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R E S E A R C H Open Access
Determinants and prevalence of relapse
among patients with substance use
disorders: case of Icyizere Psychotherapeutic
Centre
Eric Kabisa
1,2*
, Emmanuel Biracyaza
2,3
, Jean d’Amour Habagusenga
2
and Aline Umubyeyi
4
Abstract
Background: Relapse to substance use after successful detoxication and rehabilitation is a public health concern
worldwide. Forty to sixty percent of persons in general relapsed after completing detoxication and rehabilitation
treatments. Although substance use remains a burden in Rwanda, very little is known about relapse among people
with substance use disorder (SUD). Hence, this study aimed to examine prevalence and the factors associated with
relapse to substance use at Icyizere Psychotherapeutic Centre (IPC), Rwanda.
Methods: Retrospective, cross-sectional survey was conducted among 391 patients with SUD at IPC. Multiple
logistic regression models using STATA version 13 were used to determine the factors associated with relapse
among the patients with SUD.
Results: Majority (84.1 %) of the participants were males. More than half (54.1 %) of them were aged between 18
and 30 years with the age average of 33 years (SD = 11.9 years). The results showed a higher prevalence of relapse
among patients with SUD (59.9 %). The multivariate analyses indicated that people with SUD living only with their
mothers had a greater risk of relapse compared to those with both biological parents [OR = 1.9, 95 % CI (1.02–3.6),
p = 0.04]. Patients that were hospitalized between one to three months were more likely (11.2 times) to relapse after
treatments compared to those who spent more than three months in hospitalization [OR = 9.2, 95 % CI (1.1–77.6),
p = 0.02]. Furthermore, people that used more than two substances had 1.5 greater risk to relapse than those who
consumed one substance. Participants were more likely to relapse if they lived with their peers [OR = 2.4, 95 % CI:
(1.2–7.8), p = 0.01] or if they lived in a family with conflicts [OR = 2.1, 95 % CI (1.05–9.7), p = 0.02].
Conclusions: This study is conducted at one institution caring for patients with SUD. The prevalence was 59.9 %.
Future studies are recommended to investigate the effectiveness of the existing relapse prevention programs in
order to adjust prevention strategies.
Keywords: Relapse, Substance use disorder, Detoxification‐rehabilitation, Rehabilitation centre
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* Correspondence: eric.kabisa@gmail.com
1
Rwanda Palliative Care and Hospice Organization (RPCHO), Kigali, Rwanda
2
Department of Health Policy, Economics and Management, School of Public
Health, College of Medicine and Health Sciences, University of Rwanda,
Kigali, Rwanda
Full list of author information is available at the end of the article
Kabisa et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:13
https://doi.org/10.1186/s13011-021-00347-0
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Relapse refers to a breakdown in the person’s attempt to
change substance use behaviors or return to pre-
treatment levels of drinking or continue using substances
after a period of sobriety or setback in a person’sattempt
to change or modify any target behavior [1,2]. The sub-
stance use after successful detoxication and rehabilitation
is a common problem globally and it remains higher in
low and middle income countries (LMICs) than the high
income countries [3,4]. Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) states that substance use
disorder (SUD) are characterized by maladaptive patterns
of substance use leading to clinically significant impair-
ment or distress [5,6]. The evidence coming from recent
robust epidemiological studies have showed that
substance use after successful treatment and rehabilitation
is the biggest problem that requires effective preventive
measures. More than 50 % of person with SUD relapsed
after treatment [4,6]. Other studies have documented that
the relapse rates following treatments are high [4,7]and
typically reaches 40–75 % in 3 weeks to 6 months period
following treatment [6,8–10].
The studies conducted in different countries with high
rates of completion of inpatient treatments show a high
prevalence of relapse with 33 % in Nepal, 55.8 % in
China and 60 % in Switzerland. Similar studies find out
that the relapse is between 1 month and 1 year after
discharge from treatment programs [6,10,11]. From the
treatment perspective, relapse and recovery is key issues,
highly prevalent and frustrating problem, although the
prevalence of patients with substance use remain high
[12,13]. Relapse is the health concern that can be
triggered by stress, cues associated with past drug usage,
or re-exposure to the substance [5,14].
