Quality of Life and its Related Factors in Iranian Drug-depentent Women Referring to Substance Abuse Treatment Centers

Background: Substance-Related Disorders are among the most common social problems caused by the use of legal and illegal substances. Therefore, this study aimed at determining the quality of life and its related factors among drug-dependent women referring to substance abuse treatment centers in Hamadan, west of Iran. Methods: This cross-sectional study was carried out on 120 Iranian female substance users recruited through the census sampling method in 2018. Data collection tools consisted of demographic characteristics and quality of life questioner (SF-36). Data were analyzed using SPSS-16 via one way ANOVA and chi-square tests. Results: The mean age of the participants was 33.2±12.1 years. The mean score of the total quality of life was 35.35±13.5. The results of multiple linear regression analysis indicated that using methamphetamine (β=-6.62) was the predictor of Qol in women. Moreover, there was a signicant association between quality of life and age (p <0.001), educational level (p = 0.011), age at rst use (p <0.001). Conclusion: According to the results, the participants' quality of life was found to be an unsatisfactory level. So, implementing educational help-seeking behavior for treatment and effectiveness intervention is especially adolescents and young, low-educated and early drug use, methamphetamine user women, which may increase the quality of life.

dependence among women; based on the results of such studies, several factors such as the availability of substance, lack of awareness, pressure from spouses or friends, the need for a detachment from reality, poverty, domestic violence, and sexual abuse, psychological anxiety, the presence of drugdependent persons in the family, and divorce are the reasons for drug use in females (8,9).
The use of narcotic substances by females has negative consequences and outcomes. We may note abandonment, the formation of an addicted generation, violence, self-mutilation, tattooing, shared injection, unprotected sexual behavior, and reduced communication with ordinary individuals (10).
According to studies conducted in Iran, of all women with a drug dependence problem, 5-17% have a history of unprotected sexual relationships; moreover, hepatitis C is observed in 1.9-100%, tattooing in 35.7%, the use of shared syringes for injection in 45%, sexually transmitted infections such as syphilis in 1-6%, chlamydia in 1-5%, herpes in 38-61%, and HPV in 42% of female drug users (11). Due to the most prevalent HCV transmission mode is injecting drugs with unclean needles or syringes, intravenous drug users are the most crucial group who should be considered (12). However, drug-dependent Women share needles and syringes with partners who have high-risk sexual behaviors (11). One study reported 78.1% of females with substance abuse problems reporting repeat sexual abuse, and 82.1% reported repeat physical abuse (13). However, most women with drug dependence and drug use disorders conceal their problems as they fear stigma and discrimination (10,14). Nowadays, improving the quality of life is one of the most important goals of treatment intervention programs. Based on the de nition, the quality of life is an individual's perception of his / her health status and the degree of satisfaction with that condition. The World Health Organization de nes the quality of life as a person's perception of his / her status in life associated with goals, expectations, values, and individual concerns. Existing evidence suggests an undesirable quality of life among Iranian drug-dependent women (15) and generally con rm the Iranian female population as a high-risk group that did not satisfy their QoL (16). Evidence showed that Self-assessed addiction to crack was strongly and negatively associated with all SF-36 subscales (17).
Since women are responsible for motherhood and the next generation's upbringing, the presence of a drug-dependent mother in the family can cause serious harm to spouse and children and, consequently, to the community (18). Therefore, it is essential to design and implement comprehensive interventions to prevent substance abuse in women. Furthermore, to devise effective educational programs and interventions to improve the quality of life of drug-dependent women, it is essential to obtain information about the status of abusing drugs and the related changes in the quality of life. Therefore, the present study aimed at determining the quality of life and its related factors among drug-dependent women covered by substance abuse treatment centers in Hamadan.

