1. Background
For years, human society has been challenged with drug addiction and sustained notable financial and spiritual losses. The problem of drug addiction is one of the top four world crises and the main social crisis in Iran. Drug addiction has to do with economic and cultural aspects and the like (1). Given the cultural factors, wrong beliefs, and unique geographical position, Iranian youth are at a high risk of drug addiction (2). Unfortunately, about 60% of Iranian prisons are filled by drug addicts and those convicted for drug related crimes. This means that notable resources of the country in different fields are wasted to deal with the crisis. Drug addiction is the root of insecurities in the society and poses threats to health and hygiene of the patient and the society as the whole (3). Among the destructive effects of drug addiction are aggressiveness, cognitive nervous breakdown, dissatisfaction with marital life (both the addict and the spouse), family life disorders, loss of interest in sexual relationships, anxiety, depression, and problems in public health (4-11). Due to medical, health, economic, social, and legal problems caused by drug abuse, the society needs to seriously pay more attention to effective preventive strategies (12, 13). Choosing the right strategy to deal with mental pressures can be effective in decreasing the effect of these pressures on physical and psychological heath of the patients (14, 15). One of the strategies proposed by the researchers is life skills training. The term “life skills” refers to a large set of mental, social, and interpersonal skills that can help people make more informed decisions, effectively interact with others, enjoy physical-mental and social health, and deal with challenges and needs of their daily lives (3). In general, life skills training is a comprehensive and general program that actually deals with the skills that an individual needs for life. Skills like self-awareness, proper communication, decision making, problem solving, anger management, and handling stress are of the main concepts dealt in training (16). Participation in life skills workshops provides an opportunity for drug addicts to meet and communicate with others who have the same problem. The participants can share their remedies and approaches to deal with drug abuse, avoid recurrence, and handle temptations. They can provide multilateral support to improve the chance of keeping away from the drug. Moreover, intra-network social supports are against the sense of seclusion and isolation and foster interpersonal relationships (17). Malouff, Thorsteinsson, and Schutte (2007) carried out a meta-analysis study to examine the effect of interventions based on life skills trainings on attenuating mental and physical problems of 2895 participants in Australia and showed that the majorities of studies in this area had emphasized the effectiveness of the intervention (18). The trainings have been helpful for controlling smoking and drinking habits and drug abuse (19-22), preventing violence and crime (16), preventing suicide (19), improving emotional and social adaptation, decreasing anxiety, and preventing sexual promiscuity (23, 24). Life skills training program is designed to improve the mental health and prevent social damages. The bedrock of the program is the academic research on mental and social damages and its main purpose is to create opportunities to learn professional skills along with life skills (16, 25, 26). According to authors, there are two types of coping styles known as “problem-centered coping” and “emotion-centered coping.” Choosing these styles depends on one’s assessment of the situation (primary assessment) and his/her capability to deal with the situation (secondary assessment). Researchers have gained a great insight by examining coping styles of successful and unsuccessful individuals. They have found that people who manage problems successfully usually have equipped themselves with a variety of coping skills, and life skills training adds to one’s coping skills (15, 16, 25, 27). World Health Organization (WHO) has listed these skills along with introducing actual practices. The key to have these skills is to practice and use them in daily life. The listed skills are self-awareness skills, empathy, effective communication, interpersonal skill, stress coping skill, managing emotions, problem solving skill, decision making skill, creative thoughts, and critical thinking skill (16, 19). Nurses play an effective role at three prevention levels. Public education about a healthy lifestyle constitutes the main part of the first level of prevention (28-30).
Stability of drug abuse prevention programs in Iran is very limited because they mostly follow a one-dimension approach (e.g. reducing availability of the drugs) and novel approaches are mostly implemented for a short period of time and merely on the basis of public informing measures, which are far away from being considered as large scale health improvement interventions (31). Fortunately, drug abuse preventive programs have recently been steered toward adopting a wider social perspective. In this regard, the life skill educational program to prevent drug abuse is a novel preventive approach in which the main focus is on development of personal and social skills (32). Literature review revealed that there were few studies on the effects of life skills education on social relationships of the health service seekers referring to drug clinics. Therefore, the present study is an attempt to introduce a safe and affordable educational program and help the health service seekers develop their social relationships. Three sources of parents, spouse, and friends are focused by the program.