Substance use dependence are episodic, with periods
of abstinence, reduction of use, and relapse the prevail-
ing pattern, often with the course of events being influ-
enced by external factors such as availability of drugs
and societal pressures [9,15]. Moreover, various factors
are associated with relapse to SUD. Those factors are
classified into individual, socio-demographic, psychiatric,
medical conditions, and socio-cultural influences that
may be controlled [16–18]. For instance, preceding stud-
ies found that young age at initiation, sex, unemploy-
ment, singular status, peer group influence, family
history of substance use, conflict and poor family sup-
port, environmental factors like availability and accessi-
bility of drugs are contributing factors of relapse [2,7,9,
19–22]. Physical factors can also increase the risk of re-
lapse including physical illnesses, physical dependence
on drugs, withdrawal from drugs and being in negative
physical state [20,23,24]. In addition, a previous study
showed that 50 % of old friends influenced people with
addiction to get the habit to retake drugs after discharge
from rehabilitation centres [6,21,25]. It was also reported
that people with SUD who have been discharged from re-
habilitation centres and living in drug-free social environ-
ment had higher abstinence rates and are low in relapse to
SUD [8,19,26]. On the other hand, multiple factors such
as post-treatment incarceration, mental or other co-
morbid disorders, craving for drugs were reportedly asso-
ciated with relapse [7,10,22].
The Rwanda Mental health survey conducted in 2017
reported that the prevalence of SUD in population aged
14–65 years has been 0.4 % for males and 0.2 % for
females [27,28], further it was demonstrated that the
population aged 46–55 years had the highest prevalence
(0.6 %) compared to other age groups. Little research is
available on relapse following SUD treatment in Rwanda.
This leads to poor relapse prevention strategies in differ-
ent rehabilitation centresers. After realizing that the
prevalence of SUD is high especially in youth and most
of people treated in those centre are often the same due
to relapse, we decided to conduct this study to show its
prevalence and the reasons of relapse. The rationale of
this study is that the findings will provide knowledge as
baseline for other researchers to carry out the similar or
related studies countrywide. The findings will also con-
tribute to setting up preventive strategies for reducing
the relapse on substance use and manage its risk factors.
We hypothesized that SUD would increase the probability
of a high prevalence of relapse among patients with SUD
and that socio-demographic characteristics would consti-
tute independent risk factors for the relapse in the targeted
setting for this research.
Conceptual framework
Figure 1. displays the tentative concepts and several ideas
that result in a unified conceptual framework and then
leads to unified holistic understanding of the phenomenon
- relapse and its factors - under the present study. This
conceptual framework indicates various factors classified
into socio-demographic, environmental, interpersonal,
intrapersonal and physical risk factors. This framework
was designed using the literature from the prior studies.
Methods
Study design
Retrospective cross-sectional survey was conducted to
assess the prevalence and contributing risk factors to
relapse among patient with SUD at IPC. The study was
conducted using secondary data from patient’s records
in five consecutive years from 2014 to 2018.
Study setting, participants and sampling
The study was conducted at Icyizere Psychotherapeutic
Centre (IPC) located in Kicukiro District, Niboye Sector,
Kigali City, Rwanda. Icyizere Rehabilitation centre is a
Kabisa et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:13 Page 2 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
branch of CARAES-Ndera Neuro-psychiatric Hospital
that has specialized unity in drug-related. This Rehabili-
tation Centre is one of three detoxication and rehabilita-
tion centres for patients with SUD in Rwanda including
Iwawa rehabilitation centre located in Western Province
and Isange Rehabilitation Centre located in Huye dis-
trict, Southern Province, Rwanda. These rehabilitation
facilities provide various treatments and psychosocial
interventions for patients with SUD. IPC is a mental
health centre that offers detoxication and rehabilitation
for patients with SUD or with comorbidity of psychiatric
illnesses. The mission of the three centres is to rehabili-
tate delinquents from across the country so that they
stop drug use or any other deviant behavior. These de-
linquents are equipped with vocational and hands on
skills that help them integrate in the community and
participate on the socio-economic and political develop-
ment. A variable indicating co-morbid psychiatric dis-
order (0 = no, 1 = yes) was based on recorded
International Classification of Diseases (ICD-10) diagno-
ses (F20–F99), which was either registered during a
previous mental health or SUD treatment stay, and/or
based on the clinicians’assessments in the period
between 2014 and 2018. These patients are treated as in
or outpatients. At this centre, especially in the unit of
detoxication and rehabilitation, 1135 patients with SUD
were treated in 2017, while in 2018 were 966 both Out-
patient Department (OPD) and inpatients.
Participants to this study included hospitalized pa-
tients who were admitted due to SUD at IPC between
2014 and 2018 and found in patient’s register and med-
ical files in that period. We have excluded patients who
were not hospitalized in the period of five consecutive
years (2014–2018), outpatients and patients files which
were not well completed (addresses and diagnosis not
visible). However, no medical registers or register were
excluded because there was no missing variable for the
patients diagnosed with SUD. At the end, all medical pa-
tients’files (n= 391) identified through the registers
from 2014 to 2018 were considered.
Variables of the study
Outcome variable
The outcome variable for this study was relapse among
patient with SUD. This variable was binary; the relapse
case was the patient who was previously treated, rehabil-
itated for the SUD and discharged but after a certain
period; the same patient was rehospitalised for the same
diagnosis. To confirm relapse case, the medical tests in-
cluding urine toxicology, blood test, and alcohol test
were measured at the discharge time and when the
patient came back for the same reason, the same exams
Fig. 1 Conceptual framework. Based on the prior studies, this figure shows that the relapse is associated with various determinants that are
classified into environmental factors, interpersonal or social factors, socio-demographic factors, intrapersonal factors and physical factors.