Methods
The present study was a cross-sectional study conducted on women referring to Hamadan's substance abuse treatment centers in 2018. The present study was carried out on 120 Iranian female substance users recruited through census sampling methods. After identifying and listing substance abuse treatment centers in Hamadan that exclusively provided services for females, the samples were selected from all women referring to the centers using the census methods.
After coordinating with the authorities and obtaining their approval, the researcher visited the substance users and invited them to participate in the study.
Data gathering in the present study attempted to achieve diversi cation by distributing questionnaires at various days and times in the multi-centric, high tra c substance abuse treatment centers to complete questionnaires and allow all willing women to ll out questionnaires and participate in the study concerning inclusion and exclusion criteria.
The researcher ensured the volunteers about the con dentiality of the research and collected data on quality of life. The study had speci c inclusion criteria, and it only recruited drug-dependent people who were living in the city or suburbs of Hamadan, had a history of substance abuse in the past or present, were willing to take part in an interview or complete a questionnaire, and had a history of referring to public substance addiction treatment centers exclusively designed for women. Based on the exclusion criteria, the researchers excluded individuals visiting private centers and were unwilling to cooperate with the research team. In this study, data collection tools consisted of one standard questionnaire and one checklist that collected data on the status of substances and life quality. After obtaining informed consent, the questionnaires were completed using interviews and self-reports by the participants.
Moreover, demographic data, including age, life status, education level, and job status, were obtained from the participants. Also, the status of substances abuse Checklist was used to collect data on the type of substance, including cannabis, opium, heroin, cocaine, ecstasy, and new industrial substances abused by the subjects within the past one month, six months, and one year. Each item was investigated using a separate question, answered with yes or no (19).
Questionnaire on the quality of life with 36 questions (SF-36): This questionnaire has 36 items categorized into eight subscales. These subscales are physical functioning (10 questions), role impairment due to physical health /role physical (4 items), role impairment due to emotional health /role emotional (3 items), energy and fatigue /vitality (4 questions), mental health (5 items), social functioning (2 questions), bodily pain (2 items), and general health (5 questions). Furthermore, two other general subscales are achieved by integrating the subscales known as Physical Component Summary (PCS) and Mental Component Summary (MCS). In this questionnaire, lower scores represent a lower quality of life, and vice versa (20). It is necessary to be mention; the previous study indicated that the SF-36 tool produced reliable data on the health status of substance abuse disorders populations (17).
The collected data were analyzed by SPSS 23 using descriptive statistics (mean, standard deviation, etc.) and linear regression tests to determine the predictors of quality of life. Statistical analysis was performed at a signi cance level of 0.01.

Results
In this study, 120 drug-dependent women participated, and all women present in treatment centers during data gathering took part in the survey. It is needed to be mention; 20 participants were excluded from the study due to incomplete completion of the questionnaire and were not analyzed.
The age range of the participants was between 15 to 73 years old, with a mean age of 33.2 ± 12.1 years; of all, 33.3% of the participants were in the age group of 26-35 years old and 30.8% of the participants were in the age group of 15-25 years old. Other demographic data are presented in Table 1. The most commonly used drugs by the study participants, which were abused in the past one month, were crystal, methadone, and heroin, with a prevalence of 53.3%, 20.8%, and 12.5%, respectively.
Moreover, the most commonly used drugs by the drug-dependent women, which were abused in the past six months, were crystal, methadone, and heroin, with a prevalence of 48.3%, 18.3%, and 18.3%, respectively. The most commonly used drug in the past year was crystal, with a prevalence of 45.8%. The most commonly used drug among the studied participants, abused in their life span, was opium and its derivatives (burnt, sap, etc.) that was reported by 64.2% of the participants, followed by crystal, methadone, and heroin that, respectively, were reported by 53.3%, 49.2% and 40% of the participants (Figure 1).
Based on the results, the participants obtained only 35.3% of the maximum achievable score of the quality of life (total score of quality of life), indicating the low quality of life among the drug-dependent women in Hamadan. Moreover, considering the pain and discomfort score results, the participants obtained 38.3% of the maximum achievable scores, which indicated an unfavorable status. The participants got a score of 8.75 in the subscale of physical function (role physical), which was the minimum score among all the subscales and indicated the most favorable condition. Table 2 presents the scores of all subscales of the quality of life among the studied people.  The National Drug Strategy framework suggested several drug types that cause the most harm. This classi cation included: alcohol, tobacco, cannabis, methamphetamines (e.g., MDMA) and other stimulants such as cocaine, new psychoactive substances -synthetic drugs, opioids, including heroin, the non-medical use of prescription drugs (21). Base on this framework, we classi ed substances into ve categories" cannabis category included marijuana, cannabis; opium category included opium, heroin, methadone, tramadol and, crack; the non-medical use of prescription drug category included norjizak; methamphetamine category included ecstasy (MDMA), crystal; cocaine category include cocaine. The present analysis of crack's chemical combination showed that this substance in Iran is a heroin-based narcotic that is different from the cocaine-based crack used in Western countries (22).
Based on the simple linear regression analysis results, the methamphetamine category (B = -6.62) was identi ed as the predictor of the quality of life of the women who participated in the study (Table 4).

