The Association of Mental Health with Family Relationships and High-Risk Behaviors in Female Students of South-Eastern Iran


avatar Fariba Shahraki-Sanavi ORCID 1 , avatar Fatemeh Rakhshani 2 , avatar Alireza Ansari-Moghaddam 3 , avatar Mahdi Mohammadi ORCID 3 , *

Public Health Department, Health Promotion Research Center, Zahedan University of Medical Science, Zahedan, Iran
Public Health Department, Safety Promotion and Injury Prevention Research Center (SPIPRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
Epidemiology and Biostatistics Department, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

how to cite: Shahraki-Sanavi F, Rakhshani F, Ansari-Moghaddam A, Mohammadi M. The Association of Mental Health with Family Relationships and High-Risk Behaviors in Female Students of South-Eastern Iran. Health Scope. 2020;9(1):e55998.



The current study aimed at examining the association of mental health with family relationships and high-risk behaviors among female students in Iran.


The current cross sectional study was conducted on 457 10th-grade students from four public female high schools in South-Eastern Iran. Information was collected using the General Health questionnaire-28 (GHQ-28) of mental health and Self-report questionnair of family relationships and high-risk behaviors with good content validity and reliability (α) 0.71. Data were analyzed by linear and binary logistic regression using SPSS version 15.


The mean scores of mental health and high-risk behaviors of the subjects were 31.06 ± 16.44 (of maximum 84), and 18.03 ± 3.72 (of maximum 78), respectively. The most prevalent problems were associated with social performance scale. Binary logistic regression showed a statistically significant relationship between mental disorders and communication with parents, as well as relationship with opposite gender and sleeping time. A significant correlation was also observed between mental health, family behaviors, relationship with opposite gender, nighttime sleep, being abused by parent, and high-risk behaviors (P < 0.01).


The results suggest that parent the education and counseling programs should be designed and implemented to protect adolescents and prevent socio-mental problems and high-risk behaviors in them. Such program should also be used as a basis for healthy growth of students.

1. Background

Emotional and mental disorders are increasingly important factors in morbidity, disability, and reduced quality of life within all communities (1). Mental, social, and physical health is intertwined like deeply interdependent strands. According to the latest World Health Organization (WHO) report, one out of five young people under 18 have an advanced form of behavioral or emotional problems. Furthermore, it is expected that neurological and mental damage increase about 50% and account for 15% of the global burden of disease by 2020 (2). According to released statistics, mental and behavioral disorders are highly common so that 20% - 25% of all people may be afflicted with such disorders at some times in their lives (3).

Adolescence is a critical period in individual’s mental and social development. The phenomenon of puberty and specific crises during this period, as well as the feelings of confusion and low self-esteem highlight this stage of life in terms of mental health (4). Unfortunately, the evidence indicates a high prevalence of mental disorders in adolescence (5-8); 50% of youth and adult mental disorders are rooted in childhood and adolescence (9). According to UNICEF, 20% of adolescents have mental health problems (10). In this regard, the percentage of adolescents with mental disorders varies from 12% to 29% based on a WHO report (11). The prevalence of mental disorders in Iran varies from 10% to 40% in different regions (12, 13). Additionally, data suggest a high prevalence of mental disorders in females compared to males due to biological factors, gender roles, environmental stress, Limited source of satisfaction and limitation of social participation of females in society (12).

On the other hand, behavior, social, economic, and cultural conditions of families may play an important role in their mental health (14). Studies show that behavioral problems and distortions are mostly rooted in homes and a large proportion of all offender adolescents are from families with poor parents model (15). In fact, parents play a very important role in the transition from this period and the degree of support and warmth of parents affect their health; if they feel accepted by their parents, they would be happier and healthier. The kind behavior of parents works as a major factor in mental health. Moreover, behavioral science experts emphasize that children need love, and deprivation from love, especially maternal love, may deeply annoys the spirit of children (13).