Environmental included the factors such as availability and accessibility to drugs, interpersonal or social factors include peer influence, social
category, conflict, employment status. But socio-demographic characteristics include the factors such as age, sex, residence, education, marital
status, parental status of the participants. For intrapersonal factors, prior studies reported negative emotion whereas phsyicla factors included
chronic or acute diseases, physical dependence, withdrawal, illness, post-surgical distress and injury
Kabisa et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:13 Page 3 of 12
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were taken to confirm the relapse. By checking the med-
ical records, the relapse cases were mentioned after find-
ing the positive results from the urine, blood and alcohol
tests. Therefore, in this study, relapse was dichotomized
into being relapsed, as opposed to not being relapsed.
Explanatory variables
The independent variables were collected using medical
records and registers. Socio-demographic variables that
were used include age, gender, marital status, education,
residence, religion, occupation, and parental status. The
environmental variables included were the availability,
the accessibility to drugs and the types of accessibility.
Further, peer group pressure and social problems were
also included. The physical factors considered physical
dependence, withdrawal, chronic and acute illnesses,
post-surgical distress and injury. In addition to these var-
iables, we included the variables such as hospitalization time,
substance used. Furthermore, the research included the vari-
ables such as stressful influences, family related stressors,
psychiatric illness and drug usage, medical conditions and
drugs, type of medical condition. The consideration of all
independent variables was based on their relationship with
relapse demonstrated in prior studies [29,30].
Data collection
Data collection was performed by the first author and
two trained data collectors whose background is clinical
psychology. To collect accurate data and become experts
in the research tool, data collectors were provided
with short term training about the questionnaires and
how to use the medical records of the patients with
SUD.
Data analysis
STATA version 13 was used to perform descriptive and
analytical analyses. For descriptive statistical analysis,
prevalence of relapse related SUD was computed. The
characteristics of the participants were presented using
frequency and percentage. For analytical analysis, bivari-
ate and multivariate logistic analysis techniques were
used to determine the association between explanatory
variables and relapse. Variables that indicated p< 0.05 in
bivariate analyses were included in the multivariate lo-
gistic regression model. This was because the signifi-
cance level of 5 % was considered sufficient to control
residual confounding in the final multivariable model.
The odds ratio was computed for indicating the associ-
ation between relapse and explanatory variables within
95 % confidence intervals and 5 % significance level.
Therefore, in this study, the guidelines for strengthening
the Reporting of Observational Studies in Epidemiology
statement in writing the manuscript (STROBE) was
respected [29].
Ethical consideration
In accordance with the Declaration of Helsinki [30],
before using patients medical files, the IPC was con-
tacted to provide the permission to use the information
related to this study available in patient’s files and regis-
ters . Then, the authorization to access patients data
admitted at IPC, a branch of CARAES Ndera Neuro-
psychiatric hospital was obtained from the Ethical Com-
mittee of CARAES-Ndera Neuro-psychiatric Hospital
N°: (007/CNEC/2019). The study protocol was reviewed
and approved by Institutional Review Board of College
of Medicine and Health Sciences (IRB/CMHS) within
the University of Rwanda (No 307/CMHS IRB/2019).
Data collection forms were coded and anonymity was
respected for confidentiality purpose. After the data
collection, all forms were kept in a locked cupboard and
only the principal investigator has access to the key.
Results
Prevalence and socio‐demographic characteristics
Table 1. demonstrates the description of the participants
using the frequencies and percentage. Out of 391 patients
with SUD, 62(15.9 %) were females and 329(84.1 %) were
males. Concerning age, the mean age was 33 years (SD =
11.8 years). Majority (54.2 %) of the patients was aged
between 18 and 30 years and in terms of marital status,
majority (78.8 %) was males and single. Concerning educa-
tion, majority (53.5 % )of the patients did secondary edu-
cation. In terms of occupation, majority (47.3%) were
student while (26.6 %) did agricultural or no ocupation .
By looking at religious status, majority (59.3 %) was Catho-
lics and minority (2.5 %) was with no any religion. Nearly
78 % were living in the city of Kigali. Concerning the
prevalence of relapse, the results indicated that 59.9 % of
the participants had relapsed one or more time after being
discharged from the treatment centre and most of them
were relapsed one to two times (52.7 %).
