Health, Spirituality and Medical Ethics

Introduction
Due to cultural reasons, misbeliefs, and specific geographical location, Iran is a proper condition for the addiction of adolescents (1). Drug abuse put these individuals at high academic risk. In addition, poor adaptability and performance of schools raise the risk of school drop-out and decreases future opportunities to achieve a proper social status among adolescents. Furthermore, drug-using adolescents have a higher tendency to suicidal and criminal acts, compared to normal individuals (2).
One of the factors that can effectively prevent and reduce mental disorders and their associated problems, such as suicide, drug addiction, depression, and anxiety, is religious beliefs. Religion is one of the factors affecting behaviors and cognition (3). Religious factors, through accentuating human values and creating a sense of safety, calmness, and trust, making life purposeful, and increasing tolerance in the face of problems, are regarded as protective factors against addiction, especially among juveniles.
Various studies have evaluated the relationship between religion and addiction. In a review by Alterman, Casillo, Ivy, and Donna, religion, spirituality, and optimism were introduced as the main protective factors against drug abuse (4). Results obtained by Hajjarian and Ghanbari indicated a significant inverse relationship between religious orientation and the rate of drug abuse (5). Moreover, Mekrame and Zanjani marked that having religious beliefs and believing in the consequences of drug use played a significant role in the reduction of drug abuse (6). In another study by Asghari, Kord Mirza, and Ahmadi, religious orientation played an important role in the tendency of students to drug use (7).
Allport[u1] [S2]  divided religious orientation into two internal and external categories. Individuals with external religious orientation have religious beliefs, and religion is the tool to meet their primary needs (8). While believing in God and adhering to religious principles lead to the belief that God helps people and they are not alone at the time of distress, lack of internalization of religious values in a person with external religious orientation results in a cognitive extension, and consequently, the individual attributes events to external factors or chance, hence reducing the sense of satisfaction and joy (9). On the other hand, individuals with internal religious orientation internalize values and regard religion as a target. In this orientation, religion assumes an autonomous and independent function and turns into a superior motive (8).
 
