The Relationship between Mental Health and General Self-Efficacy Beliefs, Coping Strategies and Locus of Control in Male Drug Abusers.

BACKGROUND: Various studies have been conducted to determine the causes of drug abuse from a psychological perspective. Mental health has also been among the studied factors. The present study aimed to investigate the relationship between mental health and general self-efficacy beliefs, coping strategies and locus of control in male drug abusers.
METHODS: This was a correlational descriptive study involving all male drug abusers (4,493 cases) at self-introducing detoxification centers in Kerman, Iran, during 2010-11. A total number of 354 patients were selected randomly with cluster sampling. Measurement tools were included Goldberg's General Health Questionnaire (GHQ-28), Generalized Self-Efficacy Scale (GSE-10), Coping Responses Inventory (CSI), and Internal-External Locus of Control Scale (I-E). The survey data were analyzed by SPSS using Pearson correlation and stepwise regression.
FINDINGS: There were significant correlations between mental health and self-efficacy beliefs (r = -0.626), problem-oriented coping strategy (r = -0.535), emotion-oriented coping strategy (r = 0.573), external locus of control (r = -0.298), and internal locus of control (r = -0.525) (P < 0.01 for all). The results of the regression analysis showed that 58.7 percent of total variance of mental health can be estimated by general self-efficacy beliefs, coping strategies and locus of control.
CONCLUSION: In general, the results showed that increased levels of general self-efficacy, problem-oriented coping strategy and internal locus of control will improve mental health. In contrast, decreased general self-efficacy, emotion-oriented coping strategy and external locus of control would lead to decreased mental health.

Introduction

One of the pillars of the community health assessment is the community mental health. Mental health plays an important role in ensuring a dynamic and efficient community.1 The World Health Organization (WHO) has defined mental health as the absence of any mental illness accompanied with a state of social welfare and health.2 It is composed of various complex factors as well as the interaction between physical, psychological and social agents.3 Among these factors are general self-efficacy, coping strategies, and locus of control. In his social cognitive theory, presented self-efficacy as an original concept which points to perceived abilities for willingly performing an action.4

According to Bandura,5 self-efficacy has a central role in regulation of emotional states. In other words, self-efficacy beliefs make people able to interpret potentially threatening expectations as manageable significant challenges and help them feel less stressful in such situations. Thus, by reducing the negative thoughts and concerns of potential threats, they can regulate their emotional states.6 In addition, Bandura,7 Kim,3 Muris,4 Roddenberry and Rank,8 and Bals et al.9 found a relationship between low mental health and general self-efficacy.

According to Folkman et al.,10 stress coping strategies are cognitive and behavioral efforts used in order to manage (dominate, tolerate, reduce, or minimize) the external or internal specific demands which are beyond their resources of power. People are distinct in terms of problem-focused coping and emotion-focused coping strategies. In the problem-focused coping strategy, one can focus directly on the event causing the stress to change or inhibit it. In the emotion-focused coping strategy, a person tries to inhibit the excitement caused by stress.

Based on the model suggested by Ghazanfari,11 people try cognitive skills for problem solving by using the strategy of problem-focused coping. Accordingly, the ways to deal directly with the problem are examined and psychological satisfaction is usually achieved by finding solutions to the problems which helps improve their mental health.

On the contrary, the use of emotion-focused coping strategy will prevent the person from having direct and effective involvement with the problem and reduces his ability of problem solving. This condition causes disturbances in integrity of intellectual and emotional distresses and can reduce the mental health. Some studies have shown that problem-focused coping strategies are related to reduction of psychological distresses. Emotion-focused coping strategy (ineffective or avoidant) is associated with increased psychological distressing.12-14

From Clarke point of view,15 locus of control also refers to overall stability that results in the ability to control events throughout the life of a person. People believing that their behavior to achieve desired results is a causal factor have the internal locus of control. In contrast, people who believe that achieving desired results is controlled by other forces (such as luck, fate, God or other powerful individuals) have external locus of control.16

