Drug addiction, also called substance use disorder (SUD), is a disease that affects a person's brain and behavior and leads to inability to control the use of a legal or illegal drug or medication. SUD has become an increasingly prevalent community health problem worldwide, affecting individuals in all geographical regions regardless of age, race, sex, and socioeconomic status, despite decades of efforts to find a solution (Bowen et al., 2014; Mulia et al., 2017; Mumba & Snow, 2017). According to a report published by the United Nations Office on Drugs and Crime (UNODC; 2016), one of 20 adults aged 15 to 64 has used an addictive substance at least once in their lives. More than 29 million people who use drugs have SUD and the outcome of this disorder continues to be destructive to a person's health (UNODC, 2016). SUD, which is a chronic brain disorder, can lead to various medical problems over time, such as impaired social functioning, loss of productive life years, and death (Eroglu, 2015; Ghitza, 2015; Whiteford et al., 2013).
SUD causes individuals to lose productivity, which is unacceptable in workplaces, schools, and society. Thus, individuals with SUD gradually withdraw from society. Not taking an active part in society creates a decline in social functioning, which leads to deterioration in interpersonal and familial relationships; psychological issues, such as loneliness and inadequacy; and losses in work life that can lead to poverty (Simsek, 2010). These phenomena negatively affect physical, psychological, social, and spiritual conditions of individuals (Memnun, 2006). To cope with these stressors, individuals may turn or return to substance use (Davis et al., 2008). Relapse, defined as the return to a previous problematic substance use behavior after treatment, has a high incidence rate and is the most significant problem in drug addiction treatment (Maarefvad et al., 2015; Mulia et al., 2017; Ögel et al., 2014; Smyth et al., 2010; Suter et al., 2011).
Relapse in SUD requires intervention because it prevents completion of treatment, creating a vicious cycle that negatively impacts individuals' social functioning and perceived wellness (Orbon et al., 2015). When developing effective relapse prevention strategies and programs, the following should be considered: common characteristics of individuals who use drugs and the substances used, use patterns, factors that exacerbate use, and motivation to quit (Pattij & De Vries, 2013; Perry & Lawrence, 2017). Psychosocial treatment approaches in line with these considerations have been found to have positive effects on many areas related to SUD, especially relapse prevention (Min et al., 2011; Mulia et al., 2017; Pashaei et al., 2013; Perlman & Jordan, 2017; Perry & Lawrence, 2017). Despite the positive effects of these programs, relapse prevention programs can be improved based on new understanding of the mechanism of relapse. The latest research on relapse prevention suggests that cognitive-behavioral approaches that educate individuals on their own automatic thoughts, beliefs, emotions, and behaviors that contribute to substance use provide a way to change these thoughts to more functional ways of thinking to gain new coping mechanisms and survival skills, which will increase functioning and self-efficacy (Marlatt et al., 2002; Salehi & Alizadeh, 2018). In addition, some programs that include a cognitive-behavioral structure to treat substance use/misuse have been found to be effective (Ögel & Coskun, 2011; Ögel et al., 2014). Thus, we established a relapse prevention psychoeducation program based on Marlatt et al.'s (2002) and Ögel et al.'s (2014) programs that focuses on creating a permanent lifestyle change in individuals with SUD. Nurses can use simple strategies within the therapy models when working with individuals with SUD. In addition, nurses are in a prime position to educate individuals about these evidence-based therapies and refer patients to therapists or advanced practice nurses with training and expertise in these nonpharmacological treatments for SUD.
The aim of the current study was to evaluate the effect of a relapse prevention psychoeducation program on relapse rate, social functioning, perceived wellness, and coping methods in individuals who have received treatment for and recovered from SUD.
Study Design and Sample
A quasi-experimental study was performed, including pretest, posttest, and follow up, in intervention and control groups.
Participants were outpatients at the Alcohol and Substance Use Disorders Treatment Center (the only comprehensive SUD center in Turkey). When calculating the population of the sample using NCSS PASS 207 power analysis software, it was determined that a total of 56 individuals, 28 each for the intervention and control groups, should be included in the study.