2. Objectives
As argued by studies in this field, lack or elimination of one of the main life skills makes the individuals prone to social damages. It seems, therefore, reasonable to provide opportunities for people to learn such skills. Since patrons of drug clinics are people who either are suffering or have suffered social and emotional damages, informing them about major life skills can be helpful in preventing or decreasing emotional and mental problems they are faced with. In the light of this, the present study aimed to survey the effectiveness of life skills training in the social relationship of the health service seekers who refer to drug clinics.
3. Methods
3.1. Design and Setting
The study was carried out as an interventional semi-experimental study. Participants were male drug addicts who referred to Tavalod Novin Drug Clinic in Larestan, Iran.
3.2. Inclusion and Exclusion Criteria
Among inclusion criteria were being at least 20 years old, having a history of drug addiction as confirmed by a nurse or physician based on drug test, expressing informed consent, having willingness to participate, and gaining minimum and/or below average score in Pierce’s Social Relationship Inventory.
A score higher than average (> 42) in Pierce’s Social Relationship Inventory in one of the aspects of spouse, friends, and parents before the intervention, failure to attend one of the intervention sessions, reluctance to participation, returning to drugs during the intervention, and referral to another clinic were the exclusion criteria.
One of the participants had passed a course on life skills and four of them were under supervision of the physician or using psychiatric medication; therefore, they were excluded from the study.
3.3. Participants
The study group consisted of 42 drug addicts in the age range of 20-68 under methadone and buprenorphine therapy. The participants were selected through non-probability sampling technique (convenience sampling) among the health service seekers who were at drug rehabilitation stage under supervision of physicians and nurses in Larestan City, Iran. The diagnosis of addiction was finalized by the doctor and the clients were under constant care at the drug abuse clinic. The number of the participants was determined (n = 32) using the relevant formula at a significance level of 5% and power of 90%, based on the effect of nurse-centered life skills training program, and following Ghaleh Asadi et al. in Iran (33). Taking into account probable leaves, 42 participants were selected finally.
3.4. Data Collection
After filling out the demographics questionnaire, 42 patients who had an electronic file entered the study and after a briefing session about the study, all of them signed an informed consent form. After filling out the inventory, the participants attended a life skills training course held by the author (seven 2-hour sessions). Immediately after and one month after the course, the participants filled out the inventory and to avoid biased answers, they were required to fill out the inventory in the class. The sessions were scheduled based on the schedule of the patients in the clinic. All the participants filled out the quality of relationship inventory.
The participants were grouped in smaller groups with 10 members for more effective training. All the training materials were represented to all groups in the form of lectures. In addition, the material was provided to all participants in CDs and pamphlets.
