No Yes No Peer pressure Unemployment Place connected to the Poor attitude addictive behavior Time connected to the Family problems addictive behavior Roll modelling

PART 3: SOCIAL

A. Employment

67. Employment Status:

a. Employed - Since: …………. B. Not Employed - Since…………………

c. Never employed d. Others, please mention ……………

If you are employed go to Question 68, if not employed go to question 69

68. Type of Employment:

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a. Manual b. Professional c. Administrative d. Other, please

mention…

69. History of Employment: Current job…………………………………………… Next to current………………………………………. Second to current……………………………………. Others, please mention …………………………….. 70. Did you lose your job in any of the above mentions because of your dependence? a. Yes b. No 71. Since you start taking drugs/drinking alcohol, has your job ever been affected? a. No b. Yes, positively c. Yes, negatively 72. Did you lose a chance of promotion in your job because of your dependence? a. Yes b. No 73. What support do you want to progress towards being employed? a. Literacy b. Numeric c. CV writing d. References e. Experience f. Skills g. Others, please mention:……………………………………..…B. Accommodations

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74. Type of Accommodation:

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a. Owned b. Rented c. Homeless f. Prison g. Others please mention ……….…

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75. Who is living with you?

a. Spouse b. Parents c. Dependent children d. Friends e. Other drug user f. Others g. alone h. Step parents i. Siblings j. Half siblings l. Live-in domestic help

76. Do any of the above use drugs or alcohol? a. Yes b. No If Yes, please indicate who ……….……………………….. If No, go to question No. 77, 77. How do you feel about maintaining your accommodation? a. Important issues b. Not important C. Education

78. I finished my studies before my addiction. a. Yes b. No 79. I finished my studies despite my addiction. a. Yes b. No 80. I did not complete my studies because of my addiction. a. Yes b. No 81. I did not complete my studies because of reasons not related to addiction. a. Yes b. No Others, please mention……………………………………………….

D. Marital history

82. How many times did you get married? a. One b. Two c. Three d. Four e. Not married 83. Number of marriages: Current:………... Past………… 84. Did any of the previous marriages ended because of addiction? a. Yes b. No 85. Do you have another partner other than your wife, such as a girlfriend? a. Yes b. No 86. Do you have dependent children? a. No b. Yes (1) b. (2-5) children 4- more, (No. children………………)

87. Are you involved in caring for your children? a. Yes b. No 88. If not who is caring for them now? a. Wife/husband b. family c. others …………………………. 163

89. Do you use drugs or drink alcohol in front of your children? a. Yes b. No

E. Financial issues

90. What is your source of income? a. Employer b. Social support c. Other(s), please mention…………… 91. Did your income change after your initial usage of drugs/alcohol? a. Yes b. No c. Yes, positively a. Yes, negatively 92. If you have only Dhs 1000 how would you spend it them over the following items: a. Food b. Drug and alcohol needs c. Accommodation d. Children & Family 93. If there is anything else you would rather spend Dhs 1000 on (apart from drugs or alcohol), what is it? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………..

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APPENDIX – 4: NRC IRB APPROVAL

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CURRICULUM VITA

SAMYA MOHAMMED AL MAMARI – BScN. MQM. MPH PERSONAL DATA Nationality: UAE. Date of Birth: 16thSeptember 1974 Marital Status: Married Profession: Registered Nurse Current Position: Director of Nursing EDUCATION

2011–Currently: Doctor of Public Health Program in Health Care Management and Leadership for the Emirate of Abu Dhabi Johns Hopkins Bloomberg School of Public Health Abu Dhabi - UAE / Baltimore - USA

2008 – 2011: Master of Public Health Program in Health Care Management and Leadership for the Emirate of Abu Dhabi Johns Hopkins Bloomberg School of Public Health Abu Dhabi - UAE / Baltimore - USA

2005 – 2007: Master of Quality Management University of Wollongong - Dubai - UAE

2001 - 2003: Bachelor of Science in Nursing (GPA 3.62) University of Sharjah - Sharjah -UAE

1997 - 2001: Higher Diploma in Nursing (GPA 3.03) 173

Higher Colleges of Technology Abu Dhabi Women’s College - Abu Dhabi - UAE

1992 - 1994: Practical Nursing Course (93.61%) School of Medical Services Zayed Military Hospital - Abu Dhabi - UAE

1990-1991: High School Certificate/Science (75%) Women Union - Abu Dhabi - UAE ATTENDANCE 14th – 15th April, 2018 ASAM 49th Annual Conference San Diego – USA 12th – 13th March 2018 Hemaya International Forum Dubai – UAE 26th – 29th Oct 2017 9th ISAM Annual Conference Addiction Medicine: New Frontier Abu Dhabi – UAE 24th May, 2012 Scope of Practice User Guide Dubai – UAE 14th May, 2012 – 19th May, 2012 Substance Abuse & Clinical Service Intensive Overview McLean Hospital – USA 15th Feb, 2012 – 16th Feb, 2012 Leadership & Team Building Workshop Abu Dhabi – UAE 25th Sep, 2011 Crash Trolley Course Abu Dhabi – UAE 23rd Sep, 2011 – 24th Sep, 2011 International Trauma Life Support (ITLS) - Advance Abu Dhabi – UAE 11th July, 2011 – 14th July, 2011 Infectious Diseases & Disaster Response Abu Dhabi – UAE 28th July, 2011 Leadership and Management in Nursing Dubai – UAE