Inclusion criteria were: having a non-alcohol SUD; providing voluntary consent for participation; verbally expressing determination to quit substance use; having a negative urine screen; and having no additional psychiatric diagnoses. Individuals who met the criteria to participate in the research were randomly assigned to the intervention and control groups. A total of 92 individuals (n = 46 in the intervention and control groups, respectively) with SUD were included in the study. However, 34 participants could not complete the study due to several reasons: 21 participants could not be reached, four participants moved to other cities, four participants withdrew from the study, three participants started using substances again, one participant went to jail, and one participant joined the military. Consequently, the study was completed with a total of 58 participants (n = 29 in the intervention and control groups, respectively) (Figure 1).
Consort flow diagram of the study.
The Personal Information Form, Social Functioning Scale, Perceived Wellness Scale, and Ways of Coping Scale were used to collect participant data. To determine whether relapse had occurred, participants were required to provide a urine sample.
Personal Information Form. This form comprises a total of 18 questions, including demographic and substance use–related variables that are related to relapse.
Social Functioning Scale (SFS). The SFS is a measurement tool developed by Birchwood et al. (1990) that measures an individual's perception of their social role. The scale comprises 79 questions and seven sub-scales, including social engagement/withdrawal, interpersonal behavior, prosocial activities, recreation, independence-competence, independence-performance, and employment/occupation, with higher scores indicating a positive trend toward functionality (Yaprak Erakay, 2001). A Turkish validity and reliability study of the scale by Yaprak Erakay (2001) reported Cronbach's alpha of 0.91, and it was suggested this scale be used for chronic diseases affecting mental condition. In the current study, Cronbach's alpha was 0.87.
Perceived Wellness Scale (PWS). The PWS was developed by Adams et al. (1997) to assess an individual's perception of their wellness. The PWS comprises six subscales—emotional, physical, spiritual, social, intellectual, and psychological wellness—with six items in each subscale, for a total of 36 items. Responses are scored on a 6-point Likert-type scale, with scores ranging from 36 to 216. A score ≤144 indicates low wellness, and a score >144 indicates high wellness. Turkish validity and reliability were tested by Memnun (2006), and Cronbach's alpha was 0.82. In the current study, Cronbach's alpha was 0.83.
Ways of Coping Scale (WOCS). The WOCS, developed by Folkman and Lazarus (1985), is a 4-point Likert-type scale comprising 68 items. A Turkish validity and reliability study of the 30-item form of the scale was conducted by Sahin and Durak (1995). The scale comprises the following subscales: self-confident approach, optimistic approach, seeking social support approach, helpless approach, and submissive approach (Folkman & Lazarus, 1985; Sahin & Durak, 1995). According to Sahin and Durak (1995), Cronbach's alpha was 0.80 for the self-confident approach, 0.68 for the optimistic approach, 0.47 for the seeking social support approach, 0.73 for the helpless approach, and 0.70 for the submissive approach. In the current study, Cronbach's alpha was 0.83 for the self-confident approach, 0.69 for the optimistic approach, 0.47 for the seeking social support approach, 0.77 for the helpless approach, and 0.68 for the submissive approach. In the evaluation of the scale, when the scores obtained from the self-confident, optimistic, and seeking social support approaches increase, the use of effective coping methods increases; when the scores obtained from the helpless and submissive approaches increase, the use of ineffective coping methods increases.
Urine Sample. Participants' urine was tested for presence of substances (e.g., opiates, cannabis, cocaine, benzodiazepines, amphetamines).
The sessions of the psychoeducation program used in the current research were created using two sources: (a) Cigarette, Alcohol, and Substance Use Treatment Program Clinical Guide developed by Ögel et al. (2014); and (b) clinical guidelines for implementing relapse prevention therapy developed by Marlatt et al. (2002) (Table A, available in the online version of this article). Studies by Brandon et al. (2007), Carroll et al. (2006), and Brownell et al. (1986) were also used to develop program content. The psychoeducation program is based on mindfulness and cognitive-behavioral therapy (CBT) for the purpose of preventing relapse. The structure and flow of the sessions were based on the session structure suggested by Beck (2014). The session agendas of the 10-week program were as follows: (1) Introduction to the Program; (2) Addiction, the Brain, and Relationship With Addiction; (3) Gaining Motivation; (4) Identifying and Understanding Emotions; (5) Dealing With Relapses and Urges, Emotions, and Thoughts That Cause Relapse, and Identifying Risky Situations; (6) Steps Required to Get Better; (7) Thinking Traps That Cause Relapse; (8) Anger and Coping With Anger; (9) Increasing Self-Efficacy and Conclusion; and (10) Termination.
Content of group sessions.
