Association between Spiritual Health and the Quality Of Life in Opioid-Dependent Men in Qom , Iran

Introduction owadays, drug dependence is one of the most widespread social and health crises, and its devastating wave has affected all social, economic, political, cultural, psychological, and educational areas (1,2). The illegal use of opioids (including opioid analgesics and heroin) is a growing public health concern. In Iran, the number of opiate users, especially the users of opium, heroin, syrup, and morphine, has been estimated 6 million (3). Nowadays, the effects of different types of addiction treatment methods on the quality of life of addicts are considered to be greatly important because addiction is associated with physical and psychological damage and threatens the health and safety of an individual (4). Studies have shown that substance abuse leads to lower quality of life (2,5). In the last three decades, quality of life has attracted much attention as an important factor in evaluating treatment outcomes (6). The World Health Organization defines the quality of life as an individual's perception of his/her position in life, in terms of the culture of their value systems, goals, expectations, standards, and priorities (7). Research has shown that abuse of opioid, alcohol, and sedatives is associated with low quality of life (8). In general, studies have shown that quality of life in substance abusers is lower (9,10). On the other hand, there is a great deal of evidence that there is a link between higher quality of life and more successful treatment of opioiddependent people (11). As mentioned, one of the issues that can affect the quality of life of N Abstract

Please Cite This Article As: Yaghobi M, Abdekhoda M, Khani S. Association between spiritual health and the quality of life in opioid-dependent men in Qom.Health Spiritual Med Ethics.2018;5(1):26-32.Downloaded from jhsme.muq.ac.ir at 13:37 IRST on Saturday December 29th 2018 addicts is the health status.Spiritual health is one of the health aspects (12).Attention is currently being paid to the spiritual aspect in defining the concept of health.In general, the absence of an acceptable definition of spiritual health is obvious and there is no consensus on the spiritual structure and therefore the concept of spiritual health (13).According to the Islamic perspective, spiritual health is defined as a situation in which insights, tendencies, and abilities that are proportional to a person's capabilities, are provided for him/her to achieve spiritual excellence.Inner and outer voluntary behaviors that fit this spiritual excellence emerge toward God, person, and society (14).The study of Salmabadi et al. on the relationship between spiritual health and quality of life in addicts and non-addicts, showed that there was a significant relationship between the religious aspect of spiritual health and quality of life (2).Habibian et al. also investigated the relationship between religious orientation and quality of life.They found that religious orientation had a significant relationship with quality of life (15).There has been research on the relationship between spirituality/religiousness and quality of life in addicts, which indicates a direct correlation between these two variables.However, studies that have examined spiritual health have often used instruments that measure religiousness rather than those that measure spiritual health as a whole concept.These instruments sometimes do not really measure what their developers have claimed (14).In the current study, we used an instrument to measure spiritual health that was developed based on the definition of the Academy of Medical Sciences of Iran and in accordance with the sociocultural and religious characteristics of the Islamic community of Iran.Besides that, to the best of our knowledge, no study has yet been conducted on the relationship between spiritual health and quality of life in people who are under methadone maintenance treatment.The purpose of this study was to investigate the association between spiritual health and the quality of life in opioid-dependent men in Qom.

Methods
This research was a descriptive-correlational study conducted in 2015-2016.The study population of this study included all opioiddependent men in Qom, from whom 107 people were randomly selected.From methadone maintenance centers, four centers from the north, south, west and east of Qom were selected by convenience sampling.Patients' lists of these centers were provided.To perform randomized sampling, 107 people were randomly selected from 300 opiate addicts referring to the addiction treatment centers using random number table.
Inclusion criteria were being able to read and write, being aged 18-45 years, having at least 2-year history of opioid abuse, male gender, and having no long-term and simultaneous dependence on multiple substances, and exclusion criteria were suffering from psychiatric disorders (based on the SCID-DSM diagnostic interviews performed by a clinical psychologist) and having history of receiving psychological interventions during the past month.
For data collection, the methadone maintenance treatment centers were referred to and information about the study was provided to the participants.Participants completed 36-Item Short Form Survey (SF-36) and a spiritual well-being questionnaire.

