Psychosocial factors associated with reports of physical dating violence among U.S. adolescent females.

Howard, Donna E. ; Wang, Min Qi ; Yan, Fang 等

INTRODUCTION

Increasingly, over the past fifteen years, dating violence among adolescents has emerged as a growing public health concern. While the first article on late teen courtship violence appeared in 1981 (Makepeace, 1981), a current search of the PubMed database, using the key terms "adolescent dating violence," identified 110 articles published since 2000; this is more than a three-fold increase in the number published during the preceding 7-year period. Furthermore, dating violence has been incorporated in Healthy People 2000 and 2010, the blueprints for national decennial public health initiatives (U.S. Department of Health and Human Services, 2000a, 2000b). Finally, dating violence prevalence trends are now regularly monitored through the Center for Disease Control's Behavioral Risk Factor Surveillance System, specifically the Youth Risk Behavior Study (YRBS) (YRBSS).

National trends in the prevalence estimates of physical dating violence victimization over the previous 12-month period among high school youth indicates its relative stability; prevalence rates in 2005, 2003 and 1999 were 9.2%, 8.9%, and 9.1%, respectively (MMWR, 2006a MMWR 2006b; Howard & Wang, 2003a, Howard & Wang, 2003b). In other words, on an annual basis, dating violence takes its toll on a substantial number of youth. Moreover, victimization appears undifferentiated by gender and is associated with risk behaviors for both male and female high school students (MMWR, 2006b; Cercone, Beach, & Arias, 2005; Gray & Foshee, 1997). Based on 1999 national YRBS data, a risk profile of youth who reported past year physical dating violence victimization was identified. Overall, being a victim of dating violence was associated with reports of sad/hopeless feelings and engagement in high-risk sexual practices, specifically, recent multiple sex partners and unprotected sex. Gender differences in this risk profile emerged as well. Among males, attempted suicide and fighting behavior were correlated with victimization, while among females, binge drinking and cocaine or inhalant use were predictors (Howard & Wang, 2003a; Howard & Wang, 2003b). The co-occurrence of dating violence victimization with emotional well-being and engagement in other risk behaviors has been substantiated by a host of studies across geographic locales and diverse samples of youth (Roberts, Auinger, & Klein, 2005; Silverman, Raj, & Clements, 2004; Ackard & Neumark-Sztainer, 2002; Foshee, Benefield, Ennett, Bauman, & Suchindran, 2004; Foshee, Linder, MacDougall, & Bangdiwala, 2001).

While prevalence rates for dating violence victimization by gender are quite similar during adolescence, the adult literature suggests that Intimate Partner Violence (IPV) is largely a gender-specific issue with victimization rates for females ranging from three to six times those for males (Silverman, Raj, & Clements, 2004; Tjaden & Thoennes, 2000). Even during adolescence, females are more likely to suffer injury (Cercone, Beach, & Arias, 2005; Halpern, Oslak, Young, Martin, & Kupper, 2001; Foshee, 1996; Lane & Gwartney-Gibbs, 1985). Furthermore, adolescent females are more vulnerable to violent sexual abuse from dating partners than males (Foster, Hagan, & Brooks-Gunn, 2004). For these reasons, the focus here is on adolescent females.

The present study aims to update prevalence estimates and examine the robustness of the risk profile of dating violence among adolescent females based upon the most current and representative data from the national 2005 YRBS of U.S. high school students.

METHOD

Sample

The 2005 national school-based Youth Risk Behavior Survey (YRBS) data were used for this study. This survey is one component of the Youth Risk Behavior Surveillance System (YRBSS) that was established by the Centers for Disease Control and Prevention (CDC) to monitor the prevalence of youth behaviors that most influence health. Comprehensive design and sampling procedures are available from the CDC's Morbidity and Mortality Weekly Report series, and are excerpted here in condensed form (MMWR, 2006a). The YRBS survey used a three-stage cluster sample design to produce a nationally representative sample of high school students in grades 9-12. The first stage contained 1,270 primary sampling units (PSUs), which consisted of large counties or groups of smaller, adjacent counties. From these, 52 were selected from 16 strata, formed on the basis of the degree of urbanization and the relative percentage of African-American and Hispanic students in the PSU. Each PSU was selected with probability proportional to the size of the school enrollment. The second sampling stage selected 203 schools, also with probability proportional to school enrollment size. The third stage randomly selected one or two intact classes of a required subject (e.g., English or social studies) from the entire 9th-12th grades at the chosen school. All students in the selected classes were eligible participants. A total of 159 schools with 15,349 students completed survey questionnaires. The school response rate was 78%, and the student response rate was 86%, resulting in an overall response rate of 67%. For the purpose of this study, only female participants (N = 7,179) were selected for the analysis.

