The Relationship between Health-promoting Lifestyle and Suicidal Ideation in Addicted Women.

Background: Addiction is one of the most important problems of the present century that can be the basis of many social and family problems. Addiction severely affects the physical and mental health and lifestyle of addicted people and sometimes leads to suicide. The aim of this study was to investigate the relationship between health-promoting lifestyle and suicidal ideation in addicted women.
Methods: In this descriptive-correlational study, the statistical population included all addicted women who referred to psychiatric hospitals in Kerman, Iran, in 2020, among whom 118 people were selected using convenience sampling method. Data were collected using Beck Depression Inventory (BDI) (1974) and were analyzed using Spearman's correlation coefficient test. Findings: 44.9% of women had no suicidal ideation, 23.7% were ready to commit suicide, and 30.5% attempted suicide. There was a significant inverse relationship between health-promoting lifestyle and its components (nutrition, physical activity, health responsibility, stress management, interpersonal relationships, and spiritual growth) with suicidal ideation.
Conclusion: The results of this study can have important applications in the care and rehabilitation of addicted people and reduce suicidal ideation among them. In the rehabilitation of addicted people, one of the important goals should be improving the quality of life (QOL) and lifestyle of these people.

Introduction

Today, drug abuse and addiction have become one of the most important global threatening problems, especially in the family and among women. Addiction has many negative consequences and problems in the individual, family, and social context.1 Addiction causes various problems in the family, including the tendency to addiction among other family members, as well as abnormal and maladaptive behaviors such as suicide.2

Addiction in the family and women causes inappropriate behaviors in women, which are completely different from men. Social perversion and prostitution, high-risk behaviors related to sexual intercourse, abortion, getting imprisoned, divorce, and even suicide are the consequences of addiction in women.3

The rapid rise in suicide since the 1960s has required new and serious studies. The increasing prevalence of suicide and suicidal ideation in communities is quite noticeable.4

Suicide and suicide attentions were reported as a major public health and anti-social behavior issue at the World Health Organization (WHO) Summit in 1996. This phenomenon is considered as a Social issue in addition to its personal and family harms. Suicide attempts are made with the aim of self-harm consciously and are more in people who are self-centered, anxious, aggressive, and unable to make social communication.5 According to the WHO, suicide is an act in which a person intentionally and without the intervention of others engages in unusual behavior, such as self-harm or misuse of a substance prescribed for treatment, and her/his goal is to achieve his/her expected changes.6 Suicide is the second leading cause of death in people aged 15-29 years. It is also the second leading cause of death in women aged 15-19 years.7

The global age-standardized suicide rate was 10.5 per 100000 population for men and 7.5 per 100000 population for women. Suicide is still a serious problem in developed countries, while 79% of all global suicides occur in developing and undeveloped countries. However, the issue of suicide prevention is a low priority for governments and policymakers in these countries. 1.5% of the global burden of disease is related to suicide. The burden of economic costs of suicide on governments is high. Estimates in Ireland and Scotland show that each suicide attempt costs an average of €1.5 million.8,9

Although suicide rate in Iran is lower than in most Western countries, it is higher than the rest of the Middle East and has grown significantly over the last three decades. The prevalence of suicide attempts in Iran under the influence of cultural and regional factors varies from 16.8% of 1000 people in the south of the country to 117.8% of 1000 people in the north of the country.10 In Iran, the highest suicide rates are in the western region of the country and are higher in women than men, while in some provinces, the suicide rate is higher in men than women. The suicide rate among Iranian students as a young and dynamic part of the society has varied from 1.8% to 3.5%.11

The main factors affecting suicide attempt are depression, hopelessness, age, gender, race, marital status, employment status, physical health, addiction, lifestyle, history of suicide attempt, and suffering from a mental disorder.12 Some of the social causes of suicide include living alone, lack of family and social support, as well as stressors such as divorce, unemployment, poverty, loss of loved ones, failure to work or study, forced marriage, etc.13 Therefore, people's lifestyle can be considered as one of the factors involved in suicidal ideation.

Lifestyle refers to routine daily activities that people have accepted in their lives in an acceptable way, so that these activities affect people's health. By choosing a lifestyle to maintain and improve their health and prevent diseases, individuals take measures and activities such as following a proper diet, sleep and activity, exercise, weight control, non-smoking and non-consumption of alcohol, and immunization against diseases, which constitute lifestyle.14 53% of deaths are related to the individuals' lifestyle.15 According to the WHO, 70% to 80% of deaths in developed countries and 40% to 50% of deaths in developing countries occur due to lifestyle-related diseases,16 and 60% of a person's quality of life (QOL) and health status depends on his/her lifestyle.17