Ethical considerations
The participants participated in our study voluntarily and after they provided written informed consent to participate in it.The participants were allowed to withdraw from the study whenever they wished to do so.The participants were also assured that their information would be kept confidential.
Data collection instruments Demographics checklist: The demographics checklist consisted of items on age, education level, substance abuse history, and employment status that was completed by the participants before the study began.
The SF-36: The SF-36 is a short, 36-item scale to measure health with eight subscales: Downloaded from jhsme.muq.ac.ir at 13:37 IRST on Saturday December 29th 2018 Physical function, physical role, physical pain, general health, vitality, social function, emotional role playing, and emotional wellbeing.The score on each of these subscales ranges from 0 to 100.A higher score in each of the subscales represents the more desirable condition of the individual with respect to the subscale of interest.Validity and reliability of the SF-36 have been confirmed in the United States and some other countries (16,17).The internal consistency coefficients of the eight subscales of the SF-36 have been reported 0.72-0.93.The other study reported the testretest reliability coefficients of the eight subscales of this scale with a 2-week interval to be between 0.33 and 0.81, and the highest and lowest test-retest reliability coefficients were obtained for the physical function and emotional role playing subscales, respectively and reliability of the SF-36 were evaluated by Montazeri et al. for the first time in Iran with 4136 people aged 15 years and older most of whom were married.The reliability coefficients of the eight subscales were derived between 0.77 and 0.95 (19).
Spiritual Well-Being Questionnaire: The Spiritual Well-Being Questionnaire used in the current study has 48 items to measure spiritual well-being.Validity and reliability of this questionnaire have been confirmed by experts.The results of the factor analysis revealed the existence of the 6-factor model in the structure of the developed items and the optimal model was explained in terms of (1) cognitive/emotional and (2) behavioral components.It consists of three constructs, tendency, insight, and behavior, each of which has three subconstructs, relationship with God, relationship with self, and relationship with the surrounding.All items of this questionnaire are rated on a 5-point Likert scale ranging from Absolutely agree (1) to Absolutely disagree (5), and then the scores are calculated on a 0-100 range (1=100, 2=75, 3=50, 4=25 and 5=0) (20).The goodness of fit of the drawn model was determined to be optimal by confirmatory factor analysis.Internal consistency for all subconstructs of the questionnaire was desirable, with Cronbach's alpha of over 0.7 (20).For analysis of the demographic information of the participants, measures of central tendency [mean (standard deviation)] were used.Data analysis was performed by the SPSS version 21 and Pearson's correlation coefficient.

Result
In this study, 107 opioid-dependent men were studied.The mean age of the participants was 31.41 (4.62) (range: 19-40) years.Of these men, 86.9% were married and 71.6% had an education level under high school completion.Regarding substance abuse history, 26.2% of the participants abused substance for less than 3 years, 65.4% for 3-5 years, and 8.4% for more than 5 years.In addition, 86% of them were employed.
The mean score of spiritual health was 69.15 (74.84, 69.01, and 64.52 for the tendency, insight, and behavior constructs, respectively).The mean score of quality of life was 69.15 (Table 1).There was a direct correlation between spiritual health and quality of life (Table 2).
Multiple linear regressions were used to predict and explain the level of quality of life according to general spiritual health and its aspects.According to the regression model, there was a significant direct correlation between spiritual health and the subscales of quality of life except for physical function, limitation in playing the role due to physical health problems, and pain.Among spiritual subscales, the behavioral aspect had a significant direct correlation with the subscales of quality of life, except for Downloaded from jhsme.muq.ac.ir at 13:37 IRST on Saturday December 29th 2018 physical function, limitation in playing the role due to physical health problems, and pain.Increased spiritual behavior was significantly associated with higher levels of quality of life.In addition, general spiritual health was derived to be a significant predictor of promoted quality of life.The correlation coefficient between these two variables was 0.37 (Table 3).