A weighting factor was applied to each participant to adjust for non-response and for the varying probabilities of selection, including those resulting from the over-sampling of African-American and Hispanic students. The weights were scaled so that (a) the weighted count of students was equal to the total sample size, and (b) the weighted proportions of students in each grade matched national population proportions.

Survey Procedures and Measures

Surveys were administered anonymously in order to protect the participants' privacy; participation was voluntary. Parental permission was obtained before survey administration. Students completed the self-administered questionnaire in their classrooms during a regular class period and recorded their responses on a scannable answer sheet.

The survey focused on priority health-risk behaviors that resulted in the most significant mortality, morbidity, disability, and social problems during both adolescence and adulthood. Monitoring progress in these areas was relevant in assessing how the national health objectives for the year 2010 were achieved. Results were also to be used to help focus programs and policies for comprehensive school health education on those behaviors that contribute most to the leading causes of mortality and morbidity.

The dependent variable was physical dating violence, which was measured by the question: "During the past 12 months, did your boyfriend or girlfriend ever hit, slap, or physically hurt you on purpose?" The response categories for this variable were yes or no.

The independent variables included four dimensions: violence, suicide, substance use, and sexual risk behavior. Violence-related behavior encompassed two questions: (1) "During the past 30 days, on how many days did you carry a gun?" The response categories were coded as 0 days or 1 or more days. (2) "During the past 12 months, how many times were you in a physical fight?" The response categories were coded as 0 times, 1 time, or 2 or more times. Suicide consisted of two questions: (1) "During the past 12 months, did you ever seriously consider attempting suicide?" (2) During the past 12 months, how many times did you actually attempt suicide?" The response categories for both variables were yes or no. One additional question examined sad or hopeless feelings: "During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?" The response categories were yes or no.

Substance use behavior consisted of four questions: (1) "During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?" The response categories were coded as 0, 1 or fewer cigarettes, or 2 or more cigarettes per day. (2) "During the past 30 days, on how many days did you have at least one drink of alcohol?" The response categories were coded as 0, 1-5 days, or 6 or more days. (3) "During the past 30 days, on how many days did you have five or more drinks of alcohol in a row, that is, within a couple of hours?" The response categories were coded as 0 days, 1-5 days, or 6 or more days.

(4) "During the past 30 days, how many times did you use any form of cocaine, including powder, crack, or freebase, or sniff glue, or breathe the contents of aerosol spray cans, or inhale any paints or sprays to get high?" The response categories were coded as 0 or 1 or more times.

Sexual risk behavior consisted of three questions: (1) "During the past three months, with how many people did you have sexual intercourse?" The response categories were coded as never had sexual intercourse, none during past three months, 1 person or 2 or more people. (2) "Did you drink alcohol or use drugs before you had sexual intercourse the last time?" The response categories were coded as never had sexual intercourse, yes or no. (3) "The last time you had sexual intercourse, did you or your partner use a condom?" The response categories were coded as never had sexual intercourse, yes or no.

In addition, the demographic variables grade and ethnicity were included. Some of the above-mentioned variables were recoded, as necessary, based on the frequencies in response categories and the appropriateness for statistical analysis.

Data Analysis

All statistical analyses were performed using the Statistical Analysis System (SAS, V9.1, 2004) survey procedures. The survey procedures can account for a multistage sampling option by including the design factors (i.e., the stratum and PSU levels) in the analytical model. The data were first analyzed using univariate logistic models between the dependent variable (physical dating violence) and each independent variable (substance use, suicide, physical fights, and sexual risk behaviors) to examine their relationship. The unadjusted odds ratios (OR) and 95% confidence intervals (CI) as well as [X.sup.2] tests were examined. To identify the most significant variables in relation to physical dating violence, multivariate logistic regression was used to include all significant independent variables from the bivariate analyses. Adjusted OR and 95% CI were examined to assess the significance of the relationships.

RESULTS

In terms of prevalence, 10.3% of female adolescents reported experiencing physical dating violence. As indicated in Table 1 prevalence estimates increased with grade and varied by ethnicity.