In addition, some researchers believe that the tendency of adolescents toward high-risk behaviors that is increasing every day is a reflection of cognitive and emotional problems they face. Therefore, some major causes of the tendency of the majority of adolescents toward high-risk behaviors are to deal with feelings of depression, anxiety, inefficiency, loss of self-confidence, lack of satisfaction with life, inability to accept oneself, etc. The results of the studies indicated that the likelihood of an increase in high-risk behaviors in people with mental health problems. The feelings of depression, loneliness, and isolation in adolescents are often directly associated with high-risk behaviors such as suicide attempt, and similarly high self-esteem and strong social support sources are among protective factors of adolescents against high-risk behaviors (16-18).

Accordingly, in addition to potential benefits in the area of health, promoting the mental health of adolescents is one of the known methods to prevent high-risk behaviors and strengthen social security. On the other hand, communities and families that have adolescents with mental disorders bear significant therapy costs and dropouts, as well as business and future life failure (19). Furthermore, for females, adolescence is the foundation of their future that guides the next stages throughout their lives and directly affects their future family and children. Then, investigating female adolescents’ mental health status is essential due to their two-fold role within the health of the community and impeding generations' health. Therefore, due to the importance of adolescence in human life as a basis for present and future health, the current study aimed at examining the association of mental health with family variables, sleeping time, and high-risk behaviors in female students of South-Eastern Iran. Logically, investigation of mental health problems and preventive measures, as well as early interventions, would lead to subsequent cost savings.

2. Objectives

The current study aimed at assessing the mental health concerning family relationships and high-risk behaviors in female students of South-Eastern Iran, and applying the results for designing and implementing intervention and consultation programs in schools.

3. Methods

The current cross sectional study was conducted in Zahedan, South-Eastern Iran, from October to November in 2015. Sample size was estimated based on the pilot study and the following formula with P = 0.2, d = 0.04, and α = 0.05:

Equation 1.n=pqz2d2

Due to unisexuality in Iranian schools, at first a list of females’ schools was prepared and four public high schools were randomly selected. Then all 10th-grade students (n = 457) were enrolled. Subjects were included in the study voluntarily and they were assured about the confidentiality of their information.

Mental health was assessed by the General Health questionnaire-28 (GHQ-28) that is a self-administered instrument measuring four basic factors including physical status, anxiety or insomnia, social function. This questionnaire undergoing psychometrics in more than 70 countries (20-22) possesses the highest reliability, sensitivity, and specificity. Persian version of the questionnaire also has a criterion validity coefficient of 0.87 and split-half reliability of 0.90 as well as Cronbach’s alpha of 0.97 (23). The items are multiple-choice questions (no, a bit, high, and very high) scored based on the four-point Likert scale from zero to 3. Finally, based on the cutoff point, subscales were categorized into four groups of low (score 0-6), mild (score 7 -11), moderate (score 12 - 16), and severe (score 17 - 21).

The second questionnaire included demographic and family connections (four items), and high-risk behavior (14 items) questions; i.e., safe and violent behaviors within the month before the study, going out and leaving home without notice, smoking hookah, chewing tobacco, drinking alcohol, using drugs, and having sex during the student life. Answers to multiple-choice items, response rate, and mean scores of high-risk behaviors were calculated. The questionnaire had good content validity ratio (CVR) and content validity index (CVI), with reliability (α) of 0.71.

The study protocol was approved by the Ethics Committee of Zahedan University of Medical Sciences (code no.: IR.ZAUMS.REC.1394.251). In order to collect information, research method, questionnaires completing method, attracting cooperation, trusting, and ensuring the confidentiality of responses were explained to the participants. All 10th-grade students attending the schools were enrolled in the study, and only one student was excluded from the study due to unwillingness. The average time to complete the questionnaire was approximately 30 minutes. The collected data were analyzed by SPSS version 15. Descriptive statistics were used to report the findings and the data were expressed as mean ± standard deviation or frequency and percentage. Binary logistic regression, and liner regression were used to analyze data and P values less than 0.05 were considered significant.