However, individuals who feel more in control perceive the threat associated with the situation as less. When people believe to be powerless and incapable of controlling a situation, they would feel more helpless and threatened. Individuals with external locus of control feel more helpless, anxious and stressed compared to those with internal locus of control.17 Some studies have shown that the internal and external locus of control are associated with mental health.3, 8, 11, 18, 19

On the other hand, in the context of drug use, several factors such as psychological, social, familial and biological factors are involved, none of which alone can be determining in drug abuse.20 Various studies have been conducted regarding psychological causes of drug abuse and some of them referred to mental health as an effective factor.20-22

The epidemiological data showed that approximately 50% to 80% of drug abusers have the minimum criteria for a psychiatric diagnosis during their life cycle.23 Therefore, low mental health tends could affect drug abuse. Previously mentioned studies indicated general self-efficacy, coping strategies, and locus of control to lead to low mental health which in turn tends to be one of the causes of drug abuse.

Thus, it can be concluded that there is a relationship between these three variables and mental health among male drug abusers. Some international studies were conducted to support this hypothesis. For instance, John et al. showed that self-efficacy is the predictor of depression resulting in dependency on cigarette smoking.24 Likewise, Tate et al. found that individuals who had experienced more life stress and had lower self-efficacy demonstrated earlier recurrence than those who had experienced less stress and had more self-efficacy.25 Minnix et al. also reported similar findings.26

Galaif, Nyamathia and Steina examined the role of psychological factors in predicting drug dependency and suggested less positive strategies and depression to be predictors of drug dependency.27 Holahan et al. showed a significant relationship between symptoms of depression, alcohol consumption and drinking behavior, i.e. people who consumed alcohol in this study used drinking behavior as a coping strategy to deal with depression.28 Friedman-Wheeler et al. could also find similar results.29

Wise et al. expressed a relationship between the external locus of control and psychological distress (including depression) and drug dependency.30 Zeiner et al. stated that alcoholic patients were more depressed and more anxious and their scores of internal locus control were lower than the non-alcoholic group.31 Identical results were presented by Ludenia and Russell32 and Caster and Parsons.33

In Iran, previous studies evaluating the relation between mental health and general self-efficacy beliefs, strategies for coping with stress, and locus of control have been conducted in different populations other than male drug abusers. However, based on their results, these three variables are expected to be associated with mental health. Since reduced mental health promotes the tendency towards drug abuse, this study aimed to investigate the relationship between mental health and general self-efficacy beliefs, coping strategies and locus of control among male drug abusers. It also determined the factors being able to predict mental health better.

Methods

This was a descriptive correlational study. The statistical community consisted of all male drug abusers (4,493 cases) who referred to self-introducing detoxification centers to quit their drug use in Kerman during 2010-11. Among this statistical population, only subjects with at least the secondary school education (a high school diploma) were included. Based on the statistical sample table provided by Krejcie and Morgan,34 the sample size was determined to be 354. However, considering the possibility of sample loss, 408 subjects were randomly selected with cluster sampling procedures. Thus, a number of centers were randomly selected. Eligible patients were randomly selected from each center. They answered the questionnaires and 54 questionnaires were excluded due to deficiencies. Finally, 354 valid completed questionnaires were prepared for the analysis. In order to discover the relationship between the variables, Pearson correlation coefficient was used. Multivariate stepwise regression analysis was used in inferential statistics to determine the contribution of each variable (general self-efficacy, stress coping strategies and locus of control) and in predicting mental health. Data was analyzed using SPSS and the significance level was determined as P < 0.01.

This questionnaire is used to measure mental health. It was developed by Goldberg and is widely used to diagnose mild mental disorders.35 In each item, options A to D are scored zero to three. As a result, every individual can score between zero and 84. The questionnaire cut-off score is 23, i.e. those with scores less than 23 have a high mental health and those with scores of 23 or higher have a low mental health.36 Previous studies confirmed the questionnaire to be valid and reliabe.36,37 Using Cronbach's alpha in the present study, the reliability of the total score was calculated as 0.76.