Bivariate Relationships between Physical Dating Violence and Risk Factors

The unadjusted odds ratios for the relationships among personal, psychological, and behavioral factors and physical dating violence reveal a picture of risk that is quite striking (see Table 1). Adolescent girls who reported having been hit, slapped or physically hurt on purpose by a boyfriend or girlfriend over the past year were more likely to also report emotional distress, violence-related behaviors, substance use, and engagement in sexually risky behavior. Furthermore, compared to 9th graders, 10th and 12th graders were significantly more likely to have been victimized. Compared to White youth, Black females were approximately 50% more likely to report dating violence.

Multivariate Relationships between Physical Dating Violence and Risk Factors

To detect the most significant risk factors associated with physical dating violence, multivariate logistic regression analysis, which included all significant variables from the bivariate analyses, were conducted (see Table 2). The odds of being a victim of physical dating violence were greater for Black females, as well as girls who had sad or hopeless feelings, had considered suicide, engaged in physical fighting, had been sexually active (1 or more sexual partners) in the most recent period or had unprotected sexual intercourse.

DISCUSSION

These findings provide the most current and comprehensive assessment of physical dating violence against U.S. adolescent girls. The risk profile presented offers vital information for intervention and prevention efforts.

First, dating violence against adolescent girls was widespread. Approximately one in ten 9th- through 12th-grade female adolescents who participated in the 2005 Youth Risk Behavior Survey reported being a victim of physical dating violence within the past year. That is, a boyfriend or girlfriend had hit, slapped or physically hurt them on purpose.

Second, no systematic pattern emerged by grade level for physical dating violence. Indeed, such findings make clear that prevention and intervention efforts should be initiated early, preferably before entrance to high school.

Third, the prevalence of physical dating violence was lowest for White girls, compared to females of other ethnicity. Compared to their White peers, Black girls were approximately 1.5 times as likely to report physical dating violence. Clearly, more needs to be learned about the relationship between ethnicity and physical dating violence. Not withstanding, these findings suggest the need for culturally sensitive preventions, as has been emphasized elsewhere in the area of the risk-behavior prevention and intervention (Freudenberg & Zimmerman, 1995).

Fourth, from the bivariate analyses, it was evident that engagement in a host of risk behaviors and emotional vulnerability were associated with reports of physical dating violence. Emotionally, experiencing sad or hopeless feelings or having considered or attempted suicide were linked to accounts of dating violence. The odds were increased that a female would have experienced physical dating violence if she reported other violence involvement, including fighting or gun carrying, use of a variety of substances such as tobacco, alcohol, cocaine or inhalants, and engagement in risky sexual behavior (unprotected sexual intercourse, multiple recent sexual partners). The co-occurrence of these factors supports the notion of an at-risk profile for adolescent girls, and reinforces the concept of problem behavior, in that adolescents who engage in one risk behavior are likely to be involved in other risk behaviors as well (Jessor, 1982, 1991; Dryfoos, 1990; Diclemente, Hansen, & Ponton, 1996; Resnick, Bearman, Blum, Bauman, Harris, Jones, Tabor, Beuhring, Sieving, Shew, Ireland, Bearinger, & Udry, 1997).

Finally, once multivariate analyses were adjusted for the effects of all significant risk factors, the risk profile of adolescent girls who reported physical dating violence became more distinct. Emotional distress, multiple physical fighting episodes, recent sexual intercourse, and unprotected sex were salient, significant predictors.

Consistent with previous studies, these girls were significantly more likely to have sad or hopeless feelings and have considered suicide. Regarding the associations with emotional well-being, it must be noted that the lack of temporal clarity precludes understanding of antecedents and consequences. It is possible that dating violence precipitates these feelings; alternatively, adolescent girls who experience strong feelings of sadness or hopelessness may seek out or passively find themselves in dating situations where they may be disrespected and/ or abused (Blum, Gallagher, Resnick, & Tolman, 1999).

The profile of females who reported dating violence suggests a relationship with other forms of violence. That is, girls who had engaged in fighting were significantly more likely to report victimization. This may suggest a generalized tendency toward violence in interpersonal relations, or perhaps a lower threshold for precipitation of violence. Without examination of contextual or developmental factors, it is difficult to determine the origins or temporal relations of these findings.