Description of factors influencing relapse in SUD
Table 2shows the description of factors influencing
relapse in substance use disorders. The results found
that 98.2 % of the total study population was hospitalized
between one and three months and only 1.8 % was
followed in hospitalization between two and twelve
months. A big number used two to three substances
54.2 %. Peer group influence was high with 81.1 %. Results
documented that 70.1 % the patients were influenced by
the accessibility of substances including 55 % who had
barriers to financial and geographical accessibility. We
have also found that stressful influence was another factor
that influences SUD at 76 %. Results indicated that the
family conflict was 39.1 % followed by inoccupation with
20.2 %. Family conflict combined with other stressful
events like poverty, inoccupation and inability to pay loans
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was 13.3 %. A low percentage of patients with psychiatric
illness combined with substance use were reported. 16.9 %
of them had at least one psychiatric illness such as bipolar
mood disorder, psychosis, posttraumatic stress disorders
(PTSD), and depression whereas 0.8 % had two psychiatric
illnesses and more psychological disease like depression,
psychosis and PTSD. The participants with other medical
conditions were 3.6 % whilst psychiatric diseases and acute
diseases were 2.8 % and 0.8 % respectively.
Association between relapse and socio‐economic profiles
Table 3indicates the results of bivariate logistic linear
regression analyses corresponding to the factors associ-
ated with relapse among patients with SUD. Statistically,
significant factors associated with relapse included
parental status, hospitalization (p= 0.01), hospitalization
time (p= 0.01), number of different substances used (p=
0.008), peer pressure (p= 0.001), psychological stress
(p< 0.001), type of accessibility (p< 0.001), number of
substances, peer group influence, stressful events, family
conflict, others stressful events and inoccupation. But
relapse was not significantly associated with age (p=0.6),
gender (p= 0.9), marital status (p= 0.7), residential setting
(p= 0.3), education level (p= 0.1), religion (p= 0.2), occu-
pation status (p= 0.8), psychiatric diseases, accessibility
(p= 0.07), medical conditions (p= 0.8) and type of medical
conditions (p=0.9).
Risk factors of relapse among the person with SUD
Table 4indicates multiple logistic regression models that
illustrate variables related to the likelihood of relapse
among the patients with substance use disorders at Icyi-
zere Rehabilitation Centre. The current model included
all the variables that were statistically significant at 5 %
or 1 % in the bivariate logistic regression. So, it include
parental status, hospitalization time, influences of peer
groups, accessibility, types of accessibility, number of
substances used, influences of stress, and family related
problems. The results from the model showed that the
most significant common factors of relapse were peer
group influence and family-related stresses. The patient
Table 1 Prevalence and socio-demographic characteristics of
participants (N= 391)
Characteristics Frequencies (n= 391) Percentage
Relapse
No 157 40.1
Yes 234 59.9
Number of relapses
None 157 40.1
One/Two 206 52.7
Three and above 28 7.2
Participants’age
18–30 212 54.2
31–40 88 22.5
41–50 57 14.6
51–81 34 8.7
Gender
Female 62 15.9
Male 329 84.1
Marital status
Married/cohabiting 70 17.9
Separated/Widow/Divorced 13 3.3
Single 308 78.8
Education
Less than secondary 21 5.4
Secondary 209 53.5
University 161 41.1
Occupation
No occupation/Agriculture work 104 26.6
Professional 75 19.2
Sales services/Domestic work 27 6.9
Student 185 47.3
Religion
Catholic 232 59.3
Muslim 10 2.6
No Religion 10 2.6
Protestant/Adventist 139 35.5
Residence
Kigali city 305 78
Eastern Province 26 6.6
Foreigners 20 5.1
Northern Province 6 1.5
Southern Province 26 6.7
Western Province 8 2.1
Parental status
All alive 207 52.9
No parents 91 23.3
Table 1 Prevalence and socio-demographic characteristics of
participants (N= 391) (Continued)
Characteristics Frequencies (n= 391) Percentage
Only father alive 17 4.4
Only mother alive 76 19.4
The table displays the socio-demographic characteristics of the participants
and then described them using the frequencies (N= 391) and percentages. In
this table, the prevalence of the relapse was indicated as the main outcome of
this study
Concerning education: The participants who attended primary school were
coded as “1”, who attended secondary school were coded as “2”while the
highest level of education was University of higher that was coded as “3”. All
participants attended schools and had different level of education
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with SUD and lived with only their mothers had a
greater risk to relapse than those living with both bio-
logical parents [OR = 1.9, 95 % CI (1.02–3.6), p= 0.04].
The patients who spent one and three months of
hospitalization were 11.2 times likely to relapse after
treatments compared those hospitalized more than three
months of hospitalization [OR = 9.2, 95 % CI (1.1–77.6),
p= 0.02]. Additionally, findings indicated that patients
used two to three substances were associated with
increase of odds of relapse compared to those using
substance [OR = 1.5, 95 % CI(1.3–8.9), p= 0.02]. Partici-
pants were more likely to relapse if they were living with
their peer or drug dealers [OR = 2.4, 95 % CI (1.2–7.8),
p= 0.01], family related problems such as intra-family
conflicts [OR = 2.1, 95 % CI(1.05–9.7), p = 0.02]. But the
results indicated that the participants with geographical
accessibility had less risk to relapse than others [OR =
0.09, 95 % CI (0.008-0.9), p= 0.04] (Table 4).