Implementation of the Research
Ethical approval from Hacettepe University Non-Invasive Research Ethical Committee (08-07-2015/438-19) and necessary permissions from the relevant institution were obtained. After informing individuals of the study aim and protocol, oral and written approvals were obtained from those individuals who met the inclusion criteria and provided consent.
After obtaining the necessary permissions, participant selection was started. The first participant who met study inclusion criteria was randomized to the intervention group, and the second participant was included in the control group; inclusion of participants in the intervention and control groups continued in this way. Participants were not informed as to which group they had been assigned. When the necessary number of participants was reached for the initial intervention and control groups, the sessions of the psychoeducation program were initiated. While the sessions of the first group started, participant selection continued in the polyclinic. A total of 356 patients were interviewed, with a final sample of 92 participants (n = 46 in the intervention and control groups, respectively).
The study was conducted between September 2015 and May 2016. During the study period, five intervention groups of 10 to 12 participants and five control groups of 10 to 12 participants were formed. Group sessions of the relapse prevention psychoeducation program were conducted by the researcher who completed the CBT training. The program consisted of 10 sessions in total and was applied to the intervention group in addition to routine treatment provided at the center. Group sessions were held at least once per week for an average of 120 minutes. Participants could miss one of the 10 sessions. If possible, participants made up the missed session at another time. Participants who missed two or more sessions were excluded from the research. No intervention outside of routine treatment provided at the center was applied to the control group.
All participants completed the Personal Information Form at the beginning of the study. The SFS, PWS, WOCS, and urine sample were completed by participants in the intervention and control groups before the psychoeducation program, at the end of the program, and 3 months after the last session.
SPSS 17.0 statistical software was used for data analysis. Mean, standard deviation, range, number, and percentage were used to examine participants' sociodemographic and descriptive characteristics. Chi-square test was used to assess whether the intervention and control groups showed similar characteristics. To determine whether there was a significant difference between the mean scores of the SFS, PWS, and WOCS in the intervention and control groups, a one-way analysis of variance for repeated measures was used. The Bonferroni test was used to determine origin of the differences. Odds ratios were used to evaluate the effect size of the psychoeducation program on the relapse rate.
Table 1 provides participants' sociodemographic characteristics. Most participants were male, single, and lived with their parents. No significant differences were found between the invention and control groups in regard to sociodemographic variables.
Participant Demographics (N = 58)
At posttest, the relapse rate in the control group was found to be statistically significantly higher than the relapse rate in the intervention group (31% vs. 0%, respectively; p = 0.002). At 3-month follow up, the relapse rate in the control group was higher than the relapse rate in the intervention group (20.7% vs. 3.4%, respectively; p = 0.102).
At posttest, the possibility of non-relapse for individuals in the intervention group was 14.29 (range = 1.7 to 120.2) times higher than individuals in the control group (p = 0.014). At 3-month follow up, the possibility of non-relapse for individuals in the intervention group was 7.3 (range = 0.82 to 65.11) times higher than individuals in the control group (p = 0.075).
The total SFS score of the intervention group was significantly higher than the control group at post-test and 3-month follow (p = 0.02). When total score changes within groups were examined, scores before the psychoeducation program (106.62 [SD = 27.23], range = 51 to 154) increased after the psychoeducation program (124.41 [SD = 19.31], range = 90 to 160) and at 3-month follow up (134.58 [SD = 20.27], range = 100 to 167). This change in scores was statistically significant (p ≤ 0.001). Although the total score of the control group increased over time, this difference was not statistically significant (p = 0.094) (Table B, available in the online version of this article).
Comparison of Mean Scores of Social Functioning Scale (SFS) of Intervention and Control Groups
When the subscales of the SFS were examined, the difference between groups was significant only in the employment/occupation subscale; however, when intra-group differences were examined, a statistically significant increase was found for all subscales in the intervention group (p < 0.05). In the control group, when the intragroup differences of the subscales were examined, a significant difference was found for only the social engagement/withdrawal, interpersonal behavior, and independence-competence sub-scales (p < 0.05) (Table B).
Total PWS scores of the intervention group were significantly higher than scores of the control group at post-test and follow up (p = 0.05). When intra-group differences were evaluated, mean scores of the intervention group at posttest (156.24 [SD = 15.81]) and follow-up (164.72 [SD =16.76]) were higher than the pretest mean score (138.55 [SD = 26.64]) (p ≤ 0.001). When scores of the control group were examined, mean scores at post-test (145 [SD = 27.94]) and follow up (148.96 [SD = 28.60]) increased compared to mean pretest score (142.24 [SD = 21.78]), but this increase was not statistically significant (p = 0.224) (Table C, available in the online version of this article).