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10th Dec, 2010 Nephrology Nursing Symposium Abu Dhabi – UAE 25th Jan, 2009 – 29th Jan, 2009 Fundamentals of the Terrorism Incident Planning Process Medical Countermeasures Abu Dhabi – UAE 16th Nov, 2008 – 20th Nov, 2008 International Practicum on Quality Improvement & Accreditation Dubai – UAE 19th July, 2008 – 22nd July, 2008 2nd FME/EDTNA/ERCA Middle East & Africa Renal Education Program Prague – Czech Republic 16th May, 2008 Nursing Development Conference: Committing to Nursing Excellence Dubai – UAE Feb, 2005 – Feb, 2007 Leadership for Change Program – Phase 2 Abu Dhabi – UAE (under WHO & ICN) 27th, Sep 04-29th, Sep 04: CRRT and MultiFiltrate Training Fresenius Medical Care - Dubai - UAE 4th June 04- 6th June04: Peritoneal Dialysis Course PD Academy / Baxter Company - Muscat–Oman 25th Jan 04-28th Jan 04: Hemodialysis Nurses Training Fresenius Medical Care - Dubai - UAE Sep 2002-Dec 2003: Nursing and Health Care Leadership & Management University of Sharjah - Sharjah - UAE EXPERINCE Oct 2017-till today: Head of DG Technical Bureau National Rehabilitation Centre - Abu Dhabi July 2013-till today: Director of Nursing National Rehabilitation Centre - Abu Dhabi

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Jan 2012-July 2013: Nursing Unit Manager National Rehabilitation Centre - Abu Dhabi Aug 2010-Jan 2012: Acting Deputy Director of Nursing Zayed Military Hospital - Abu Dhabi Aug 2009-Aug 2010: Acting Director of Nursing Zayed Military Hospital - Abu Dhabi July 2007-Aug 2009: Assistant Director of Nursing Zayed Military Hospital - Abu Dhabi Sep 2005-Jan 2012: Nephrology Unit Manager Nephrology Unit - Zayed Military Hospital - Abu Dhabi March 2005-Sep 2005: Deputy In-charge of Nephrology Unit Nephrology Unit - Zayed Military Hospital - Abu Dhabi Feb 2005- Feb 2007: Part-time Nursing Instructor School of Medical Services - Zayed Military Hospital - Abu Dhabi July 2003-March 2005: Register Nurse (RN)/Dialysis Nurse Nephrology Unit - Zayed Military Hospital - Abu Dhabi Jan 1994-August 1997: Practical Nurse (PN) - Med/Surgical, ICU, VIP Zayed Military Hospital - Abu Dhabi ACHIEVEMENTS/ MEMBERSHIPS  Awards:

- Abu Dhabi Excellence Award Shortlisted Nominees: January 2017 - Abu Dhabi Medical Distinction Awards Shortlisted Nominees: February 2013 - Rashid Award for Scientific Outstanding: May 2008 - Caring Expert in the Gulf countries First Skill competition: Caring team won Gold medal in Al Ain. March, 2008 - Caring Expert in the Emirates International Skill competition: Caring team won Silver medal in Japan. Nov, 2007

 Committees: 176

- NRC Research Committee (member): 2017 till today. - International Addiction Review Journal (Executive Board member): 2017 till today - National Committee of Treatment & rehabilitation & Social Reintegration (member): 2016 till today - NRC Phase 2 Operational Committee (Head): 2015 till today - Scientific Committee for Practice (Member): 2010 till today - UAE Nursing and Midwifery Council (Observer): 2010 - Shaikha Fatma Health Science College Advisory Committee: 2008 - Nursing and Midwifery Advisory committee for the Emirates of Abu Dhabi: 2007

 Organizing:

- The 2nd Nephrology Nursing Symposium: 30, May 2008 - Nurses International Day Organizing committee: 2007 - 3rd General Assembly – Emirates Nursing Association: 2007 - Child Abuse in UAE Symposium: 2006 - The 1st Nephrology Nursing Symposium: Sep, 2006

 Presentation:

- ISAM 19th Conference: A study of the characteristics of a clinical population of substance misusers in the UAE. 28th Oct, 2017 - WHO–NRC Regional Capacity Building Workshop for the National Managers on Development of Services for Prevention and Management of Substance Use and Substance Use Disorders: Human Resources Capacity Building. 2nd Nov, 2016 - WHO–NRC Regional Capacity Building Workshop for the National Managers on Development of Services for Prevention and Management of Substance Use and Substance Use Disorders: Quality & Accreditation. 2nd Nov, 2016 - 2nd INCAN: The Human Touch and Nursing Practice. 5th, September 2014

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- 7th FME Middle East and Africa Renal Nurses Education Program: Taking Nursing Forward In Middle East & Africa: Stairs To Success 2nd Dec 2013 - Fatima College Conference: Bridging The Gap Between Nursing Education and Practice: 15th, March, 2012 - Nephrology Nursing: Where we stand: 10th, Dec 2010 - Nurses International Day: Shared Governance: 12th, May 2009 - Child Abuse in UAE: 2006

 Official Documentation:

- As part of being a member in the Scientific Committee for Practice, participated in writing and reviewing:  The UAE Registered Nurse Scope of Practice.  The UAE Registered Midwife Scope of Practice:  The UAE Practical Nurse Scope of Practice.  The UAE Practical Midwife Scope of Practice  Positive Environment Document

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