Discussion
This study explored the prevalence and risk factors of
the relapse among the patients with SUD who were
hospitalized at IPC of Rwanda. Majority (54.2 %) of the
participants was aged 18–30 years and 84.1 % were
males. Different studies also documented that SUD
mostly occur among younger people than older age
people who can maintain abstinence [31,32].
The findings of this study reported that approximately
58 % of persons relapse between two weeks and three
months respectively following treatment for substance
use, and as high as 90 % when relapse has been defined
as the consumption of a single drink after treatment.
These results are consistent to the previous studies that
indicated that the average time from abstinence to re-
lapse varies from 4 to 32 days for tobacco, alcohol, and
opiates [2,5,11,33]. They are also supported by the
prior studies that showed that substance use following
treatment typically is higher up to more than 75 % in the
3-6-month period following treatment [30,34]. Consid-
ering South African statistics in 2013, 22 % of admissions
into treatment centres were relapsed. These findings
provide some insights into the significance of our results
that revealed that more than one in two patients (rate of
59.9 %) was relapsed one or more times after completing
the treatment.
The results revealed that there was a significant associ-
ation between parental status and relapse where an
orphan of father has a significant greater risk to relapse
after treatment. Numerous studies have shown that the
parent’s primary role during treatment is to provide
support, and in some cases, this involves treatment for
the parent directly [35]. In fact, most rehabilitation
centre reported that it is often the mother or father who
Table 2 Description of factors influencing relapse in substance
use disorders (N= 391)
Variables Frequency
(n= 391)
Percent
Hospitalization time
Between one and three months 384 98.2
Between three and twelve months 7 1.8
Substance used
Four substances and above 44 11.3
One substance 135 34.5
Two/Three substances 212 54.2
Peer groups
No 74 18.9
Yes 317 81.1
Accessibility
No 117 29.9
Yes 274 70.1
Type of accessibility
Financial accessibility 6 1.5
Geographical accessibility 53 13.6
Accessibility & financial accessibility 215 55
None 117 29.9
Stressful influences
No 94 24
Yes 297 76
Family related stressors
Family conflict 153 39.1
Poverty 52 13.3
Inoccupation 79 20.2
None 94 24
Others (poor insight, poor management of
triggers,…)
13 3.3
Psychiatric illness and drug use
No 322 82.3
Yes 69 17.7
Medical conditions and drugs
No 377 96.4
Yes 14 3.6
Type of medical condition
Acute diseases (Gastritis, Pancreatic) 3 0.8
Chronic diseases (Diabetes, Cancer, Hypertension,
Hepatitis, HIV/AIDS)
11 2.8
None 377 96.4
The table displays the descriptive analysis for the medical and clinical
characteristics. The hospitalization time had two categories (1 to 3 months; 3 to
12 months of stay at the heath facility), type of medical conditions, the patients
were categorised into acute diseases (gastritis and pancreatic), chronic diseases
(Diabetes, Cancer, hypertension, hepatitis or HIV), and the third category was
for the patients with no chronic diseases. The other characteristic was for the
patients with stress that was coded as 0 = no stress and 1 =Stress. The families
influenced were analysed where 1 represents family conflicts, 2 = poverty, 3 =
unemployment, 3 = no family influence, and 5 = other family influence such as
poor insight, or poor management of triggers.; HIV: Human Immunodeficiency
Virus/ Acquired Immuno-Deficiency Syndrome
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Table 3 Bivariate analysis of relapse among patients with substance use disorders (N= 391)
Characteristics Relapse Odds ratio
Yes No Total OR 95 % CI p-value
Age of the respondents 0.6
18–30 130 82 212 Ref..
31–40 52 36 88 1.1 (0.6–1.8)
41–50 35 22 57 0.9 (0.5–1.8)
51–81 17 17 34 1.5 (0.7–3.2)
Sex 0.9
Female 37 25 62 Ref.
Male 197 132 329 0.9 (0.5–1.7)
Marital Status 0.7
Married/Cohabiting 41 29 70 Ref.
Single 184 124 308 0.9 (0.5–1.6)
Separated/Widow/Divorced 9 4 13 0.6 (0.17–2.2)
Level of education 0.1
Less than secondary 11 10 21 Ref.
Secondary level 117 92 209 0.8 (0.3–2.1)
University level 106 55 161 0.5 (0.2–1.4)
Occupation 0.8
No occupation/agriculture work 60 44 104 Ref.