Discussion
This study aimed to determine the quality of life and its related factors among drug-dependent women covered by substance abuse treatment centers in Hamadan. According to the study results, the age of the participants at the rst abuse of different materials ranged between 16 and 25 years, with a mean age of 23.57 ± 1.54. These ndings indicate that the vulnerability to substance abuse is higher among people at a young age (23). Therefore, it can be concluded that the probability of drug abuse increases in this age range. Undoubtedly, women in the mentioned age range experience severe stress and distress and may consider drug abuse to reduce stress. As observed in the results, the most commonly used drugs by the participants in their lifetime were opium and its derivatives and crystal, methadone, and heroin. This nding is in line with the results reported by Rahimi-Movaghar et al. (7).  (25).
The development of the phenomenon of tolerance and physiological and psychological dependence on addictive substances can lead to irritability, aggression, and other psychological symptoms. In general, this process reduces physical functioning, undermines psychosocial capabilities, and decreases individuals' quality of life. Generally, QoL is considered multifactorial, one of which is the mental health dimension. In the current study, this dimension was lower than the others. Although, mental state disorders usually encompass those psychiatric disorders seen such as mood, anxiety, and substance use disorders (26). Thus, personality disorder commonly co-occurs with mental state disorders, causing enormous consequences of substance abuse disorders. Several studies indicated that mental state disorders were associated with an increased risk of low quality of life in physical, psychological, social domains (27). Therefore, mental state disorders have been associated with signi cant impairment in quality of life (26,28). So, it seems that the analytical study includes a case group (substance abuse disorder women), and a control group (healthy women) was essential. Also, it is necessary to design and implement educational interventions to improve these women's quality of life.
In the present study, age, education, and age at rst drug abuse were associated with women's quality of life. As observed, the quality of life was lower among drug-dependent women who were younger, had lower education levels, and started drug abuse at younger ages. The results of this study are consistent with the results of other studies. For example, in research by Marini et al., the quality of life of people with a history of substance abuse had a relationship with the level of education (29). Findings of a study by Muller et al. showed that the quality of life in illiterate women and those with a low level of education was unfavorable (24). The results of Sadeghi et al. 's study showed that implementing therapeutic interventions in young women and those who started taking drugs at an early age helped to improve different dimensions of quality of life improved one, four, and eight months after the treatment (30). Therefore, it is necessary to design interventions for drug-dependent women who are younger have a low level of education, and those who started taking drugs at an early age to improve their quality of life.
In the present study, the methamphetamine category's abuse was identi ed as the predictor of drugdependent women's quality of life. Findings of a study by Falck et al. showed low quality of life in Crackcocaine users (17). Hence, it is essential to design interventions for drug-dependent women who are Crack users.
This study had some limitations, as it was conducted only on women with a history of drug abuse referring to substance abuse treatment centers in Hamadan. It is recommended to conduct similar studies on other drug-dependent women who do not refer to substance abuse treatment centers. Selfreporting and the use of a cross-sectional design were among the other limitations of the study. Due to this study design, causality could not be demonstrated; it is suggested to conduct qualitative studies to explain the reasons for women's addiction and explain the low quality of life in women who abuse substances. Examination variance in the severity of harm with Substance Consumption level and purity of substance investigations in participation is another limitation of our study, which performs preclinical toxicology and observational assessment to understand the damages related to the quality of life the future research were suggested. A multi-centric data gathering method was used; as indicated, all women present in treatment centers during data gathering took part in the study. But the sample size is small and doesn't represent all the substance abuse disorder women population for generalizability. This current study's strengths include age, education, early drug use, abuse of methamphetamine category, and cocaine category are essential factors in identifying QOL in substance abuse disorder women population. Also, applying the SF-36 questionnaire for evaluating QOL in drug-dependent women seems to possess some additional evidence of using this reliable questionnaire even in this sample.

Conclusion
According to the results, the participants' quality of life was found to be at an unsatisfactory level. So, implementing educational help-seeking behavior for treatment and effectiveness intervention education in substance abuse prevention programs is essential, especially in adolescents and young, low educated, early drug use, methamphetamine user women, which may increase the quality of life. Availability of data and materials: All supporting data is available through the corresponding author.
Authors' contributions MB and HJ developed the original idea and the protocol, abstracted, and prepared the manuscript. AK participated in the study design and analyzed the data. KB and TN contributed to study design and data gathering. All authors read and approved the nal manuscript.
Ethics approval and consent to participate: All the women were informed about the quality of the project's implementation, con dentiality of the information, and the project's purpose, and only if they would like, they were enrolled in the study. Participants indicated their informed consent by clicking the "I Agree" button before completing the questionnaire. Also, the number of participants under 16 was low (n=3), without any parents. According to the Iranian ethics committee guidelines, the participants were considered emancipated minors and written informed consent was received from them and the care centers' manager. The Ethics Committee approved this study with all consent process at Hamadan University of Medical Sciences