Subject and purpose of the sessions were determined based on WHO and UNICEF’ guidelines (3). (See Table 1)
Table 1.Subject and Purpose of the Sessions
| Materials | Subject | Objective |
|---|---|---|
| Session 1 | Self-awareness skill | Defining self-awareness, personal zones, and psychological aspects of human being in a simple way; expressing stresses and pressures deep inside and explaining the concept of emotional intelligence and its effect on an individual in a simple way; explaining the concept of self-dignity and its use in the way of realizing goals; naming different ways of self-awareness |
| Session 2 | Anger and emotions control skills | Knowing the negative emotions, learning about one’s specifications in the situations that cause anger, knowing the causes of anger, naming the situations that cause anger, naming the specifications of those who can control their anger, naming different ways to control one’s anger in different situations, explaining the concept of determinism and its effect on controlling anger. |
| Session 3 | Stress control skills | Defining stress, perceiving personal difference in dealing with stressors, expressing effects of stress on human and the relationship between stress and psychophysical diseases, explaining relationship between stress and emotion, combined anger control and stress coping skills, naming short/long-term methods to control stress. |
| Session 4 | Problem solving and decision making skills | Defining the concepts of problem and problem solving, making familiarity with the relationship of problem solving and emotional self-awareness, explaining the concept of brainstorming and the way of examining solutions, developing one’s skills in choosing, implementing, revising and finding the best solutions. Making familiarity with specifications of the people unable to make decision, listing specification of a good decision, explaining the stages of making, implementing, and revising a proper decision; learning about specifications of the people who cannot solve problems |
| Session 5 | Improvement of interpersonal relationships | Defining relationships, explaining proper relationship skills, explaining importance of proper relationships, naming the effect of interpersonal relationship, teaching how to create an effective relationship, and naming the methods to improve quality of relationships with others |
| Session 6 | Practicing empathy and courage | Defining empathy and how to have an empathetic relationship with example, explaining the importance of sympathetic relationships with others, what are the differences between empathy and sympathy; defining skills of self-expression, determinism, and courage to deal with life problems and hardships |
| Session 7 | Reviewing the course and summarizing | All the topics of the past six sessions are summarized. The trainings are evaluated and the participants’ questions are answered. |
3.5. Research Instruments
3.5.1. Demographics Checklist
Demographics data included the level of education, job, age, and duration of drug dependency, which had been registered in the demographic checklist.
3.5.2. Quality Relationship Inventory (QRI)
Quality Relationship Inventory (QRI) is a self-assessment questionnaire developed by Pierce and Sarason in 1991 to measure the support received from the key relationships in life. This Inventory consists of 29 questions with three subscales of social support, importance and depth of relationships, and interpersonal conflict. Each subscale is scored separately; that is, nine separate scores are obtained (support, conflict, and depth of relationship in terms of spouse, friends, and parents).
Pierce and Sarason (1991) reported Cronbach’s alpha for the subscales of social support, depth of relationship, and conflicting relationships as 0.83, 0.88, and 0.86, respectively (34). The questionnaire was first translated into Farsi in 1992 by Ebrahimi and its Cronbach’s alpha value was reported as 0.73 (35).
The statements are designed based on a four-point scale. Before filling out the inventory, the participant is asked to think about some of his/her friends (including those with positive and negative influence on his/her life). Then, the participant should answer each statement based on a four-point scale (0 = nothing, 1 = low, 2 = moderate, 3 = high). Afterward and according to the theoretical basis of the test, three independent mean scores (social support, conflicting relationship, and depth of relationship) and nine independent mean scores (support, conflicting relationships, depth of relationship with parents, spouse, and fiends) are obtained.
Minimum and maximum possible scores of the questionnaire are 0 and 78, respectively; the higher the score, the higher the quality of social relationships (3). To check the validity of the inventory, it was sent to experts; and reliability of the tool was determined using Cronbach’s alpha. In terms of the subscales of social support, conflict, and depth of relationship, α-values were obtained as 87%, 88%, and 83%, respectively.
3.6. Data Analysis
Descriptive statistics including mean, standard deviation, and data frequency were used to describe the variables depending on their type (quantitative or qualitative). To compare the changes in the mean score of social relationships of the subjects before, immediately after, and one month after the life skills education, repeated measures analysis of variance was used. Moreover, Kolmogorov-Smirnov (KS) test was used to examine the normal distribution of the data. The collected data were analyzed by SPSS (v.16) (P < 0.05).
3.7. Ethical Consideration
The research was approved by the ethics committee of Shiraz University of Medical Sciences (CT-9378-7318). All participants signed an informed letter of consent. The main objectives and protocols of the study were explained to the participants. Along with emphasis on confidentiality of information, participants were free to withdraw from the study at any time during the study.
