Social Capital and its Relationship with Drug Use among Southeast Iranian Adolescents.

BACKGROUND: Social capital (SC) is one of the most important assets and a vital determinant of sustainable development of any country. The aim of this study was to determine the prevalence and the relationship between SC and substance use (SU) in Southeast Iranian adolescents.
METHODS: This cross-sectional study was conducted among high school students in three cities located in south east of Iran. We recruited 600 adolescents (329 girls and 271 boys) through multistage sampling during September to November 2018. The data collection instrument was a self-administered standardized questionnaire that included basic demographic characteristics, SC constructs items, and questions about SU behavior in the participants.
FINDINGS: The mean SC score among boys and girls studied was 3.46 and 3.33, respectively (from 5 score). Among the SC constructs, respectively, the lowest and highest score belonged to social trust and [2.84 in girls and 2.98 in boys with 95% confidence interval (CI) of 0.06-0.21, P < 0.001] and bonding to family (3.92 in girls and 4.25 in boys with 95% CI of 0.22-0.44, P < 0.001). The ever use prevalence of at least one substance abuse was 55.9% (n = 181) for boys and 36.6% (n = 68) for girls. Hookah (41.8%) and alcohol (16.9%) were the most substances abused by participants. One-point increase in score of the constructs of social participation, social cohesion, bonding with family, and bonding with schools was associated with a reduce of 17%, 22%, 26%, and 46% in the probability of ever SU, respectively.
CONCLUSION: There was a strong relationship between SU and SC. Thus, rising SC as an effective community-based and indirect approach can help policy makers and professionals in preventing SU in Iran. However, prior to any intervention, identification of more causality may be required.

Introduction

Social capital (SC) is one of the most important assets of any country. The most sociologists consider it as one of the vital determinants of sustainable development. Despite its intangible nature, SC determines the direction of other capital of any country.1

SC refers to features of the social organization such as communication, civic participation, social norms, trust to others, social cohesion, and social support, which encourages people to cooperation and social partnerships.2,3

SC by increasing hopes reduces the stressors and the risks of stress in society. Moreover, with reducing negative life events, helps people when changes and challenges come about in life.4

The weakness or lack of social bonding in the community and the reduction of SC make it difficult for people to face the pressures and challenges of life, thus cause negative feelings in people which lead to crime and social exclusion.5

In the last two decades, SC has increasingly been a way of explaining the causes of delinquency,6 social dysfunction, public health and health promotion,7 and social participation.8

Studies have shown that SC is associated with a variety of health behaviors and outcomes such as physical and mental health including mortality, and violent crimes.2,9 Increasing SC reduces social harms, substance use (SU), smoking and alcohol,2,10 and increases the health determinants of the community,7 such as longevity,11 better educational achievement, more effective government, improved children's welfare, and low abuse of children.9,12

Besides, in a society with a higher social attachment, the prevention of chronic diseases for people is better, and they have higher socio-economic and health situations than others.3,7 Fukuyama has used antisocial behaviors statistics such as drug use, divorce rates, crime statistics, suicide, the amount of refers to the courts, or economic crime for measuring the rate of SC in a society.13

Increasing SC in adolescents is a key protective factor on SU, alcohol, and tobacco.9 According to a recent survey conducted by the Iran Drug Control Headquarters in 2018, about 2808000 people were addicted to drugs.14 And based on a survey in 2017, the SU rate in the age group of 15-19 years was 14% of the total population of addicts in Iran.14 The relation between SC and SU was shown in different studies. Increasing SC, social participation, social bonding, and trust between adolescents had an inverse relationship with SU,2,9 violence15, crime and delinquency,16 social harm,17 and positive effect on better educational achievement in adolescents.18

In a world study in comparison with other countries, the rate of SC in Iran was relatively good.19-21 Moreover, Kerman province has a very low SC compared to other provinces of Iran.22

The eastern cities of Kerman province of Iran, including Bam, Reagan, and Fahraj, located in the vicinity of Sistan-Baluchestan province, one of the main routes and main streams related to the entry of drug traffickers to the center of Iran.23 Thus, adolescents of these cities are more likely to be exposed to SU. Therefore, this study aimed to determine the prevalence and the relationship between SC and SU in adolescents in this area to carry out plans to prevent and protect adolescents from antisocial behaviors such as SU.

Methods

In this cross-sectional descriptive-analytical study, we recruited 329 girls and 271 boys of urban high school students in Bam, as a fairly large city, and Rigan and Fahraj, as two small cities, in the east of Kerman province from Southeast of Iran during September to November 2018. These three cities with a population of about 400000 people are located in the path transit of drugs to the Iran western borders and Europe. Using multistage sampling method, these students were elected from four high school (two boys’ and two girls’ schools) of Bam and one boys’ school and one girls’ school from each of two other cities. Within each school, from all the 10th, 11th, and 12th grades, some students were selected by proportional allocation (from each class that has more students, more samples were selected). 113 boys and 97 girls in 10th grade, 124 boys and 90 girls in 11th grade, 92 and boys and 84 girls in 12th grade were selected.