Professional 44 31 75 0.9 (0.5–1.7)
Sales services/ domestic work 15 12 27 1.1 (0.4–2.5)
Student 115 70 185 0.8 (0.5–1.3)
Religion 0.2
Catholic 146 86 232 Ref.
Protestant/Adventist 77 62 139 1.3 (0.8–2.1)
Muslim 7 3 10 0.7 (0.1–2.8)
No Religion 4 6 10 2.5 (0.6–9.2)
Residence 0.3
City of Kigali 186 119 305 Ref.
Eastern Province 14 12 26 1.3 (0.5 2.9)
Northern Province 5 1 6 0.3 (0.03–2.7)
Southern Province 17 9 26 0.8 (0.3–1.9)
Western Province 4 4 8 1.5 (0.3–6.3)
Foreigners 8 12 20 2.3 (0.9–5.9)
Parental status 0.01**
All alive 129 78 207 Ref.
No Parents 59 32 91 0.8 (0.5–1.4)
Only mother alive 37 39 76 1.7 (1.02–2.9)
Only father alive 9 8 17 1.4 (0.5–3.9)
Hospitalization time 0.01**
Between three and twelve months 1 6 7 Ref.
Between one and three months 233 151 384 9.2 (1.1–77.6)
Number different substances used 0.008**
One substance 73 62 135 Ref.
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initiates treatment for their minor or adult children.
Drug addiction is such a severe condition that evens the
strongest-willed individuals cannot get help on their
own. Patients with SUD, therefore, are dependent upon
their parents to reach out for help for them that contrib-
ute to their health improvement. But the role of parent
goes far beyond just getting the patients with SUD to
treatment. Several studies found that the absence of par-
ents or poor parent-child attachment especially a father
makes the children to be independent and sometimes
they do not obey the instructions of their mother. For
the young people with SUD; this can lead to relapse after
treatment due to poor support and follow-up by the
family [5,11,36].
Our findings revealed that hospitalization time was also
significantly associated to relapse where those who are ad-
mitted one to three months had greater risk to relapse
comparing to SUD than those who were hospitalized
Table 3 Bivariate analysis of relapse among patients with substance use disorders (N= 391) (Continued)
Characteristics Relapse Odds ratio
Yes No Total OR 95 % CI p-value
Two/three substances 141 71 212 0.5 (0.3–0.9)
Four substances and above 20 24 44 1.4 (0.7–2.7)
Peer group pressure < 0.001*
No 31 43 74 Ref.
Yes 203 114 317 0.4 (0.2–0.6)
Accessibility 0.07
No 62 55 117 Ref.
Yes 172 102 274 0.6 (0.4–1.03)
Type of accessibility 0.03**
None 62 55 117 Ref.
Geographical/financial accessibility 136 79 215 0.6 (0.4–1.03)
Geographical accessibility 35 18 53 0.5 (0.2–1.1)
Financial accessibility 1 5 6 5.6 (0.6–49.7)
Stressful influence < 0.001*
No 28 66 94 Ref.
Yes 206 91 297 0.1 (0.1–0.3)
Social problems (stress) < 0.001*
None 28 66 94 Ref.
Poverty 30 22 52 0.3 (0.1–0.6)
Family conflict 124 29 153 2.1 (1.1–7.1)
Inoccupation 48 33 81 0.2 (0.1–0.5)
Others 4 7 11 0.7 (0.2–2.7)
Psychiatric illness 0.3
No 191 131 322 Ref.
Yes 43 26 69 0.9 (0.5–1.6)
Medical condition 0.8
No 226 151 377 Ref.
Yes 8 6 14 1.1 (0.3–3.3)
Type of medical condition 0.9
None 226 151 377 Ref.
Chronic diseases 6 5 11 1.2 (0.3–4.1)
Acute diseases 213 0.7 (0.1–8.3)
This table indicates a bivariate logistic regression analyses for determining the association between relapse and socio-demographic characteristics and medical
factors collected from the medical files of the admitted patients at Icyizere Rehabilitation Centre. The confidence intervals (95 %) were computed. Thus,
statistically significant results when using odds ratio corrected p-values at 0.05 and 0.01.
(*) indicates significant level at 1 % and (**) at 5 %; Ref: Reference group or comparable group; OR: Odds ratio
Kabisa et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:13 Page 8 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
more than three months. The length of stay (LOS) at IPC
for patients with SUD also is a commonly debated subject
amongst treatment professionals. Majority of studies
examining LOS on abstinence rates post treatment find a
direct relationship between longer duration of stay and
higher abstinence rates. In a study solely examining pa-
tient in residential treatment, abstinence rates were lower
for those who had short stays (1–30 days) than those who
had longer LOS. Similarly, individuals who attended a
long term institutional treatment were found to be more
likely to be abstinent at six months post-treatment com-
pared to the short-term (three to six month) residential
treatment program [35,36]. Moreover, the results of this
study suggest that the PUD who experienced low accessi-
bility to drugs had a greater risk to relapse than the
patients who appropriately accessed to required health
treatments. This result is in line with the previous studies
that confirmed that environmental risk factors increase
the risk of relapse such as the increased availability and
accessibility of drugs [19,21,34,35,37].