Comparison of the Mean Scores of the Perceived Wellness Scale (PWS) of the Intervention and Control Groups
When the subscale scores of the PWS were examined, the intra-group scores of the intervention group were statistically significantly higher for the emotional, spiritual, and intellectual subscales (p < 0.05). In the control group, a significant difference was found for the social wellness subscale (p < 0.05) (Table C).
Mean scores of all subscales of the WOCS increased statistically significantly in the intervention group (p < 0.05). In the control group, no score increase in the subscales was found to be statistically significant (p > 0.05). When intra-group differences were evaluated, means scores of the intervention group significantly improved (p < 0.05) compared to the control group in the self-confident approach, helpless approach, and submissive approach subscales (Table D, available in the online version of this article).
Comparison of the Mean Scores of the Ways of Coping Scale (WOCS) of the Intervention and Control Groups
The current study aimed to determine the effects of a relapse prevention psychoeducation program on relapse rate, social functioning, perceived wellness, and ways of coping in individuals with SUD. The relapse rate in the intervention group at the end of the program was 0%, whereas the relapse rate in the control group was 31%. At 3-month follow up, the relapse rate was 3.4% in the intervention group and 20.7% in the control group. Urine samples were used to determine relapse; however, the nature of the urine test provides information regarding use of substances within the past 1 week only. Therefore, substance use over the entire 3-month period following the end of the program could not be determined. On the other hand, participants in the control group were receiving routine treatment and participants may have had negative drug screens during this 3-month period. However, when these findings are considered as a whole, the results indicate that the relapse prevention psychoeducation program was effective at preventing relapse. As a result of the analyses to determine the magnitude of the effect of the psychoeducation program on the relapse rate, the likelihood of non-relapse in individuals in the intervention group at the end of the program was 14.29 times higher than in the control group and 7.3 times higher than the control group at 3-month follow up.
Comparing the results of the current study with other studies in the literature, the relapse rates obtained at the end of the program and at 3 months were lower. Türkcan (2001) reported a relapse rate of 27.7% at 3 months after a 12-session CBT program. In Pashaei et al.'s (2013) study of a 10-session group therapy program to prevent relapse, the rate of relapse in the intervention group was 36.4% compared to 63.6% in the control group at the end of the program. In Jafari et al.'s (2010) therapy program, which included Marlatt's relapse prevention model, the relapse rate was 16% in the intervention group and 65% in the control group at the end of the program. Min et al. (2001) reported a relapse rate of 62.8% in the intervention group and 83.3% in the control group 3 months after a relapse prevention group therapy program. Bowen et al. (2014) conducted a study on three separate groups, including eight sessions of standard therapy, a relapse prevention therapy program, and a CBT program, respectively. At the end of the study, the relapse prevention program was found to be more effective, and at 3-month follow up, relapse rates were 20% in the standard therapy group, 11% in the relapse prevention therapy group, and 14% in the CBT group. In a study conducted by Maarefvand et al. (2015), abstinence rates were significantly greater for patients who received a community-based relapse prevention program compared to individuals receiving usual treatment at 45 days (n = 27 and 20, respectively, p < 0.004) and 90 days (n = 27 and 21, respectively, p < 0.007) after discharge. In a study where interventions applied by nurses to individuals with alcohol addiction were examined, CBT interventions were found to reduce the rate of alcohol use (Yaman & Yilmaz, 2020). On the other hand, different from the current findings, according to a systematic review and meta-analysis conducted by Grant et al. (2017), mindfulness-based therapy methods did not have a significant clinical effect on relapse in individuals with SUD.
No studies in the literature investigate the effect of a relapse prevention psychoeducation program on the level of social functioning of individuals with SUD. In the current study, the total and subscale mean scores of the SFS for the intervention group significantly increased at the end of the psychoeducation program and at 3-month follow up. Psychiatric problems, such as SUD, affect social functioning negatively by causing social withdrawal, impairment of interpersonal relationships, difficulty in maintaining one's own health, and loss of function in the workplace (Budak, 2011; Can & Tanriverdi, 2015). Another interesting result of the current study was that there was a significant increase in the level of certain social functions for the control group, yet in the comparisons of the intervention and control groups over time, there was no significant difference except in the social functioning and employment/occupation subscales. Whether participants were in the intervention or control group, none wanted to start using substances again, which may be related to this result.