Nevertheless, limited studies have been conducted on the mechanisms through which religion affects drug use (10). Religious orientation can play a role in the tendency to addiction through effects on social support and self-efficacy among individuals. Social support can be defined as the provision of support, peace, and confidence by family or other social units or community members in the face of stressful situations. In fact, the core of a large number of neuropsychological disorders is the feeling of loneliness and solitude. In order to explain the effect of social support on tolerance of individuals in stressful situations, two models of direct and indirect impact (buffer theory) were presented. Comparison of these two models demonstrated that lack of or reduction of social support caused physical and mental impairments through a direct effect, whereas in the buffer theory, lack or reduction of social support was associated with increased stress level, resulting in the emergence of such disorders (11).
On the other hand, self-efficacy denotes the belief of individuals in their own abilities to set motivations, use cognitive resources, and exercise control over a certain event. One of the essential aspects of self-efficacy is believing that the person can control the outcomes in life, especially when faced with stressful events, having a sense of control over the situation, which is an important factor for adapting to various situations (12). Self-efficacy is judging about the capabilities of an individual to set and conduct the necessary courses of action to manage proactive situations affecting life (13).
Tate et all [u3] [S4] demonstrated that poor self-efficacy lays the foundation for drug abuse among adolescents and adults. Those who consider themselves more efficient, have a higher level of satisfaction with life and a lower tendency to high-risk behaviors in addition to being more successful in terms of performance (14).
Aboulghasemi found that adolescents with low self-efficacy used drugs to cope with problems (15). Therefore, given the importance of recognizing variables involved in the tendency to addiction, this study aimed to shed light on the relationship between internal and external religious orientations and addiction potential among adolescents and whether social support and self-efficacy can play a mediatory role in the relationship between religious orientation and addiction potential.
Materials and Methods
This descriptive correlational study was conducted on all male adolescent students of schools of Zanjan rood, Iran (N=384) in the academic year 2015-2016. Sample size was estimated at 181 using Morgan table. The subjects were selected through the single-stage cluster sampling method. Three out of six high schools in the town were randomly chosen. Overall, 90 individuals were selected from Professor Shahriar High School, 25 cases from Imam Sadegh High School, and 66 students from Velayat High School considering the school populations and academic levels of the students using simple random sampling. Dlata collection was carried out using the following tools.
Religious Orientation Scale by Allport
This 21-item questionnaire is scored based on a four-point Likert scale with no cut-off points. According to the scoring process, higher scores are indicative of a higher tendency to the evaluated factors. In this questionnaire, items 1-12 are related to internal religious orientation, and items 13-21 evaluate internal religious orientation. This test was translated and normalized in Iran in 1998 and its reliability and validity were confirmed by John Bozorgi (1998). Internal consistency of the test was confirmed at Cronbach’s alpha of 0.71 and test-retest reliability of 0.74. Allport and Raus designed this scale in 1967 to evaluate the internal and external religious orientations. After conducting primary studies, it was observed that the correlation of internal and external orientation was 0.21. According to the research by Allport, there was a correlation between components of internal religious orientation and those of external religious orientation (r=-0.21) (16).
In some other studies, such as the study by Fagin, the correlation between internal and external religious orientations was -0.20. In addition, the reliability of the questionnaire was confirmed by Jun Bozorgi at Cronbach’s alpha of 74 (17) and by Mokhtari et al. at 0.71 (18). In the present study, the reliability of the questionnaire was estimated at Cronbach’s alpha of 0.80.
Wax Social Support Scale
The Wax Social Support Scale (SS-A, 1995) was designed by Wax, Phillips, Holly, Thompson, Williams, and Stewart (1986) (quoted by Zeynivand, 2005). This 23-item questionnaire is scored based on a four-point scale (1- support related to family, 2- support related to friends, 3- support related to acquaintances, and 4-total social support, which is the sum of the former three scores. In a research by Khosh Konesh et al., Cronbach’s alpha of 0.81 was estimated for the whole questionnaire (19). In the present study, Cronbach’s alpha of 0.74 was calculated .
General self-efficacy scale  Sherer and Maddux
In this research, the 17-item self-efficacy by Sherer was employed. This scale is scored based on a five-point scale. Reliability of the scale was estimated at 0.86 by Sherer and Maddux. In a research, Bakhtiari Barati (1997) correlated the scores obtained from this scale with the values of several personal characteristics evaluated using Rutter's Inner And Outer Control Scale, subscales of personal control, Marlo and Keiran Social Rank Scale, and Rosenberg’s Interpersonal Competence Questionnaire) to assess the construct validity of the general self-efficacy scale. The predicted correlation between the self-efficacy scale and the personal characteristics was moderate (0.61 at the significance level of 0.05), confirming the construct validity of the scale (quoted by Keramati and Shahr Arai, 2004). Moreover, reliability of the scale was estimated at 0.76 by Guttman split-half method and Cronbach’s alpha of 0.85 (20). In the present study, the reliability of the scale was calculated at 0.75.
Addiction potential Scale (APS)
This 41-item questionnaire  that Made by Wade and Butcher in 1992, has two yes and no alternatives for each item. However, some of the items are reverse scored, that is, the correct alternative was allocated zero and the wrong option was assigned a score of one. The final score is the sum of all scores. Two methods were applied in order to estimate the validity of the scale. In criterion validity, the APS was used to differentiate between addicts and non-addicts. This was also performed on rehabilitation candidates, who referred to rehabilitation centers, and employees of an industrial unit (N=841) in Ahvaz, Iran, which led to the confirmation of the reliability of the scale at Cronbach’s alpha of 0.90 (favorable level).(21) In the present study, reliability of the questionnaire was estimated at Cronbach’s alpha of 0.71.
The inclusion criteria were lack of history of addiction in the subjects and their families, no apparent psychiatric or medical disorders, and willingness to participate in the study. Not meeting the inclusion criteria resulted in the exclusion of some of the participants. Written informed consents were obtained from the subjects prior to the research, and they were assured of confidentiality terms regarding their personal information. Eventually, the questionnaires were distributed among 181 students.
 
In total, 170 students fully completed the questionnaires, whereas 11 failed to complete the scales (lack of answering to one or some of the items). However, all of the questionnaires were assessed due to the remissibility of the missing data. Data analysis was performed by using SPSS version 20, linear structural relations
(LISREL), and structural equation modeling.
 
Results
Means and standard deviations of religious orientation, social support, self-efficacy, and addiction potential were 2.0±5.52, 3.34±0.5, 3.23±0.51, and 0.52±0.07, respectively. Normal distribution of the data was evaluated by applying the Anderson-Darling test. Results demonstrated that the P-value was 0.903 in the religious orientation variable, which confirmed the normal distribution of the data.
 