While previous analyses, based on the national 1999 YRBS survey, suggested that risky sexual behavior, specifically, multiple sexual partners and lack of condom use, were important risk factors for dating violence, in the present study these findings were only partially replicated. Indeed, sexual intercourse, whether it involved one or more partners over the most recent 3-month period, was significantly associated with dating violence. Additionally engaging in unprotected sex was associated with having been a victim of dating violence. Unlike the profile of risk which emerged from the 1999 YRBS which suggested that adolescent girls who used substances, used them excessively, or used them before sexual intercourse, were more likely to report violence in their dating relationships, there was no relationship between substance use and physical dating violence. This runs counter to extant research which suggests that courtship violence increases with consumption of alcohol by either the victim or perpetrator (Muehlenhard & Linton, 1987; Makepeace, 1988). Issues of multicollinarity, that is, the highly correlated nature of the independent variables, may account for this lack of significance in the multivariate analysis. Nevertheless, these findings underscore the need for programs that focus on healthy dating relationships and dating violence. Development of tailored interventions for adolescent girls who are at risk for physical dating violence may decrease the potential for victimization and enhance the prospects for respectful intimate partner relations as these young women mature into adulthood.

Limitations

As noted, the cross-sectional nature of the study design does afford an opportunity to examine prevalence and correlates of dating violence but it precludes examination of temporal relationships. The operational definition of dating violence is narrowly framed in its physical terms, having been hit, slapped, physically hurt on purpose, while our understanding of dating violence suggests that a more dimensional and complex characterization is needed. In addition, measurement of dating violence by single-item self-report questions is subject to a host of biases. First, reports of dating behavior as constituting intent of harm are subjective. Second, use of unitary variables to capture dynamic social phenomena may be less valid than a multiple-item questionnaire. Furthermore, while data suggests teen victims of dating violence are as likely to be the perpetrators, the study did not afford the opportunity to examine the profile of perpetrators of dating violence; nor does it provide insight into whether these experiences occur equally in same-gender and heterosexual adolescent dating relationships. While sampling for the national YRBS aimed to provide the most representative data, those students who, for a variety of reasons, were not present on the day of the survey administration may be different from attendees, limiting the external generalizability of the findings.

Based on the above noted limitations, one might question the utility of continuing to ask unitary and uni-dimensional questions on dating violence when much is left unanswered. The ability to track and monitor changes over time in the risk profile of adolescents does provide vital surveillance and highlights further lines of inquiry. The function of such ongoing observational data gathering is critical to current and future planning efforts of public health and medical care providers. Findings can assist in the development of programs and policies for comprehensive adolescent health education by focusing on behaviors that contribute to the mortality and morbidity.

Future Directions for Research

This study adds to a growing literature on the reach of dating violence into the world of adolescence and underscores the need for longitudinal research on its precursors and consequences. Without such studies, it is will remain unclear whether dating violence precipitated the sad/hopeless emotions, suicidal ideation, and risk-behavior engagement or these behaviors antedated the victimization. For example, it could be argued that girls who are more likely to engage in physical fighting continue this behavior in their dating relationships. It is also possible that other, yet unidentified factors, account for both fighting and risk of dating violence.

Analysis of the national 1999 YRBS indicated that multiple sex partners might be at the fulcrum of antecedent factors related to physical dating violence against adolescent girls. Analysis of the national 1999 YRBS indicated that multiple sex partners might be at the fulcrum of antecedent factors related to physical dating violence against adolescent girls. Yet, in the present study, recent sexual intercourse, rather than multiple partners, was significantly related to dating violence. This may simply reflect the fact that girls who are in dating relationships are more likely to be sexually active, and thus vulnerable to dating violence. It was also possible that the two variables, sexual intercourse and multiple partners, were highly correlated, thus, when one variable was included, the other variable had less chance to be significant. It is left for future research to establish the temporality of the relationship between risk engagement and dating violence against girls, not only in relation to sexual behaviors but emotional health as well. Longitudinal studies of youth, initiated well before adolescence and extending into young adulthood, would shed light on these important relationships.

At the same time, intervention efforts should be targeted at the perpetrators of dating violence or else the impression of blaming the victim is furthered. Motivations for perpetration need to be further explored in the context of adolescent dating violence. Finally, given the prevalence of violent behavior by boys in romantic relationships (Halpern, Oslak, Young, Martin, & Kupper, 2001; Centers for Disease Control, 2000; Foshee, 1996; Gray & Foshee, 1997; Gwartney-Gibbs, Stockard, & Brohmer, 1987), their role and responsibility must be addressed.