4. Results

The current study was conducted on 457 10th-grade students, aged 14 - 17 years, mostly with a birth rank of 1 - 3. Half of the fathers were employee and had high school diploma, and their mothers were housewife and had high school diploma. The majority of subjects described their socioeconomic condition of their families as moderate to good.

The mean score of total mental health (score range 0 - 84) of the subjects was 31.06 ± 16.44. As can be observed in Table 1, the most prevalent problems belonged to social functioning (26.7%), followed by anxiety and sleep problems (23.2%), depression (23.2%), and physical symptoms had the lowest prevalence.

Table 1.

The Prevalence of Mental Health Subscales and Overall Mean Scorea

Mental SubscaleValues
Somatic symptoms
Low209 (46.1)
Mild154 (34.0)
Moderate71 (15.7)
High19 (4.2)
Low209 (46.2)
Mild138 (30.5)
Moderate72 (15.9)
High33 (7.3)
Social dysfunction
Low105 (23.2)
Mild227 (50.1)
Moderate108 (23.8)
High13 (2.9)
Low271 (59.8)
Mild77 (17.0)
Moderate58 (12.8)
High47 (10.4)

The overall mean score of health-risk behavior (score range 14 - 78) in the subjects was 18.03 ± 3.72. The most frequent high-risk behaviors were sitting in a care while the driver sends or reads messages or emails (42.3%) and failing to wear a seat belt (21.9%); almost 9% of them smoked hookah, and had physical fights in or out of school (Table 2).

Table 2.

The Prevalence of High-Risk Behaviors and Overall Mean Scorea

Going out without noticePhysical fight at school
Yes422 (92.5)Never414 (90.8)
No34 (7.5)1 time22 (4.8)
Leaving home without parental notice2 - 3 time8 (1.8)
Yes408 (89.5)4 - 5 time1 (0.2)
No48 (10.5)≥ 6 time11 (2.4)
Wearing seat belt in the carUsing cigarettes
Always64 (14.0)Never446 (97.8)
Often81 (17.8)1 - 9 d10 (2.2)
Sometimes114 (25.0)10 - 19 d-
Rarely97 (21.3)20 - 29 d-
Never100 (21.9)30 d-
Sitting in a car while the driver uses mobile phone while drivingUsing chewing tobacco
Never263 (57.7)Never455 (99.8)
1 - 9 d157 (34.4)1 - 9 d1 (0.2)
10 - 19 d15 (3.3)10 - 19 d-
20 - 29 d6 (1.3)20 - 29 d-
30 d15 (3.3)30 d-
Carrying a weapon out of schoolUsing hookah
Never430 (94.3)Never410 (89.9)
1 d14 (3.1)1 - 9 d39 (8.6)
2 - 3 d6 (1.3)10 - 19 d2 (0.4)
4 - 5 d-20 - 29 d2 (0.4)
≥ 6 d6 (1.3)30 d3 (0.7)
Carrying a weapon in schoolDrinking alcohol
Never446 (97.8)Never434 (95.2)
1 d5 (1.1)1 - 9 d21 (4.6)
2 - 3 d4 (0.9)10 - 19 d1 (0.2)
4 - 5 d1 (0.2)20 - 29 d-
≥ 6 d-30 d-
Physical fight out of schoolUsing substance
Never415 (91.0)Never449 (98.5)
1 time17 (3.7)Experimental7 (1.5)
2 - 3 time12 (2.6)Current use-
4 - 5 time3 (0.7)Having sexual intercourse
≥ 6 time9 (2.0)Never450 (98.7)
With prevention-
Without prevention6 (1.3)

Compared to children with frequent contact with parents, never talking increased the risk of somatic symptoms (OR = 6.6), anxiety (OR = 4.8), social dysfunction (OR = 4.3), and depression (OR = 6.0). Children who never shared their feelings with their parents were at risk of anxiety 2.2 times more than the ones who did it. Lack of participation in decision-making increased the risk of social dysfunction 2.3 times more than the ones who were always involved in decision-making. Sexual relationship with opposite gender increased the risk of depression 3.7 times more than having no relationship. Children with extra nighttime sleep (10 hours or more) were at higher risk of anxiety (OR = 3.9), social dysfunction (OR = 3.6), and depression (OR = 3.8) than the ones with normal sleeping hours (7 - 9 hours) (Table 3).