4. Results
The findings of data analysis showed that five participants (11.90%) were illiterate, 15 (35.71%) had elementary education, nineteen (45.23%) had high school diploma, and three (7.16%) had university degrees. In terms of job, nine (21.43%) were jobless, three (7.14%) had state jobs, and the rest were businesspersons. As to age, four (9.52%) were in the range of 20 - 25, 12 (28.57%) in the range of 26 - 35, 14 (33.33%) in the range of 36 - 45, five (11.90%) in the range 46 - 55, four (9.52%) in the age range of 56-65, and three (7.16%) were older than 65 years. In terms of dependence on drugs, it was revealed that four (9.52%) were drug addicts for six months, nine (21.42%) for 1 - 2 years, 14 (33.33%) for 2-3 years, 10 (23.80%) for 3 - 5 years, and five (11.90%) for more than five years.
To facilitate the realization of the objectives of the study, the collected data are represented in Table 2. Table 2 is used to determine the score of the relationship in terms of social support, depth of relationship, conflicting relationships, and total score of social relationships of the participants throughout the study.
Using repeated measures analysis of variance, we observed that the increase in the mean score of relationship in all aspects of social support, depth of relationship, conflicting relationship, and total score of social relationships (parents, spouse, and friends) in the intervention group immediately and one month after the intervention was significant (P < 0.05).
Table 2.Mean Score of the Aspects of Social Support, Depth of Relationships, Conflicting Relationships, and Total Score of Social Relationships With Parents, Spouse, and Friends Before, Immediately, and One Month After the Intervention
| Variable Group | Stage | P-Value | ||
|---|---|---|---|---|
| Before the Intervention | Immediately After the Intervention | One Month After the Intervention | ||
| Mean ± SD | Mean ± SD | Mean ± SD | ||
| Social support | 0.000 | |||
| Parents | 12.10 ± 5.92 | 16.98 ± 3.28 | 17.17 ± 3.15 | |
| Spouse | 10.33 ± 0.93 | 17.41 ± 0.55 | 17.55 ± 0.53 | |
| Friends | 8.86 ± 5.58 | 15.71 ± 3.65 | 15.94 ± 3.19 | |
| Depth of relationship | 0.000 | |||
| Parents | 11.1 ± 6.75 | 18 ± 4.90 | 15.76 ± 4.44 | |
| Spouse | 9.33 ± 6.37 | 18.81 ± 5.39 | 16.26 ± 3.86 | |
| Friends | 10.62 ± 6.02 | 18.36 ± 3.93 | 16.76 ± 3.50 | |
| Conflicting relationships | 0.000 | |||
| Parents | 22.95 ± 1.46 | 30.14 ± 0.81 | 32.43 ± 0.88 | |
| Spouse | 52.21 ± 32.1 | 31.52 ± 0.82 | 33.81 ± 0.91 | |
| Friends | 15.69 ± 8.45 | 25.17 ± 5.95 | 27.55 ± 5.87 | |
| Total score of social relationships | 0.000 | |||
| Parents | 36.71 ± 14.53 | 65.12 ± 10.81 | 65.36 ± 10.69 | |
| Spouse | 41.18 ± 17.26 | 67.10 ± 10.80 | 67.62 ± 10.70 | |
| Friends | 37.14 ± 15.85 | 57.91 ± 10.34 | 60.94 ± 99.3 | |
5. Discussion
The effects of life skills training on social relationships of health service seekers referring to Tavalod Noving Drug Clinic-Larestan-Iran in 2016 were examined. Repeated measures analysis of variance showed that changes in the mean scores of all aspects of social relationship were significant immediately and one month after the intervention. Mojarrad Kahani et al. (2012) studied the effects of life skills training on improving the quality of relationships of patients with bipolar disorder through a semi-experimental study. The control and experimental groups each consisted of six participants. First, the intervention group was asked to fill out Pierce’s Quality Relationship Inventory and then the participant attended 10 group-intervention sessions. After the intervention, the participants filled out the inventory once again. Their findings supported a significant increase in the mean score of social support in the experimental group, which is consistent with our results (36). Sajedi et al. (2009) examined the effects of life skills trainings (nine sessions) on interpersonal relationships and self-expression in 26 visually impaired women in the age range of 20-40 registered in Fatameh Zahra Hospital, Isfahan. Their results showed that the training was not significantly effective on interpersonal relationship, which is not consisted with our results (37). They argued that insignificant effect of life skills training on the depth of relationship in visually impaired individuals was due to lack of eye contact and non-verbal communications, which are a major part of the trainings. Moreover, working with blind subjects needs more time and energy; thus, the difference between the subject groups may explain the inconsistency in the results. Lack of social skills in visually impaired individuals has been reported in several studies (38). The results of this paper are consistent with those of