Health-promoting behavior as a key issue in the concept of health promotion has attracted a widespread attention in research and program development. The people's definition of health is at the center of the view of health-promoting behavior. At this stage, health is defined using the positive qualities suggested by the WHO. Health means realizing human potential and maintaining balance and purposeful orientation in the environment. Health-promoting behavior has been defined by Walker and Hill-Polerecky as "a multidimensional pattern of self-initiated perceptions and actions that helps maintain and enhance one's health and self-fulfillment". Health-promoting behaviors have a potential effect on promoting health and QOL, and subsequently, reduce healthcare costs. According to studies, health-promoting lifestyle contributes to a positive life.18

In a study by Pearson et al. in China, 14 women under the age of 35 years who committed suicide and lived in rural areas of China were examined. They found that 75% of women were married and their average age was 26.6 years, the average number of years of education was 5.1, and 87% of them participated in productive activities. The most common suicide method used by 147 people who attempted suicide was poisoning, and family conflicts, financial problems, addiction, and serious disease were often associated with suicide. Young rural women are usually restricted, and Chinese culture does not encourage to discuss individual problems with people outside the family.19

Chioqueta and Stiles (2015) in a study entitled “personality traits and the development of depression, hopelessness, and suicide ideation” on addicted prisoners concluded that addicted people had a better QOL and less suicidal ideation when they paid attention to their religious beliefs. Increasing participation in religious ceremonies and self-help groups, each independently, leads to a reduction in addiction among addicted people and an improvement in their life expectancy.20

In a study by Bahar et al. on Turkish women, it was revealed that family education and income were associated with health-promoting behaviors.21

In another study by Rafiee et al., the lifestyle of married women aged 15-49 years who referred to health centers in the west of Ahvaz, Iran, was investigated. The results showed that the mean age of the subjects was 30.6 ± 7.0 years. There was a significant relationship between lifestyle and ethnicity (P = 0.001), marital status (P = 0.004), occupational status (P = 0.002), and income (P = 0.001). In terms of sleep quality (29.9%), leisure time (49.7%), nutritional status (54.7%), and personal health status (48.2%), they had a moderate lifestyle. In total, 50.3% of women had a moderate lifestyle.22

Nosratabadi et al. (2017) in a study entitled "predicting suicide ideation based on psycho-social factors and probability of drug abuse in soldiers: A structural model" showed that 4.28% of soldiers and army forces were at high risk of suicidal ideation (scores higher than 10). There was a positive and significant relationship between depression and addiction with suicidal ideation (P < 0.05). Social support, family status, and socioeconomic status (SES) only indirectly affected suicidal ideation. The structural model of the study showed that 73% of the variance of suicidal ideation was explained by the variables of depression, addiction, social support, family status, and SES.23

Improper lifestyle is one of the factors affecting the incidence of mental diseases, chronic cardiovascular disease (CVD), diabetes, osteoporosis, various cancers, pulmonary obstruction, liver cirrhosis, gastric ulcer, acquired immunodeficiency syndrome (AIDS), and many health problems such as obesity and addiction. Therefore, lifestyle plays a role in the aggravation or persistence of diseases. Lifestyle also has other consequences such as feeling of emptiness and dissatisfaction with life, suicidal ideation, decreased life expectancy, poor QOL, and increased burden of health care in the field of treatment, manpower, and rehabilitation. On the other hand, paying attention to the health of women, who constitute half of the population, is not only recognized as a human right, but also because of its effect on the health of family members and society is of great importance, because choosing any lifestyle by women, in addition to their personal lives, also affects the behaviors and lifestyles of other people.

Women are the foundation of the society, family, and the health of society, and with the spread of deviations among them, the stability and strength of the family is threatened. Women in most Iranian families are responsible for their children's education, and misbehaviors such as addiction and suicide among them provide the basis for family breakdown, which is an important factor in the process of socialization of women and even their children. Therefore, the present study was conducted to investigate the relationship between health-promoting lifestyle and suicidal ideation in addicted women.

The results of this study can help health policy makers, families, and community-oriented service providers, including psychiatrists and community-oriented nurses, take effective steps to fight against women's addiction, and ultimately, promote community health. Therefore, the aim of this study was to investigate the relationship between health-promoting lifestyle and suicidal ideation in addicted women, and also, the status of addicted women in terms of health-promoting lifestyle and suicidal ideation.

Methods

In this descriptive-correlational study, the study population consisted of all female drug users who referred to Shahid Beheshti Hospital and Nourieh Hospital in Kerman, Iran, in 2018. In this study, 118 people were selected using convenience sampling method. The collected data were analyzed using Spearman's correlation coefficient test by SPSS software (version 20, IBM Corporation, Armonk, NY, USA).