This scale was made by Schwarzer and Jerusalem in 1979. It consists of ten four-option positive items. A Likert scale, from not at all true to completely true (1 to 4), is used for grading. Total self-efficacy score is obtained from all the 10 items and ranges between 10 and 40.38 The validity and reliability of this questionnaire have also been confirmed.39,40 The present study also obtained a Cronbach's alpha of 0.82 for the reliability of the total score.

This 19-item questionnaire has been made by Belanger and Moos to study the way people respond to stressful events. When completing the questionnaire, the respondents are asked to recall a crisis or stressful event that they had recently passed and then answer the questions. Based on a Likert scale, each item was scored from zero (never) to three (always). The questionnaire encompasses eight items of problem-oriented coping and eleven items of emotion-oriented coping. A maximum score of 57, including maximum scores of 33 and 24 respectively from problem-oriented coping and emotion-oriented coping, can be obtained from the questionnaire.41 Previous studies indicated the questionnaire to be of acceptable validity and reliability.42,43 We also used Cronbach's alpha and calculated the reliability of problem-oriented and emotion-oriented strategies in small-scale and total scores as 0.79, 0.78, and 0.82, respectively.

The questionnaire is a scale of self-evaluation with 29 questions about a major social event. There are 23 items each with a pair of questions (A with a score of 1 and B with a score of 0) assess locus of control. There are also 6 other items to distract the respondent from the main goal of the questionnaire. The subjects are scored based on the number of signs they put next to each query, except the six distractive questions. The total scores, ranging from 0 to 23, of individuals indicate the degree and type of their control. Individuals scoring 9 or more have external locus of control and those with scores less than 9 have internal locus of control.41 In addition to previous studies confirming the validity and reliability of the questionnaire,41, 44 we also used Cronbach's alpha and calculated the reliability of the total score as 0.79.

Results

The descriptive findings showed mean ± SD values of mental health as 29.47 ± 8.36, general self-efficacy as 23.28 ± 5.67, problem-oriented coping strategy as 14.8 ± 3.8, emotion-oriented coping strategies as 22.31 ± 4.05, internal locus of control as 6.34 ± 1.31, and external locus of control as 14.86 ± 3.49. Minimum and maximum mental health scores were 4 and 53, respectively. Minimum and maximum general self-efficacy scores were 13 and 38, respectively.

Problem-oriented strategy scores varied between 7 and 24. Emotion-oriented strategy scores ranged between 9 and 29. While minimum and maximum internal locus of control scores were 4 and 8, respectively, scores of external locus of control fluctuated between 9 and 21.

Table 1 shows the values of correlation coefficients of different variables and mental health. As it is seen, there were significant relationships between mental health and general self-efficacy (r = -0.626), emotion-oriented strategy (r = 0.573), problem-oriented strategy (r = -0.535), internal locus of control (r = -0.525), and external locus of control (r = 0.298).

Table 1

Matrix of correlation coefficients between mental health and general self-efficacy, stress coping strategies and locus of control

Variable	Mental health
General self-efficacy	-0.626
Problem-oriented strategy	-0.535
Emotion-oriented strategy	0.573
Internal locus of control	-0.525
External locus of control	0.298

For all variables p < 0.001.

As table 2 presents, the amounts of F were significant for general self-efficacy, problem-oriented and emotion-oriented coping strategies and internal and external locus of control (P < 0.01). In other words, it can be stated, with a confidence of 99%, that general self-efficacy, problem-oriented and emotion-oriented coping strategies, and internal and external locus of control can be the predictive of mental health in male drug abusers.

Table 2

Regression coefficients of mental health based on general self-efficacy, stress coping strategies and locus of control

Predictive variables model	F (P)	r2	β	t (P)	Partial
General self-efficacy	81.1 (< 0.001)	0.351	-0.736	-9 (< 0.001)	-0.596
Problem-oriented strategy	68.6 (< 0.001)	0.478	-0.756	-6.1 (< 0.001)	-0.448
Emotion-oriented strategy	55.7 (< 0.001)	0.526	0.415	3.9 (< 0.001)	0.314
Internal locus of control	49.8 (< 0.001)	0.569	-0.468	-3.9 (< 0.001)	-0.311
External locus of control	46.7 (< 0.001)	0.587	0.358	2.9 (0.004)	0.203