The results revealed that patients using multiple
substances such as two to three substances were more
likely to relapse than those only used one substance.
These results collaborated with the prior studies [17,23,37,
Table 4 Multivariate logistic regression analyses estimating the risk factors of relapse (N= 391)
Variables Odds ratio 95 % CI P. value
Parental status
All parents alive Ref.
No Parents 0.8 (0.4–1.5) 0.6
Only mother alive 1.9 (1.02–3.6) 0.04**
Only father alive 1.5 (0.5–4.8) 0.3
Hospitalization time
Between three and twelve months Ref.
Between one and three months 11.2 (1.1–105.5) 0.02**
Substance used
One substance Ref.
Two/Three substances 1.5 (1.3–8.9) 0.02**
Four substances and above 1.6 (0.7–3.6) 0.2
Influences of peer group
No Ref.
Yes 2.4 (1.2–7.8) 0.01**
Accessibility
No Ref.
Yes 6.1 (0.5–64.4) 0.1
Type of accessibility
None Ref.
Geographical accessibility, financial accessibility 0.1 (0.01–1.1) 0.06
Geographical accessibility 0.09 (0.008–0.9) 0.04**
Stressful influence
No Ref.
Yes 0.3 (0.1–1.6) 0.2
Family related problems
None Ref.
Poverty 0.6 (0.1–2.5) 0.4
Family conflict 2.1 (1.05–9.7) 0.02**
Inoccupation 0.6 (0.1–2.4) 0.5
The table displays a multiple logistic regression model analyses for indicating the determinants of relapse among the patients at the Icyizere rehabilitation centre
which is for patients under treatments of substance use disorders (SUDs). The model include: parental status, hospitalization, number of substances used, types of
accessibility, accessibility, stressful influences, and family related problems
The 95 % of the confidence interventions and the significance levels at 0.05 and 0.01 were applied.
* Statistically significant at 0.05, ** Statistically significant at 0.01; CI: Confidence Intervals; OR: Odd ratio
Kabisa et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:13 Page 9 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
38]. Indeed, those using four substances and above were
not significant but we suppose that is due to small sample
size. Our findings are also supported by the prior studies
that found that those exposed to single substance had lon-
gest abstinence period than those consumed multiple sub-
stances [13,31,32]. Peer group was also found to be
associated with relapse. Peer influence is a complex issue
due to the potentially wide variety of contexts involving
friendships and social networks. A number of studies have
addressed peer groups influence and have contributed to
theunderstandingofthestructureandsizeofsuchnet-
works and their association with relapse to SUD. The previ-
ous studies found 50 % of old friends influenced former
patients with SUD to pick up the drug taking habit after
they were discharged from rehabilitation centres [6,39].
The same author also showed that 76 % of the old friends
assist rehabilitated individuals to get the needed supply of
drugs. It was indicated that the social context can serve ei-
ther as a resource or an obstacle for behavior change by the
patient post treatment. For example, “negative peer influ-
ences have been noted in the development of substance use
behavior and the promotion of relapse [9,33]. Similar au-
thors found that patients were unable to resist either direct
or indirect attempts by others to engage them in drinking.
Further, they added that the culture makes the substance
the recreational drug of choice, it is difficult for the
patient to maintain abstinence [3,19]. The results of
this study highlighted that the patients from the fam-
ilies that experience family conflicts were more likely
to relapse to substance use compared to the PWUD
from the families that have not family conflicts. These
results also showed that the family conflicts also may
reinforce contradictions between parents, poor parent-
ing skills and an inadequate monitoring style. These
results were supported by the preceding studies that
confirmed that peer groups and domestic violence are
the risk factors of relapse to substances among the
patients with SUD [20].
Furthermore, the results revealed that the risk factors of
relapse after undergoing the treatment process are lack of
living with only mother, few time for hospitalization such
as between one and three months, consuming two to
three substances use, peer pressure, accessibility to drugs,
family and social related problems such as family conflicts.
These results are relevant to the prior studies that indi-
cated that the major causes of relapse after undergoing
the treatment process include lack of self-confidence, peer
pressure, inability to give old habit, easy access of drugs,
lack of family and social acceptance and family and social
adjustment problems [8,11,12,16,18,40].
Strengths and limitations
The current research had important contributions to the
CARAES Ndera Neuropsychiatric Hospital and especially
IPC that tend to focus on patients with SUD treatments.