Health-Promoting Lifestyle Questionnaire: This questionnaire consists of 30 questions with 6 sub-categories including nutrition (questions 1, 6, 12, 18, 24, 26, 29), physical activity (questions 3, 5, 10, 17), health responsibility (questions 8, 14, 19, 20, 30), stress management (questions 2, 11, 13, 16, 21, 27, 28), interpersonal relationships (questions 4, 9, 15, 22, 25), and spiritual growth (question 7). The questions are scored based on a 4-point Likert scale (from 0 = never to 3 = always). Walker and Hill-Polerecky (2010) reported Cronbach's alpha coefficient of 0.94 for this instrument and 0.79 to 0.94 for its six sub-categories.18 In the study of Mohammadi Zeidi et al., the validity and reliability of the questionnaire were reported good.24

Beck Scale for Suicide Ideation (BSSI): The BSSI (1974) is a 19-item self-assessment tool. This questionnaire was designed to determine and measure the severity of attitudes, behaviors, and planning to commit suicide during the past week. The scale is scored based on a 3-point Likert scale from 0 to 2. The scale's questions assess items such as the desire to die, active and passive suicidal ideation, the duration and frequency of suicidal ideation, the sense of self-control, suicide deterrents, and the readiness of a person to attempt suicide. In this scale, there are 5 screening questions. If the answers indicate an active or passive suicidal ideation, the subject should continue the next 14 questions; the average time to complete the questionnaire is 10 minutes. In this scale, there is no specific form for identifying suicidal ideation, but in terms of the content of the questions, the risk of suicide can be determined as follows.

Suicidal ideation in a person based on the score obtained by individuals is categorized as no suicidal ideation (scores 0 to 3), ready to commit suicide (scores 4 to 11), and desire to make suicide attempt (scores 12 and above).

The scale was highly correlated with standardized clinical tests for depression and suicidal ideation. The correlation coefficient ranged from 0.90 for hospitalized patients to 0.94 for clinical patients. Moreover, this scale was correlated with Beck Depression Inventory (BDI)-related suicide questions from 0.58 to 0.69. In addition, it was correlated with Beck Hopelessness Scale (BHS) and BDI from 0.64 to 0.75. The BSSI has high reliability. Using Cronbach's alpha, the coefficients of 0.87 to 0.97 were obtained, and using the test-retest method, the reliability of 0.54 was obtained.22

Results

According to the data analysis, 79.4% of the respondents were in the age range of 26 to 45 years. In terms of education, 70.3% of them had middle school and high school education. In terms of spouse's education, 28% had middle school and high school education. 80.5% of the respondents were housewives and 28.8% had an unemployed spouse. 38.1% of respondents had the history of heroin consumption (Table 1).

Table 1

Frequency distribution of demographic characteristics of the subjects

Demographic characteristics	n (%)
Age (year)
20-25	4 (3.4)
26-35	48 (40.7)
36-45	45 (38.7)
> 45	20 (16.9)
No response	1 (0.8)
Education level
Elementary	25 (21.2)
Middle school	41 (34.7)
High school	42 (35.6)
BA	3 (2.5)
No response	7 (5.9)
Spouse's education level
Illiterate	8 (6.8)
Elementary	15 (12.7)
Middle school	18 (15.3)
High school	12 (10.2)
BA	3 (2.5)
MA	1 (0.8)
No response	61 (51.7)
Occupational status
Housewife	95 (80.5)
Labor	3 (2.5)
Freelance	11 (9.3)
No response	9 (7.6)
Spouse's occupation
Unemployed	34 (28.8)
Labor	21 (17.8)
Employed	2 (1.7)
Freelance	13 (11.0)
No response	48 (40.7)
Type of drug used
Methamphetamine (Shishe)	32 (27.1)
Heroin	45 (38.1)
Tablet	1 (0.8)
Opium (Shireh)	14 (11.9)
Opium	18 (15.3)
Methadone	5 (4.2)
Others	1 (0.8)
No response	2 (1.7)

BA: Bachelor of Arts; MA: Master of Arts

Among 118 respondents, 82 (69.5%) had poor health-promoting lifestyle, 25 (21.2%) had moderate, and 11 (9.3%) had good health-promoting lifestyle. 53 (44.9%) had no suicidal ideation, 28 (23.7%) were ready to commit suicide, and 36 (30.5%) had suicide ideation (Table 2).

Table 2

Frequency distribution of status of health-promoting lifestyle and suicidal ideation in women

Demographic characteristics	n (%)
Health-promoting lifestyle
Poor	82 (69.5)
Moderate	25 (21.2)
Good	11 (9.3)
Suicide
No suicidal ideation	53 (44.9)
Ready to make a suicide attempt	28 (23.7)
Desire to make suicide attempt	36 (30.5)
No response	1 (0.8)

Spearman's correlation test showed that there was a significant inverse relationship between health-promoting lifestyle and suicidal ideation (P ≤ 0.05). There was also a significant inverse relationship between health-promoting lifestyle components (nutrition, physical activity, health responsibility, stress management, interpersonal relationships, and spiritual growth) and suicidal ideation (P ≤ 0.05) (Table 3).