In the social support variable, P-value of Anderson-Darling test was 0.019, showing non-normal distribution due to being smaller than 0.05. Therefore, Johnson conversion was applied to convert this variable to normal distribution and the highest P-value was 0.184, which made the variable normal. On the other hand, the P-value of Anderson-Darling test was 0.346 in the self-efficacy variable, whereas it was 0.933 in the addiction potential variable, indicating the normal distribution of both variables.
Diagram 1 shows the standard form of the assumed model, where variables can be compared and ranked. In this regard, higher value of the variable was indicative of more effectiveness, and positive values were interpreted as positive effect causing an increase in the dependent variables. On the other hand, negative values were indicative of negative impact reducing the values of the dependent variables.
 

Diagram 1. The model for path analysis of mediation of social support and self-efficacy in the relationship between religious orientation and addiction potential in standard solution mode

 
 
 
 
 
 

Goodness of fit index (GFI), normed fit index (NFI), and comparative fit index (CFI) of the above model was 90%, which confirms the fitness of the model. Summary of the path coefficients and significance of the model are presented in Table 1.
 
Table 1. Summary of path coefficients and significance of the structural equation model for mediation of social support and self-efficacy in the relationship between religious orientation and addiction potential

Reflective path			Graphic signs	Standard coefficient of path analysis	T
External religious orientation	Social support of family	Addiction potential of adolescents	H.KH	0.23*-0.38=0.087	3.27&-3.23
External religious orientation	Social support of friends	Addiction potential of adolescents	H.DO	0.31*-0.28=0.086	71/4- &01 /4 4.01&-4.71
External religious orientation	Social support of acquaintances	Addiction potential of adolescents	H. SH	0.19*-0.13=-0.024	90/3- &53 /2 2.53&-3.90
External religious orientation	Total social support	Addiction potential of adolescents	H.EG	0.43*-0.51=0.21	65/7- &15 /5 5.15&-7.65
External religious orientation	Self-efficacy	Addiction potential of adolescents	KO.K	0.13*-0.23=0.029	5.35&-8.88
External religious orientation	-	Addiction potential of adolescents	J.M.BI	-0.59	-7.55
Internal religious orientation	Social support of family	Addiction potential of adolescents	H.KH	0.71*-0.38=-0.269	3.98&-3.23
Internal religious orientation	Social support of friends	Addiction potential of adolescents	H.DO	0.58*-0.28=0.162	5.85&-4.71
Internal religious orientation	Social support of acquaintances	Addiction potential of adolescents	H. SH	0.27*-0.13=-0.035	3.52&-3.90
Internal religious orientation	Total social support	Addiction potential of adolescents	H.EG	0.68*-0.51=0.346	6.65&-7.65
Internal religious orientation	Self-efficacy	Addiction potential of adolescents	KO.K	0.66*-0.23=-0.151	5.56&-5.88
Internal religious orientation	-	Addiction potential of adolescents	J.M.BI	-0.68	-8.12

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluation of the demonstrated paths in the model confirmed all the hypotheses. respectively respectively first rank of effect in this model. On the other hand, the path of external religious orientation to addiction potential with the mediation of social support of acquaintances had the last rank with the coefficient of -0.02.
Discussion
In the present study, all the direct and indirect paths to addiction potential were significant and had a negative effect on addiction potential, significantly reducing tendency to addiction. The direct paths of internal and external religious orientations had the highest negative impact on addiction potential, respectively. Then, had an effect, respectively,  indirect path of internal religious orientation, total and family social support, external religious orientation, total social support, internal religious orientation, self-efficacy, external religious orientation, and self-efficacy.
In a review by Alterman, Casillo, Ivy, and Donna, factors such as religion, spirituality, and optimism were the main factors for the prevention of drug abuse (4). Raiya, Pargament, Mahoney, and Stain showed that religion increased the sense of welfare (22). Further, Flavio, Coliseum, and Parsa marked that having religious attitudes and beliefs had an impact on the reduction of psychological stress, depression, and anxiety, and prevented high-risk behaviors, such as smoking and alcohol and drug abuse (23).
In another study by Merrill, which was conducted among university students aged 17-35 years studying at higher education centers in the United States, the highest rates of consumption of tobacco, marijuana and other illegal substances were observed in individuals with less religious preferences (24). Coplo found in a study that the presence of support networks and structures plays a significant role in the prevention of drug abuse (25).
 