Total perceived wellness and emotional, spiritual, and intellectual wellness scores were higher at the end of the program and 3-month follow up for the intervention group than the control group. This finding suggests that the psychoeducation program had a positive effect on the perceived wellness of participants. SUD has a negative impact on wellness because it causes problems in individuals' professional and social lives. Decreases in wellness negatively affect existential well-being and increase the use of substances that deteriorate existential well-being (Turhan et al., 2011). In other words, as the wellness perceived by an individual increases, the use of substances decreases. In the current study, relapse did not occur in individuals at the end of the intervention, the relapse rate at 3-month follow up was low, and the increase in perceived wellness was parallel to these findings. In Unterrainer et al.'s (2013) study evaluating coping styles, spiritual well-being, and personality structures of individuals with SUD, it was reported that the implementation of a therapeutic intervention program to provide positive and meaningful support to these individuals would contribute positively to their well-being and addiction treatment. Although the perceived wellness total and subscale scores of the control group showed some increases over time in the current study, this difference was not significant except for perceived social wellness. This significant improvement in perceived social wellness, as well as the improvement in social functioning in the control group, can be explained by the fact that individuals in the control group continued standard treatment after detoxification.
At the end of the relapse prevention program and at follow up, use of the self-confident, optimistic, and seeking social support approaches for coping in the intervention group significantly increased compared to pretest. In addition, use of the helpless and submissive approaches decreased in the intervention group. These findings can be interpreted as a result of the fact that the psychoeducation program increased the ability of individuals to trust themselves when solving their problems and to look for a more positive perspective and seek more social support; the program also reduced the use of helpless and submissive coping. It is important to evaluate stress in patients with SUD and provide these individuals with effective coping strategies. Individuals with SUD increase their use of substances to cope with stress, and individuals with past SUD may start to reuse substances in the absence of effective coping strategies (Ouimette et al., 2010). Studies including individuals with SUD have found that people with stress disorders use inappropriate coping methods and consume more substances to cope with their negative feelings (Ouimette et al., 2010). Similar to the current study, it has been reported that psychosocial therapy interventions related to stress management have been effective in reducing individuals' stress and substance consumption (Fosnocht & Briand, 2016) and preventing relapse (Roberts et al., 2015). At the end of a 3-week cognitive-behavioral stress management intervention program conducted with individuals with SUD by Back et al. (2007), participants were found to have decreased stress and stress activity causing substance use and relapse, and they were found to be more effective at coping with stress.
Due to the lower percentage of female individuals with SUD who apply for treatment (Turkish Monitoring Centre for Drugs and Drug Addiction, 2019), the number of women included in the current study was low and may have created a limitation. In addition, as a urine sample only provides information on substance use in the past 1 week, it may be limited in detecting a larger and longer-lasting phenomenon such as relapse.
Psychiatric nurses with an active role in the treatment of SUD are the appropriate health care professionals to implement a psychoeducation program. Considering the results of the increased rate of relapse in the assessment conducted 3 months after the program, monthly support sessions are recommended to help patients maintain their motivation for abstaining from substance use.
A relapse prevention psychoeducation program can be effective in preventing relapse in the treatment of SUD. To better understand the cause-and-effect relationships between substance use behaviors and relapses, the content of these programs should be developed and tested in qualitative studies, and the prolonged maintenance of the program effect should be evaluated in future studies with longer follow up.