Table 3.

Binary Logistic Regression Between Mental Symptom and Relationships with Family, Opposite Gender, and Nighttime Sleepa

VariableNMental Subscalesb OR (95% CI)
Social DysfunctionDepression
Talking with parents
Always20630 (14.6)Reference 0.001Reference 0.00127 (13.1)Reference 0.001Reference 0.001
Sometimes22681 (35.8)3.2 (2.0 - 5.2) 0.0012.6 (1.6 - 4.3) 0.00168 (30.1)2.8 (1.7 - 4.6) 0.0012.4 (1.4 - 4.1) 0.001
Never2211 (50.0)5.8 (2.3 - 14.7) 0.0014.3 (1.6 - 11.5) 0.00311 (50.0)6.6 (2.6 - 16.7) 0.0016.0 (2.3 - 15.9) 0.001
Sharing feeling withNSNS
parents21443 (20.1)Reference 0.00837 (17.3)Reference 0.013
Brother and Sister12740 (31.5)1.8 (1.1 - 3.0) 0.01834 (26.8)1.7 (1.0 - 2.9) 0.038
Nobody11339 (34.5)2.0 (1.2 - 3.4) 0.00535 (31.0)2.1 (1.2 - 3.6) 0.005
Participation in decision-makingNS
Always24142 (17.4)Reference 0.001Reference 0.00643 (17.8)Reference 0.005
Sometimes18366 (36.1)2.6 (1.7 - 4.1) 0.0012.1 (1.3 - 3.3) 0.00251 (27.9)1.7 (1.1 - 2.8) 0.014
Never3014 (46.7)4.1 (1.8 - 9.1) 0.0012.3 (0.9 - 5.4) 0.05212 (40.0)3.0 (1.3 - 6.8) 0.006
Relationships with opposite genderNS
None30275 (24.8)Reference 0.35251 (16.9)Reference 0.001Reference 0.003
Online6517 (26.2)1.0 (0.5 - 1.9) 0.82420 (30.8)2.1 (1.1 - 4.0) 0.0111.9 (1.0 - 3.6) 0.037
Telephone7124 (33.8)1.5 (0.8 - 2.6) 0.12527 (38.0)3.0 (1.7 - 5.3) 0.0012.4 (1.3 - 4.4) 0.003
Physical166 (37.5)1.8 (0.6 - 5.1) 0.2638 (50.0)4.9 (1.7 - 13.7) 0.0023.7 (1.3 - 10.9) 0.014
Nighttime sleep, h
7 - 922556 (24.9)Reference 0.034Reference 0.02943 (19.1)Reference 0.011Reference 0.021
≤ 620855 (26.4)1.0 (0.7 - 1.6) 0.7120.9 (0.6 - 1.5) 0.98253 (25.5)1.4 (0.9 - 2.2) 0.1121.3 (0.8 - 2.1) 0.264
≥ 102111 (52.4)3.3 (1.3 - 8.2) 0.0103.6 (1.3 - 9.6) 0.0110 (47.6)3.8 (1.5 - 9.6) 0.0043.8 (1.4 - 10.1) 0.006
VariableNMental Subscalesc OR (95% CI)
Somatic SymptomAnxiety/Insomnia
Talking with parents
Always20627 (13.1)Reference 0.001Reference 0.00128 (13.6)Reference 0.001Reference 0.001
Sometimes22653 (23.5)2.0 (1.2 - 3.3) 0.0062.0 (1.2 - 3.3) 0.00667 (29.8)2.6 (1.6 - 4.4) 0.0012.2 (1.3 - 3.7) 0.002
Never2211 (50.0)6.6 (2.6 - 16.7) 0.0016.6 (2.6 - 16.7) 0.00111 (50.0)6.3 (2.5 - 16.0) 0.0014.8 (1.8 - 12.7) 0.002
Sharing feeling withNS
parents21434 (15.9)Reference 0.11231 (14.6)Reference 0.001Reference 0.020
Brother and Sister12731 (24.4)1.7 (0.9 - 2.9) 0.05433 (26.0)2.0 (1.1 - 3.5) 0.0101.5 (0.8 - 2.7) 0.142
Nobody11326 (23.0)1.5 (0.8 - 2.8) 0.11542 (37.2)3.4 (2.0 - 5.9) 0.0012.2 (1.2 - 4.0) 0.005
Participation in decision-makingNSNS
Always24140 (16.6)Reference 0.14044 (18.3)Reference 0.027
Sometimes18343 (23.5)1.5 (0.9 - 2.4) 0.07753 (29.0)1.8 (1.1 - 2.8) 0.011
Never308 (26.7)1.8 (0.7 - 4.3) 0.1789 (30.0)1.9 (0.8 - 4.4) 0.134
Relationships with opposite genderNSNS
None30251 (16.9)Reference 0.12259 (19.5)Reference 0.006
Online6516 (24.6)1.6 (0.8 - 3.0) 0.14615 (23.1)1.2 (0.6 - 2.3) 0.519
Telephone7120 (28.2)1.9 (1.0 - 3.5) 0.03124 (34.3)2.1 (1.2 - 3.7) 0.008
Physical164 (25.0)1.6 (0.5 - 5.2) 0.4078 (50.0)4.1 (1.4 - 11.4) 0.007
Nighttime sleep, hNS
7 - 922541 (18.2)Reference 0.255Reference 0.00145 (20.1)Reference 0.007Reference 0.020
≤ 620843 (20.7)1.1 (0.7 - 1.8)0.5202.0 (1.2 - 3.3) 0.00650 (24.0)1.2 (0.7 - 1.9) 0.3231.1 (0.7 - 1.8) 0.596
≥ 10217 (33.3)2.2 (0.8 - 5.9) 0.10211 (52.4)4.3 (1.7 - 10.9) 0.0023.9 (1.5 - 10.2) 0.005