Tuttle et al. (2006) on the effects of life skills training on students in the age range of 12-16 with a high risk of dangerous behaviors such as drug addiction. They studied 16 juveniles (10 boys and 6 girls) in junior high schools who were selected randomly. After six weeks of training, the participants filled out problem oriented screening instrument for teenage (POSIT) and the results confirmed that life skills training improved decision making ability and depth of interpersonal relationships in the subjects (39). Shechtman et al. (2005) carried out a study to examine the effect of life skills training on teachers’ perception of their environment as well as on improvement of self-efficiency and interpersonal skills. The participants were categorized into two groups of control and intervention. The results showed a significant increase in the perception of work environment and self-efficiency of the teachers in the intervention group (40). The results here are not consistent with those obtained by Mojarrad Kahani et al. (2012) in patients with bipolar disorders in terms of conflicting relationship. They reported that the mean scores of conflicting relationship between the control and experimental groups were not significantly different; that is, there was no difference between the two groups in this regard (36). To explain the inconsistent results, the nature of psychological disorder of the patients, their condition before the intervention, and biased data should be taken into account. Still, the results here are consistent with several studies on the effectiveness of life skills trainings in mental health of different groups such as students and patients with none-metastatic breast cancer in terms of conflicting relationships (16, 41, 42). Systematic review studies have shown that life skill training is a cost-effective non-drug intervention to improve social, emotional, and educational performance. Experts in health fields may use interventions to modify communicational skills of the health service seekers (43-45).
Given that the life skill education program to prevent drug abuse is a novel preventive approach and regarding that promising results in different cultures and countries have been obtained by studies in Iran (16, 19, 32, 46) and other countries (22, 39, 42, 47) and given the specific appeal and delicacies of life skills educational program, it is currently recognized as a specific preventive program in many countries to deal with social damages such as addiction (32, 48). To prevent expansion of addiction at different levels, implementation of such programs in Iran is recommended (48-50). Since the authors found no similar studies on the effectiveness of life skills education program in social relationships of drug addicts in Iran and this method is barely known in Iran, the present study tried to introduce the program as an affordable and feasible approach. Throughout the study, social relationships conditions of the subjects were improved through focusing on parents, spouse, and friends as three sources.
5.1. Limitations
Personal and psychological specifications of the subject may affect their learning capability and the way that the questionnaires are filled out by them; these are beyond the control of the researchers. Reluctance of some of the subjects to take part in the course due to their job requirement, shyness, and concerns about their social status was another study limitation. The authors made their best to convince the candidates to participate. There was also a risk of revealing the content of the course by the subjects in the intervention group so that the subjects were asked not to share the content until the end of the course. Moreover, the results cannot be generalized to the drug addict population because the subjects in this study were drug addicts referring to a drug clinic and the sampling method was convenience.
5.2. Conclusion
The findings indicated a positive significant relationship between providing life skills training to patients referring to drug clinics and improvement of their communication skills. In other words, an increase in life skills resulted in an improvement in the individual’s communicational abilities. Absence of proper social relationships in the patients would result in a variety of individual and social negative consequences for the health of patients, their families, friends, and the society. Life skills training can be perceived as an approach to supportive services for more vulnerable social groups. Implementation of trainings is recommended as an effective, useful, and economic way to prevent and control the conflicts caused by drug addiction and manage the quality of life at the society level.