The inclusion criteria were as verbal agreement of the parents, agreement of school authorities, and student’s willingness to participate in the study. We trained three graduated students in public health field to recruit the respondents. To increase the confidentiality, the respondents were approached outside the classrooms and in public places such as school hall. The questionnaires were completed by the participants themselves, and put in the ballot box. The average response time was 15 minutes, and response rate was about 96%.

Data collection tool was a valid self-administered questionnaire. This instrument was designed based on review of the literature and the related available instruments about measuring SC to generate an item pool.24-27 The content validity of the questionnaire was confirmed in expert panel by 5 specialists in health education, epidemiology, and public health who were experts in the field of SC. Face validity including cultural appropriateness, wording, and readability of the items was examined in two informal focus group discussion by 12 high school students (6 boys and 6 girls) with different socio-economic levels. The comments of these students on the content and meaning of each item led to a number of small changes in the questions.

The reliability of the instrument was examined using Cronbach's alpha coefficient in a pilot study on 28 students. Cronbach's alpha coefficient for all constructs were above 0.62 (range: 0.62-0.79). The questionnaire included three sections. The first part included the baseline characteristics of the subjects (age, sex, and parental educational level). The second part was 36 items related to constructs of SC with a 5-point Likert scale (strongly agree to strongly disagree or very much to none) including social participation (7 items), bonding to school (8 items), Social cohesion (7 items), bonding to family (4 items), relations with neighbors (6 items), and trust (6 items). The score for each construct was also the result of the average of its items. The third part included items about ever use and current use (pervious 30 days) of SU among the participants and their close friends (16 items) with yes or no scale. According to studies, most of the substances used in adolescents in Iran were hookah, cigarettes, alcohol, opium, hashish, and chewable tobacco28 that were asked.

Dependent variable was SU and independent variables included age, sex, parental education, SU among close friends, and SC constructs. Descriptive variables such as frequency, the mean and standard deviation (SD) were used to describe the results. For comparing total SC and its constructs between boys and girls, independent t test was used. Moreover, we used multiple linear regression test to study the relationship between independent variables and SU by means of SPSS software (version 23, IBM Corporation, Armonk, NY). The significance level of all tests in this study was 0.050.

The proposal obtained the ethics code with IR.KMU.REC.1398.003 number from the Ethics Committee of Kerman University of Medical Sciences. Verbal informed consent was obtained from the students and their parents after explaining the goals of the study, and assuring the privacy. Questionnaire was filled anonymously.

Results

The mean age of adolescents was 16.63 ± 1.06 years. The highest prevalence of the level of education among fathers and mothers belonged to elementary (43.4%) and middle school degree (48.1%), respectively (Table 1).

Table 1

Demographic characteristics of the subjects enrolled in this study

demographic variable		Boys	Girls	P
Age (mean ± SD)		16.34 ± 1.08	16.49 ± 1.05	0.320
Number of family members [n (%)]	Less than 3	14 (2.4)	9 (1.5)	0.310
	3	33 (10.6)	30 (11.4)
	4	75 (24.0)	57 (21.7)
	5 or More	204 (65.4)	176 (66.9)
Paternal education level [n (%)]	Illiterate	21 (6.4)	17 (6.3)	0.440
	Elementary and secondary	116 (37.7)	128 (50.4)
	High school and diploma	108 (35.1)	77 (30.3)
	Collegiate	84 (27.3)	49 (19.3)
Maternal education level [n (%)]	Illiterate	19 (5.8)	13 (4.8)	0.360
	Elementary and middle school	137 (44.2)	136 (52.7)
	High school	84 (27.1)	79 (30.6)
	College/university education	89 (28.7)	43 (16.7)

SD: Standard deviation

The prevalence of ever at least one use of substance was 55.9% for boys and 36.6% for girls, and the prevalence of current use of at least one substance for boys and girls was 36.7% and 11.2%, respectively. The most used substances were hookah and alcohol (Table 2).