A statistically significant relationship was observed between mental health, family behaviors, relationship with opposite gender, nighttime sleep, being abused by parent, and high - risk behaviors (Table 4).

Table 4.

Relationship Between High-Risk Behaviors and Risk Factor by Multiple Linear Regression

High-Risk BehaviorIndependent Variable
Unstandardized CoefficientStandardized CoefficienttP Value
BStd. ErrorBeta
Mental health0.
Family behavior0.730.160.194.600.001
Relationships with opposite gender0.700.180.163.880.001
Family structure1.560.550.112.780.006
Nighttime sleep0.690.260.102.590.010
Abused by parents0.540.230.102.370.018

5. Discussion

The findings of the current study showed that about a quarter of the students in the study had moderate to severe mental problems and the most prevalent problems were related to social functioning. Also, mean scores of mental health and high - risk behaviors of the subjects were 31.06 ± 16.44 (of maximum 84), and 18.03 ± 3.72 (of maximum 78), respectively. Moreover, female students who never talked to their parents were more at risk of mental disorders in all four studied dimensions. Moreover, non - participation in decision - making process was associated with social dysfunction; relationship with the opposite gender was associated with depression, and sleep disorders with anxiety, social dysfunction, and depression. In addition, the high - risk behaviors of adolescents had a statistically significant relationship with mental health, family variables, relationship with opposite gender, and nighttime sleep as well as.

Reviewing American literature from 2005 to 2011 showed that 11.3% of children under 17 had an advanced emotional or behavioral problem and at least one mental problem was observed in about half of 13 - 18 - year - old adolescents and severe mental problems in 28% of adolescents. The prevalence of behavioral problems in the age group of 12 - 17 years was 5.7%, and depression and anxiety 8.1% and 6.6%, respectively (24). The prevalence of mental problems in French adolescents was 12.5% (25) and the results of a study in Vietnam showed that anxiety 22.8% of adolescents had anxiety, 41.1% depression, and 26.3% suicide attempt (26).