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Participant Demographics (N = 58)
|Variable||n (%)||p Value|
|Intervention Group (n = 29)||Control Group (n = 29)|
| Male||28 (96.6)||23 (79.4)|
| Female||1 (3.4)||6 (20.6)|
| Literate||1 (3.4)||1 (3.4)|
| Primary school||11 (37.9)||18 (62.1)|
| High school||12 (41.4)||7 (24.1)|
| College||5 (17.2)||3 (10.3)|
| Employed||13 (44.8)||18 (62.1)|
| Unemployed||16 (55.2)||11 (37.9)|
| Employee||12 (92.3)||18 (100)|
| Official||1 (7.7)||0 (0)|
| Yes||28 (96.6)||29 (100)|
| No||1 (3.4)||0 (0)|
|Parents live together||0.365|
| Yes||24 (82.7)||21 (72.4)|
| No||5 (17.3)||8 (27.6)|
| Poor||6 (20.7)||3 (10.3)|
| Moderate||15 (51.7)||19 (65.5)|
| Good||8 (27.6)||7 (24.1)|
| Single||26 (89.7)||21 (72.4)|
| Married||3 (10.3)||8 (27.6)|
| Parents||26 (89.7)||20 (69)|
| Spouse and children||2 (6.9)||4 (13.8)|
| Spouse, children, and parents||0 (0)||2 (6.9)|
| Spouse||0 (0)||1 (3.4)|
| Friend||1 (3.4)||2 (6.9)|
| Multiple||20 (69)||15 (51.7)|
| Heroin||7 (24.1)||14 (48.3)|
| Marijuana||1 (3.4)||0 (0)|
| Bonzaia||1 (3.4)||0 (0)|
| No||16 (55.2)||14 (48.3)|
| Yes||13 (44.8)||15 (51.7)|
|Mean (SD) (Range)|
|Age (years)||23.14 (3.8) (17 to 31)||23.1 (4.53) (17 to 35)||0.975|
|Age of onset of substance use (years)||16.3 (2.6) (13 to 23)||17.5 (5) (12 to 33)||0.826|
|Duration of treatment (months)||8.1 (15.7) (1 to 60)||11.5 (15.2) (1 to 60)||0.059|
|Duration of substance use (months)||59.7 (38.5) (6 to 180)||49.4 (35.2) (6 to 132)||0.296|
|Duration of employment (months)||23.61 (22.3) (1 to 60)||28.55 (34.8) (1 to 108)||0.921|
Content of group sessions.
Comparison of Mean Scores of Social Functioning Scale (SFS) of Intervention and Control Groups
|SFS Subscales||Measurement||Intervention Group n=29||Control Group n=29||Difference Between Groups|
|Mean. ± Std.||Mean ± Std.||F||p|
|Intra-group Difference||F=17.739 p=0.000||F=2.475 p=0.094|
|Social engagement/Social withdrawal||Pre-test||8.82±3.04||9.03±3.05||2.416||0.104|
|Intra-group Difference||F=11.135 p= 0.000||F=4.828 p=0.012|
|Intra-group Difference||F=3.184 p= 0.049||F=4.828 p=0.012|
|Intra-group Difference||F=6.679 p=0.002||F=0.461 P=0.633|
|Intra-group Difference||F=6.183 p=0.004||F=0.615 p=0.544|
|Intra-group Difference||F=9.056 p=0.000||F=5.619 p=0.006|
|Intra-group Difference||F=6.245 p =0.004||F=0.871 p=0.424|
|Intra-group Difference||F=11.506 p=0.000||F=1.597 p=0.212|
Comparison of the Mean Scores of the Perceived Wellness Scale (PWS) of the Intervention and Control Groups
|PWS Subscales||Measurement||Intervention Group n=29||Control Group n=29||Difference Between Groups|
|Mean ± Std.||Mean. ± Std.||F||p|
|Intra- group Difference||F=16.895 p= 0.000||F=1.537 p=0.224|
|Intra- group Difference||F=13.474 p= 0.000||F=1.274 p=0.288|
|Intra- group Difference||F=11.306 p= 0.000||F=0.586 p=0.560|
|Intra- group Difference||F=1.569 p= 0.217||F=6.020 p=0.004|
|Intra- group Difference||F=5.163 p= 0.009||F=0.241 p=0.787|
|Intra- group Difference||F=26.048 p= 0.000||F=2.382 p=0.102|
|Intra- group Difference||F=3.060 p= 0.055||F=0.388 p=0.680|
Comparison of the Mean Scores of the Ways of Coping Scale (WOCS) of the Intervention and Control Groups
|WOCS Subscales||Measurement||Intervention Group n=29||Control Group n=29||Difference Between Groups|
|Mean. ± Std.||Mean. ± Std.||F||p|
|Intragroup Difference||F=5.091 p= 0.009||F=0.488 p=0.616|
|Intragroup Difference||F=8.099 p= 0.001||F=0.078 p=0.925|
|Intragroup Difference||F=16.186 p= 0.000||F=0.657 p=0.523|
|Intragroup Difference||F=13.077 p= 0.000||F=0.411 p=0.665|
|Seeking Social Support Approach||Pre-test||6.45±2.31||6.72±1.85||2.228||0.113|
|Intragroup Difference||F=4.159 p= 0.021||F=2.116 p=0.130|