Table 2

The prevalence of substance use (SU) among the participants

Type of substance	Ever Use			Current Use
	Girl	Boy	Total	Girl	Boy	Total
Waterpipe	93 (34.3)	157 (48.0)	250 (41.8)	32 (11.8)	87 (26.7)	119 (19.9)
Cigarette	32 (11.8)	62 (19.0)	94 (15.7)	11 (4.1)	22 (6.7)	33 (5.5)
Opium	13 (4.8)	16 (4.9)	29 (4.9)	7 (2.6)	8 (2.5)	15 (2.5)
Cannabis	2 (0.7)	9 (2.8)	11 (1.8)	1 (0.4)	3 (0.9)	4 (0.7)
Alcohol	13 (4.8)	88 (26.9)	101 (16.9)	5 (1.8)	28 (8.6)	33 (5.5)
Oral tobacco	2 (0.7)	24 (7.3)	26 (4.4)	0 (0)	9 (2.8)	9 (1.5)
Consume at least one substance	68 (36.6)	181 (55.9)	279 (47.1)	-	-	-

The amounts are presented as number (%).

SU in peers: The adolescents were reported that the most abusive substance among peers (close friends) was waterpipe with 63.0% in boys and 42.4% in girls, and alcohol with 47.7% in boys and 14.4% in girls, respectively. In general, about 58.7% of peers of the participants have experienced at least one of the five studied substances (Table 3).

Table 3

The prevalence of substance use (SU) in close friends of the participants

SU	Experience of substance in close friends
	Girls	Boys	Total
Waterpipe	115 (42.4)	206 (63.0)	321 (53.7)
Cigarette	33 (12.2)	85 (26.0)	118 (19.8)
Alcohol	39 (14.4)	156 (47.7)	195 (32.6)
Chewing tobacco	4 (1.5)	63 (19.3)	67 (11.2)
Opium	6 (2.2)	23 (7.1)	29 (4.9)
At least one of the substances	121 (44.8)	229 (70.2)	350 (58.7)

The amounts are presented as number (%).

SC: Among the SC constructs, the lowest score (from 5 score) belonged to social trust, which was 2.84 and 2.98 in girls and boys, respectively [95% confidence interval (CI): 0.06-0.21, P < 0.001]. The highest score was in bonding to family which was 3.92 and 4.25 in girls and boys, respectively (95% CI: 0.22-0.44, P < 0.001). The average total SC was 3.33% and 3.46% in girls and boys, respectively (CI: 0.07-0.18, P < 0.001) (Table 4).

Table 4

The score of social capital (SC) and it's constructs in adolescents (independent sample T-test)

Variables	Girl	Boy	P	95% CI
Social trust	2.84 (0.44)	2.98 (0.45)	0.001	0.06-0.21
Social participation	3.30 (0.70)	3.53 (0.64)	< 0.001	0.11-0.33
Social cohesion	3.15 (0.49)	3.30 (0.45)	< 0.001	0.07-0.22
Bonding with neighbors	3.12 (0.41)	3.14 (0.42)	0.540	-0.04-0.08
Bonding with family	3.92 (0.79)	4.25 (0.56)	< 0.001	0.22-0.44
Bonding with schools	3.60 (0.72)	3.68 (0.73)	0.170	-0.04-0.10
Total SC	3.33 (0.37)	3.46 (0.34)	< 0.001	0.07-0.18

The amounts are presented as number (%).

CI: Confidence interval

We observed that by increasing one score in the constructs of social participation, social cohesion, bonding with family, and bonding with schools, the probability ever use of SU reduced as 17%, 22%, 26%, and 46%, respectively. The SU in close friends was a very strong risk factor and the probability of SU in those which their close friends use at least one of the Alcohol, Tobacco, Other Drug (ATOD) was 11.44 more than those that their friends have not used drugs (Table 5). Boys were 1.87 times more exposed to SU comparing girls.

Table 5

Determining the relationship between ever use substance with social capital (SC) constructs and demographic variables using the univariate and multivariate regression tests

Structure and variables		Crude			Adjusted
		P	95% CI	OR	P	95% CI	OR
Sex	Girl	-	-	-	-	-	-
	Boy	< 0.001	1.57-3.05	2.19	0.009	1.16-3.00	1.87
Fathers education level	Illiterate	0.050	0.98-2.69	0.05	-	-	-
	Elementary and secondary	0.040	1.00-2.71	0.04	-	-	-
	High school	0.520	0.73-1.82	0.52	-	-	-
	College/university education				-	-	-
Mothers education level	Illiterate	0.090	0.92-2.38	1.48	-	-	-
	Elementary and secondary	0.560	0.70-1.90	1.15	-	-	-
	High school	0.940	0.63-1.62	1.01	-	-	-
	College/university education				-	-	-
Bonding with schools		< 0.001	0.43-0.70	0.55	0.350	0.56-1.22	0.83
Bonding with family		0.001	0.51-0.83	0.65	0.160	0.55-1.10	0.78
Neighborhood bonding		0.300	0.55-1.20	0.81	-	-	-
Social cohesion		0.007	0.43-0.87	0.62	0.250	0.45-1.23	0.74
Social participation		< 0.001	0.42-0.69	0.54	0.008	0.38-0.86	0.57
Social trust		0.220	0.55-1.14	0.79	-	-	-
Having a friend of drug users		< 0.001	9.81-21.14	13.94	< 0.001	7.10-18.44	11.44
Age		0.003	1.09-1.51	1.28	0.130	0.95-1.43	1.17