Furthermore, the prevalence of anxiety and depression were 19.01% and 19.74% in Iranian female students, respectively (12). Results of other studies on students in Iran also showed the highest prevalence in social functioning, followed by anxiety, depression, and physical problems. The overall prevalence of mental problems is reported 39% - 62% in different regions of Iran (13, 27). Consistent with other studies, the present study indicated that the lowest level of mental health was in social functioning scale, making up more than a quarter of students studied. The results of the study by D’Arcy and Siddique (31), on the social functioning of a group of Canadian adolescents was also in line with the results of the current study.

The findings suggested that mental disorders of adolescents could be associated with a wide range of features including physical and cognitive health, mental functioning, social environment, family features, and stressful life events (32). When there is a warm relationship between parents and adolescents, a healthy environment is created to develop adolescents (15, 33). The results of the current study demonstrated that the less the quality of the relationship between parents and children, the more the symptoms of depression and anxiety in children (34, 35) and poor social support was associated with greater risk of mental problems in adolescents. Families with more intimate relationships and less struggles possess adolescents with higher mental health (36, 37). Investigating Iranian adolescents indicated a significant relationship between their mental health and family communication patterns (38). Family communication patterns have a significant relationship with anxiety and depression in adolescents and orientating family dialogue is a significant negative predictor of anxiety and depression in children (39). The current study indicated that adolescents that never talk to their parents and do not participate in decision - making process were more at risk of mental disorders. Also, adolescent with high - risk behaviors in their families (e.g., addiction, smoking, etc.), experiences of being abused by parent, or live with other relatives were more at risk of high - risk behaviors; therefore, when the family environment provides more comfortable conditions for conversation about a wide range of subjects, children can achieve personal and intellectual maturity as well as healthiness.

In recent years, there was a rapid increase in friendship with the opposite gender among adolescents and youth of Iran. This is while friendship with the opposite gender is not accepted in Iranian culture. Such relationships are associated with mental and physical problems and conflict with parents, and are not suggested (40). In addition, a romantic relationship in adolescence is a predictor of anxiety, depression, and anger, particularly among females (41). The current study also identified increased risk of depression and high - risk behaviors among females reporting relationships with the opposite gender. In contrast, some studies show an increase in pleasure, well - being, and mental health, and a decrease in high - risk behaviors in students managing friendship with opposite gender (42).

Findings of the current study showed a significant relationship between high - risk behaviors and mental health of the subjects. Indeed, with a decrease in mental health, participation in high - risk behaviors increased. The study on American high school students revealed that stress and depression were associated with increased drug use, violence, assault, unsafe sex, and unhealthy diet (16). Also, reduction of negative emotions such as depression and anxiety was among the causes of adolescent smoking; in fact, smoking is more common in people with depression and mood disorders (43). On the other hand, studies illustrated that females were more inclined to inner destructive behaviors such as anxiety, depression, and suicide attempt. Female participation in high - risk behaviors had an emotional nature related to their stress and depression as well (44).

In line with the results of the current study, previous studies showed that sleep difficulties and hours of sleep were significant predictors of a number of substance - related problems (45) and mental problems (46). It might be useful to educate adolescents about the importance of sleeping time and the potential consequences of sleep hours on mental health and risky behaviors.

5.1. Conclusions

Therefore, it can be concluded that authorities of educational affairs and families should consider that a significant number of students lack mental health and its continuation would have negative consequences for society and families. Therefore, raising awareness about sleep hygiene and mental health, supplying healthy recreational facilities, establishing counseling and planning centers, and planning for prevention, are amongst the most important measures to prevent mental disorders and decrease high - risk behaviors in adolescents. Therefore, basic planning and policymaking are required to improve mental health of students.

5.2. Limitation

Potential bias: Subjects of the current study were limited to the public schools and grade 10, as well as female gender; therefore, they were not representatives of all adolescents in this age group. Missing values were only 2% of the participants for each variable. In addition, data collection was based on a self - administered questionnaire completed anonymous.



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