Table 3

Spearman's correlation test statistics of the relationship between health-promoting lifestyle and its components with suicide

Variable		Suicide
	Test	Spearman	P
Health-promoting lifestyle		-0.724	0.001
Nutrition		-0.700	0.001
Physical activity		-0.701	0.001
Health responsibility		-0.753	0.001
Stress management		-0.661	0.001
Interpersonal relationships		-0.619	0.001
Spiritual growth		-0.624	0.001

The results of regression test showed that the most important predictor of suicidal ideation was health responsibility (Table 4).

Table 4

Coefficients of regression model of the relationships between health-promoting lifestyle components and suicidal ideation

Variable	Beta (β)	SD	Standardized beta (β)	t	P
Permanent	19.980	1.347	-	14.832	0.001
Nutrition	-0.317	0.433	-0.157	-0.731	0.467
Physical activity	-0.013	0.511	-0.003	-0.025	0.980
Health responsibility	-1.168	0.520	-0.371	-2.247	0.027
Stress management	-0.076	0.405	-0.038	-0.189	0.851
Interpersonal relationships	-0.016	0.447	-0.006	-0.037	0.971
Spiritual growth	-1.382	1.422	-0.153	-0.972	0.334

SD: Standard deviation

Discussion

The results showed that 82 (69.5%) women had poor health-promoting lifestyle. 53 (44.9%) had no suicidal ideation, 28 (23.7%) were ready to make suicide attempt, and 36 (30.5%) had suicidal ideation. Studies on the people who have attempted suicide show that 17% to 69% of them have a type of drug-related disorder. The risk of suicide attempts and suicidal ideation increases among drug users. Drug use in soldiers and suicide statistics in Iran also show that drug use with a ratio of 1.54 is the second most common disorder in people with a history of suicide attempt or attempted suicide.23

The results showed that there was a significant inverse relationship between health-promoting lifestyle and its components with suicidal ideation, which is consistent with the results of other studies.20,23 To explain the hypothesis, it can be said that in stressful situations, a person is more likely to react based on his/her lifestyle and adapts to it. Research has shown that lifestyle is established in childhood, and is determined and interpreted by the individuals' initial hypotheses about the best way to achieve their goals. These hypotheses are formed around problem-solving strategies and lead the person to comfort and success and avoid harm and failure.20

Lifestyle is a set of behaviors based on recognizable behavioral patterns, which are the result of the interaction between a person's personality traits with psychosocial interventions and his/her economic status.25 From the perspective of researchers, six behavior classes including stress and anxiety management, establishing supportive social relationships, avoiding isolation and depression, personal development, accepting responsibility through the proper use of health resources, and exercise and healthy diet form a health-promoting lifestyle. If these components exist in one's life, the person is less likely to seek perversion and high-risk behaviors such as addiction, etc.26

On the other hand, according to the Hufford's theory, addiction through mechanisms such as anxiety and distress, increasing aggression, and decreasing the level of awareness which disrupts adaptive strategies, leads to the formation of suicidal ideation and suicide attempt. This theory has been approved by various studies.27

Conclusion

Since mothers play an important role in the formation of the family system, authorities should have sufficient knowledge about the phenomenon of addiction that these families are involved with. The findings of this study can be used to educate and increase the awareness of these organizations (especially the Anti-Narcotics Organization) of the nature of the phenomenon of addiction to better understand the situation of the ruling system of these families in order to adapt psychosocially, and reduce problems. On the other hand, by their economical, physical, and social supports, they can promote the health of these people as much as possible.

Using the results of this study, the factors reducing suicide (nutrition, physical activity, health responsibility, stress management, interpersonal relationships, and spiritual growth) in female drug users can be considered and used for primary prevention of suicidal ideation. In this regard, measures such as monitoring and screening the mental health status of female drug users at the beginning of treatment, preparing a psychological profile, providing psychological care and counseling, training related to high-risk behaviors of addiction, especially new drugs, and finally, holding regular workshops on suicide prevention and addiction in social settings are recommended.

In order to raise public awareness, especially in women, about the phenomenon of addiction and suicidal ideation and its effect on lifestyle, Iran Radio and Television Organization is suggested to produce various programs such as interviews and round table talks with experts, and also, produce and show documentaries.

Limitations: The findings of the present study were based on self-reporting tools, which can reduce the generalizability of the findings. Non-cooperation of some women in completing the questionnaires is another limitation of the study.