CI: Confidence interval; OR: Odds ratio

Discussion

This study was conducted to investigate the prevalence of SU (waterpipe, cigarettes, alcohol, opium, chewing tobacco, and hashish) and the relationship between SU and total SC and SC constructs (family, school, and neighborhood bonding, social participation, social cohesion, and social trust) in adolescents as the largest exposed group at risk of antisocial behaviors.

We found that the prevalence of SU by adolescents was notable and has a strong relationship with SU by their close friends [odds ratio (OR) = 11.44], and then with social participation (OR = 0.57), social cohesion (OR = 0.74), and bonding to family (OR = 0.78), and to school (OR = 0.83).

Participation in social activities reduced the SU, which is in line with the Hirschi's social control theory. He believes that those who are involved in occupational activities, family, positive entertainment, etc., have a lower chance of engaging in antisocial behaviors,29,30 because of having a good and warm relationship between family members, paying attention to the adolescent and understanding his emotions, and having expectations tailored to his abilities and talents; this is an important protective factor for the teenagers from turning into SU.31

Moreover, we found that the favorable social cohesion among people is a protective factor on SU, which is consistent with similar studies.31

Besides, the result about bonding to school showed that the existence of intimate relationships between the school staffs and classmates, as well as the control and supervision of school on students, was also a protective factor to SU, which is consistent with similar studies.2,31

The results of this study showed that low SC was an important risk factor of SU in adolescents, which is consistent with the results of similar studies.2,9,32 Based on the Hirschi's social control theory, a community or group with high SC or interdependent relationships among its members can control its members better.29 In such societies, adolescents become more interested and involved in school and other favorable social activities, and they better accept and believe the values and beliefs of the social environment; therefore, they are less likely to involve in antisocial behaviors such as SU.11,31

Moreover, the results of our study are in line with assumptions of social cognitive theory and social development model which emphasize on the interaction of people with various organizations and institutions and social processes.31,33 According to these theories, most people are affected by their family relationships, peer groups, educational experiences, and interactions with most influential people. If these relations are positive and incentive, people are learning the positive socialization process; otherwise they involve in antisocial process such as SU and other antisocial behaviors.

These people when faced with problems and stressful events, instead of using the problem- oriented approach, will turn into incompatible excitement exposures such as SU.31,33

In our results, among the SC constructs, the highest average score was related to the family construct, which is consistent with similar studies on SC.2,8,12,13,15,16 These studies showed that a good family relationship increase SC, and is a strong protective factor against antisocial behaviors such as SU in adolescents.

In addition, we found that social trust and neighboring relationship had the lowest average scores, which is in line with Azadarmaki and Kamali study in Iran.34 They found that in Iran, the level of mutual trust between neighbors and between individuals is very low, and they said that in Iran, the more access to the media has reduced the mutual trust of individuals and cautionary social styles, suspicion, and avoidance of others prevent the creation of trust.34

In this study, the average total SC score of girls was lower than that of boys, which is in line with the results of similar studies.2 The reason for this difference maybe is that the social network of women is lower than men. Men tend to expand their social networks, and with the diversity of these relationships, men achieve a wide range of protections, including more instrumental, emotional, and intellectual supports. These supports can increase the SC of a person.

In our study, the life time use of hookah (41.8%), alcohol (16.9%), and cigarette (15.7%) was most commonly reported by participants, respectively, that are consistent with previous studies.2,35,36 The business of alcohol is illegal in our country, and is considered a crime. Boys due to lower social stigma and more freedoms than girls have easier access to alcohol than girls, and for this reason, the prevalence of alcohol abuse in boys was four times more than girls. Unfortunately, the prevalence of alcohol abuse in adolescents was high in this study. And because of its illegal use in Iran, the types of counterfeit goods in the market are high, and this subject can cause a lot of health problems.

Although the accuracy of the questioning in this study was relatively favorable, and was carried out in a large population of students from the three cities, there were some limitations. First, different researchers have used various methods and tools to measure SC, this subject makes it difficult to compare the results. Second, to understand the causal relationships of SC and SU, longitudinal studies are necessary.

Conclusion

Based on our findings, there was a strong relationship between SU and SC. Thus, rising SC as an effective community-based and indirect approach, can help policymakers and professionals in preventing SU in Iran. However, prior to any intervention, identification of more causality may be required.