 
 
 
Results obtained by Pourni Poor Nick Dast showed that religious adolescents had lower tendency to addiction. These researchers found a reverse association between religiosity and possibility of drug use (26). In a study by Zargar, there was an inverse association between religious attitude and addiction potential (27).
Internal religious orientation is a variable helping individuals to be peaceful and resort to a powerful force in all situations, which plays the greatest role in the reduction of addiction potential among adolescents. Even external religious orientation can diminish addiction potential to a significant extent. That is to say, resorting to religion, even as a tool to achieve external and often financial goals, can decrease the tendency to addiction in juveniles. To explain this issue, it could be stated that various religions forbid their followers from committing sins, performing unfavorable acts, and consuming alcohol or any other detrimental substances. On the other hand, resorting to religion leads to inner peace and freedom from various anxieties, which can prevent the use of drugs with the incentive of reaching tranquil (28). Furthermore, it seems that joining religious groups has many benefits for individuals and creates the sense that no drug must be used and even thinking about this issue must be avoided.
Being religious increases the sense of calmness and leads to the attendance of individuals in religious groups and traditions. On the other hand, religion has always emphasized on the importance of respecting parents and seeking consultation from them. Therefore, it seems that having strong religious beliefs leads to social support from family, friends, and acquaintances. When solidarity, unity, and commitment arise among family members, a person can use their help to resolve problems and regard them as mental sedatives, which rules out the use of drugs as a short-term solution (29). On the contrary, poor skills, behaviors, and decisions of families pave the way for deviation of family members. Healthy friends who use proper solutions for dealing with problems provide the foundation for learning for other friends.
Moreover, supportive friends can provide various types of emotional, instrumental, and informative support for an individual. Membership of adolescents in felonious and deviant groups of peers, presence of problematic behaviors among peers at school, emulating peers with high-risk behaviors, smoking of friends and peers, and lack of deterrence are related to the possibility of drug use and smoking among adolescents. In addition to family and friends, acquaintances also play a role in solving problems, but to a smaller extent.
Religious teachings have also emphasized on the social role of human beings. In Hamd Surah, the majority of sentences are stated in the plural form (we pray, we seek guidance). It is obvious that humans need the support of friends and acquaintances during distress to feel more safe. Studies by Kokerham have shown that social support and social relation network, which are applied by acquaintances, significantly affect general health (30).
In the present study, social support played a mediatory role in the relationship between religious orientation and addiction potential, in a way that religious orientation lowered addiction potential by providing the infrastructure for social support.
Content and messages of religions cause a sense of empowerment and control over the situation. In other words, self-efficacy increases in the person. Those with clear, well-defined, coordinated, and almost sustainable sense of self-efficacy have a high psychological health. Therefore, they are less likely to use aberrant and unhealthy methods (e.g., drug abuse) to solve their problems.
These individuals show more strength when dealing with unfavorable and stressful events, and accept no negative thoughts about themselves and their abilities. High self-esteem increases the sense of adequacy among adolescents, encouraging them toward more effective ways of dealing with problems. Many high-risk behaviors of adolescents are due to low self-esteem. In fact, self-efficacy prevents the sense of hollowness by increasing self-esteem among adolescents, preventing many negative behaviors. In addition, self-efficacy helps the way people think, feel, generate motivation, and act in a situation.
Individuals with a higher levels of self-efficacy are more successful and use their imaginations and thoughts in line with guiding, being motivated, and acting towards goals. Therefore, these individuals act less impulsively and show less unreasonable behaviors. Bahadori Khosroshahi (31), as well as Tate, Cummins, and Sherior (32) proposed that poor self-efficacy leads to a higher risk of drug abuse among adolescents and youths. Therefore, religious orientation diminishes addiction potential by increasing self-efficacy.
Conclusion
Having a religious orientation has a remarkable impact on reducing addiction potential. However, this role is more accentuated in internal religious orientation. On the other hand, despite the fact that history points to the role of social support and self-efficacy in the reduction of addiction potential, this impact is reduced by assuming a mediatory role, which was an unexpected finding. Therefore, to shed light on this issue further studies are recommended.
In addition, our results demonstrated the mediatory roles of social support (family, friends, and acquaintances) and self-efficacy in the relationship between internal and external religious orientations and addiction potential. One of the major drawbacks of the present study was its implementation solely on male students of Zanjan rood, which limited the generalizability of the final results to other communities and female individuals. Given the important role of religious orientation in the reduction of tendency to addiction, it is suggested that studies be conducted to recognize the effective factors in religious orientation to improve religious orientation. In addition, we recommend implementing direct and indirect educational programs to encourage parents to effectively support their children and instill self-efficacy in them.
 

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