Discussion
The current study showed that there was a significant relationship between spiritual health and quality of life in opioid-dependent individuals.In other words, the psychological and physical aspects of quality of life improved with promoting spiritual health in these people.
This finding is consistent with the findings of other studies (2,15).Participants with higher levels of spiritual health reported higher quality of life.The people who have a pleasing and desirable relationship with God, themselves, and their surrounding environment, can establish better relationships with others and have better social function, and also report having higher levels of life satisfaction.
There is a positive correlation between spiritual beliefs and functional and physical status, reduction of psychological damages, emotional well-being, and promotion of coping (21,22).(23), and also the study of Savitha et al. showed that there was a significant difference in the quality of life Downloaded from jhsme.muq.ac.ir at 13:37 IRST on Saturday December 29th 2018 between people who attended the religious program of Alcoholics Anonymous and those who did not attend (24).
Substance use leads to unpleasant consequences such as physical, psychological and social problems (25).On the other hand, more severe physical and psychiatric problems are associated with lower quality of life (26).
During the process of recovery among substance abusers, higher levels of spirituality are associated with lower levels of anxiety, higher resilience to stress, optimistic orientation toward life, and higher perceived social support (27).
Studies have shown that there is an association between religiosity and mental and physical health.Having religious beliefs and religious rituals are directly correlated with life satisfaction and higher psychological wellbeing.
The important and effective role of having stronger religious beliefs in promoting mental health, emotional stability, reducing psychological stress, and preventing high-risk behaviors such as drug and alcohol abuse is undeniable (27)(28)(29).
The findings of our study showed that there was a significant relationship between spiritual health and all aspects of quality of life, except for physical function, limitation in playing the role due to physical health problems, and pain.Studies have shown that there is an inverse correlation between being religious and spiritual and substance abuse (26).
Religion can be considered a key factor for the treatment and prevention of addiction that increases the quality of life.The study of Habibian et al., showed that there was a significant relationship between religious orientation and quality of life (15).
Our findings also showed that there was a significant relationship between behavioral aspect and all aspects of quality of life, except for physical function, limitation in playing the role due to physical health problems, and pain.Addiction is responsible for changes in behavior, self-esteem, nutrition, work, and generally changes in life, which leads to a decline in quality of life (30).Some studies have reported the findings that are consistent with our findings on the significant relationship between spiritual behavior and aspects of quality of life.The study of Babaie and Razeghi (31) showed that the involvement of substance abusers in religious activities and their participation in religious ceremonies affected their relationship with others, their health, and their psychological well-being.Religious and spiritual beliefs and practices are considered a supportive factor that leads to hope and strength, gives meaning to life, and leads to a decrease in the levels of stress and promotion of quality of life in substance abusers (2).
Positive spiritual coping are associated with a decrease in anxiety and depression (32).The use of positive religious coping skills in combination with religious proscription of suicide can be a supportive factor against suicide (14).In general, positive religious coping skills (such as spiritual support and spiritual relationships) have a significant relationship with mental health and psychological well-being (2,33).

Conclusion
The findings of this study showed that behavior, among the aspects of spiritual health, and general spiritual health was more important for the quality of life among opioid-dependent men.Spiritual health, especially spiritual behavior, is an effective supportive mechanism for opioid-dependent people that can be effective in improving their quality of life.Based on the findings of this study, it can be argued that spiritual health acts as a supportive factor in dealing with life events that lead to negative emotions, physical problems, low psychological well-being, and social dysfunction.
Given the relationship between spiritual health and quality of life, it is necessary to focus more seriously on therapeutic regimens that promote mental health.Spirituality should be considered an effective factor in the treatment outcomes of substance-related disorders.
It is suggested that future studies be conducted on both men and women.Besides that, the relationship between spirituality and other psychological variables that may affect the outcome of treatments for substance-related Downloaded from jhsme.muq.ac.ir at 13:37 IRST on Saturday December 29th 2018 disorders should be examined.The findings of this study are the results of a study on the opioiddependent men in Qom.It is therefore necessary to study this issue in different communities in order to increase the generalizability of our results.

Table 1 :
Mean (standard deviation) scores of spiritual health, quality of life, and their subscales

Table 2 :
Correlation between the aspects of quality of life and spiritual health in opioid-dependent men

Table 3 :
Multiple regression of the aspects of spiritual health for prediction of quality of life and its subscales Criterion