It can be also a baseline for other researchers who want to
contribute in prevention of relapse among patients with
SUD. Data from 2014 to 2018 were pooled together to
create large sample size of patients with SUD. The mate-
rials used were standardized and no missing variables
were found from the medical records. This increased the
validity and reliability of the findings from this study.
However, some limitations were found in this scientific
work. Due to limited financial resources and time, this re-
search was focused on one detoxication and rehabilitation
centre while there are other centres in the country. Sec-
ondly, as the study was retrospective cross-sectional de-
sign, it was limited to available data, therefore some
variables (e.g. household wealth index, medication) that
were found in the literature were not collected in the
medical records. Furthermore, the study was limited to
the target population that did not permit the researchers
to generalize at the national level . This study was limited
to the cross-sectional design that did not allow the re-
searchers to provide pertinent conclusion about causality
of the factors in which we examined.
Conclusions
The prevalence of relapse after treatment of SUD was high
and the risk factors identified included family conflicts, psy-
chological stress, peer influence and socio-economic status
such as availability and accessibility of drugs, peer group in-
fluences and lack of assertiveness. Thus, the substance use
management should not be limited to detoxification only
but emphasis should be given on longer follow up in order
to prevent relapse.
IPC was recommended to add in their annual reports the
situation of relapse. It was also recommended to set-up re-
lapse prevention measures of their patients after discharge.
The Ministry of Health was recommended to evaluate the
effectiveness of existing relapse prevention strategies and
how they are implemented; to set a consistent program of
relapse prevention in order to reduce the high prevalence
of relapse; and organize several sensitization campaigns for
awareness of the burden of substance use, relapse after
treatment and its impacts to the people’s health but also
the community. The further studies should be carried out
on the prevalence of relapse and factors associated to
substance use disorders at the national level.
Abbreviations
CARAES: Cartate Aergrorum Served; DSM: Diagnostic and Statistical Manual
of Mental Disorders; IPC: Icyizere Psychotherapeutic Centre; IRB: Institutional
Review Board; OPD: Outpatient Department; PTSD: Posttraumatic Stress
Disorder; SUD: Substance Use Disorders
Acknowledgements
The investigator would like to express special thanks and sincerity to the
University of Rwanda, School of Public Health for providing this golden
opportunity to conduct the research study. A great sense of gratitude is
provided towards Prof. Aline Umubyeyi and Jean d’Amour Habagusenga for
Kabisa et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:13 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
their supervisory role. The administrators of the CARAES Ndera were highly
acknowledged for permitting us to conduct the study for providing formal
and informal permission to conduct this study in their institution.
Researchers extended heartiest thankfulness to health providers from IPC for
availing participants’files that helped us to gather necessary information.
Authors’contributions
Eric Kabisa wrote the protocol, contributed to the study conception, funding
provision, study design, acquisition of data, and coordinated the study
implementation. Emmanuel Biracyaza contributed to statistical analysis and
drafted the manuscript, Jean d’Amour Habagusanga was a co-supervisor in
protocol writing and Aline Umubyeyi played a supervisory role and review at
each stage from the development of the protocol to report writing and
manuscript writing. All authors contributed to and approved final
manuscript. They also agreed on the journal to which the study is submitted.
Funding
No funding was received for this study, except the financial contributions of
the main author.
Availability of data and materials
The datasets used and analyzed in the current research are available from
the corresponding author on researchable request. Although all data
analyzed are included within this article, they may be shared when necessary
but also data collection forms.
Ethics approval and consent to participate
The protocol was reviewed and approved by the Institutional Review Board
of College of Medicine and Health Sciences (IRB/CMHS) at the University of
Rwanda (No 307/CMHS IRB/2019). Permission to conduct the study at IPC
which is the branch of (CARAES) Ndera Neuropsychiatric hospital was
obtained from the Ethical Committee of that Hospital (N° 007/CNEC/2019).
This hospital is the only national and referral hospital for mental diseases in
Rwanda. The confidentiality, privacy and voluntariness were respected. Data
collection forms were coded and the anonymous method was used for
keeping confidential. After data collection, all forms were kept in a locked
cupboard and only the principal investigator access to that cupboard.
Consent for publication
Consent for publication was obtained from Ethical Committee of CARAES
Ndera Hospital (N° 007/CNEC/2019).
Competing interests
The authors declared no conflict of interest.
Author details
1
Rwanda Palliative Care and Hospice Organization (RPCHO), Kigali, Rwanda.
2
Department of Health Policy, Economics and Management, School of Public
Health, College of Medicine and Health Sciences, University of Rwanda,
Kigali, Rwanda.
3
Programme of Sociotherapy, Prison Fellowship Rwanda
(PFR), Kigali, Rwanda.
4
Department of Epidemiology and Biostatistics, School
of Public health, College of Medicine and Health Sciences, Kigali, Rwanda.
Accepted: 16 January 2021
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