The obtained coefficient of determination in the fourth model was equal to 0.587. Thus, it can be concluded that 58.7% of mental health prediction in male drug abusers can be made by general self-efficacy, problem-oriented and emotion-oriented coping strategies and internal and external locus of control. Likewise, beta coefficient (β) suggests that increased general self-efficacy (-0.736), problem-oriented strategy (-0.756) and internal locus of control (-0.468) are good predictors of a high mental health. In addition, emotion-oriented coping strategy (0.415) and external locus of control (0.358) are good predictors of a low mental health.

Discussion

The results of the present study showed that a statistically significant and negative relationship between the general self-efficacy and mental health of male drug abusers. In addition, low self efficacy was suggested to be a good predictor of low mental health and high self-efficacy to be a good predictor of high mental health. The findings of this study were consistent with the results of several similar studies.3,4,7-9,26

These findings can be explained by the fact that a sense of high self-efficacy can help people to manage and control themselves when they are exposed to negative events or stressful situations. As a result, they are protected against many psychological problems. On the other hand, a feeling of low self-efficacy prevents individuals from effectively dealing with stressful situations. Feeling more stress would lead to different diseases and psychiatric disorders. Therefore, drug abuser men with low self efficacy feel inefficient and unable to control themselves when facing with stressful situations. They give up easily and feel depressed, anxious and frustrated. Therefore, they try to cope with their psychological problems and to achieve relaxation and peace through alcohol and drugs.

In addition, our results showed a significant negative relationship between problem-oriented coping strategy and mental health in male drug abusers. A significant positive relationship was also found between emotion-oriented coping strategy and mental health. Problem-oriented strategy is a good predictor of high levels of mental health. On the other hand, emotion-oriented strategy is a good predictor of low mental health. The findings of this study are consistent with the results of a number of similar studies.12-14 An explanation would be that individuals who use problem-oriented strategy will be directly involved with the problem. They use all their force which makes an intellectual discipline and reduces the emotional turmoil. However, people who employ emotion-oriented coping strategy instead of problem-oriented strategy, which aims to eliminate or mitigate the problem, try to control the emotional consequences of the problem and are more influenced by their emotions. Therefore, rather than focusing on the problems, these people get involved in a series of behaviors which in turn increase their negative emotions and the level of their turmoil. Thus, a maladaptive coping strategy, along with how they perceive and assess problems, leads to acute problems and mental disorders. Such individuals use alcohol and drugs in order to cope with their problems and to feel relaxed.

Finally, similar to previous studies,3,8,11,18 our results revealed a significant negative relationship between internal locus of control and mental health in male drug abusers, i.e. internal locus of control is a good predictor of high levels of mental health. On the contrary, mental health had a significant positive relationship with external locus of control, i.e. external locus of control is a good predictor of low mental health. The reason might be that people with internal locus of control believe the stressing factors are controllable. As a result, their perceived threat reduces and the pressure can be tolerated. In contrast, people with external locus of control feel powerless in managing the situation which increases their perceived threat and makes them feel more stressed. Consequently, mental diseases, such as anxiety and depression, become more prevalent among these individuals. Therefore, since male drug abusers with external locus of control may see stressing factors as out of control, they perceive the situation threatening and feel more stressed. Such men will then depend on alcohol and drugs to cope with their psychological problems and to feel calm.

A limitation of this study was evaluating only men. Due to the absence of women in this study, the results can only be generalized for men. Future studies are suggested to assess both men and women and compare their results. Findings of this research can be employed by psychologists and psychiatrists to prevent the occurrence and exacerbation of drug addiction, as well as to avoid damages caused by the problem. The primary prevention needs to utilize questionnaires to identify individuals at the risk and prone to addiction at early ages (in school) and also older ages (in universities, offices, factories and different jobs). Since changing or eliminating sources of stress cannot be achieved by behavioral scientists, the risk for addiction can be reduced through special programs training people with skills such as self-efficacy, stress coping strategies and locus of control.