CONCLUSIONS

This study provides the most recent, generalizable findings on physical dating violence among U.S. high school females. It highlights implications for intervention and prevention research. The stability of prevalence estimates underscores the importance of dating violence as a public health problem. As part of comprehensive programs on healthy dating relationships, efforts should be directed to the targeting of girls who have risk profiles for dating victimization. Such programs may concurrently impact on violence and family planning outcomes and affect the trajectory of relationship patterns into adulthood.

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Min Qi Wang and Fang Yan, Department of Public and Community Health, University of Maryland, College Park, Maryland.

Reprint requests should be sent to Donna Howard, Dr.PH, Department of Public and Community Health CHHP, 2387 Valley Drive, University of Maryland, College Park, MD 20742. E-mail: dhowardl@umd.edu

Table 1
Prevalence and Unadjusted Odds Ratios For Relationships Between Dating
Violence and Demographic, Psychological and Behavioral Risk Factors
Among Adolescent Females Participating in the 2005 YRBS

Risk Factors Prevalence (%) Odds Ratio (95% CI)

Grade
 12th 11.70 1.45(1.15-1.84) **
 11th 10.76 1.26(0.95-1.66)
 10th 10.19 1 30(1.02-1.67) *
 9th 8.37 1.00
Ethnicity
 Black 13.66 1.49(1.13-1.96) **
 Hispanic 9.52 1.06(0.78-1.45)
 Other 11.93 1.23(0.78-1.94)
 White 8.46 1.00
Feel Sad/Hopeless
 Yes 15.50 2.33(1.96-2.78) ***
 No 7.03 1.00
Consider Suicide
 Yes 18.50 2.85(2.25-3.61) ***
 No 7.96 1.00
Attempted Suicide
 Yes 22.81 3,16(2.434.11) ***
 No 8.52 100
Physical Fight
 2+ Times 24.02 3.72(2.80-0.92) ***
 1 Time 12.82 1.89(1.46-2.44) ***
 0 Times 6.96 1.00
Gun Carrying
 1+ Days 34.62 3.92(2.01-7.66) ***
 0 Days 9.76 1.00
Daily Cigarette Smoking
 2+ Cigarettes 18.57 2.95(2.34-3.72) ***
 1 Or Less Cigarettes 15.31 2.28(1.66-3.14) ***
 0 Cigarettes 7.89 1.00
Days Drank Alcohol
 6+ Days 18.60 2.93(2.16-3.96) ***
 1-5 Days 13.01 2.06(1.65-2.57) ***
 0 Days 6.87 1.00
Had 5+ Drinks Alcohol
 6+ Days 18.72 2.77(1.66464) ***
 1-5 Days 16.05 2.41(2.04-2.85) ***
 0 Days 7.97 1.00
Used CocameAnhal ants
 Yes 17.15 2.30(1.84-2.86) ***
 No 9.00 1.00
Multiple Sex Partners
 2+ People 17.80 3.71(2.48-5.55) ***
 1 Person 16.07 3 19(2.42-4.21) ***
 Never had sex/None 5.09 1.00
Alcohol/Drugs Before Sex
 Yes 23.66 6.38(4.44-9.15) ***
 No 14.48 3.86(2.91-5.12) ***
 Never had sex 3.80 1.00
You/Partner Used Condoms
 No 20.75 5.75(4.25-7.79) ***
 Yes 12.75 3.38(2.45-4.68) ***
 Never had sex 3.83 1.00

Note: The last category was used as the reference. * Indicates
significance at p < .05; ** p < .01; *** p < .001

Table 2
Adjusted Odds Ratios for Relationships Between Dating Violence and
Demographic, Psychological and Behavioral Risk Factors Among
Adolescent Females Participating in the 2005 YRBS

Risk Factors Odds Ratio 95% CI

Grade
12th Grade 1.32 0.88-1.98
 11th Grade 1.31 0.89-1.93
 10th Grade 1.31 0.92-1.86
 9th Grade 1.00 1.00
Ethnicity
 Black 1.47 1 07-2.02 *
 Hispanic 0.99 0.71-1.38
 Other 1.01 0.53-1.92
 White 1.00 1.00
Feel Sad/Hopeless
 Yes 1.42 1.15-1.76 **
 No 1.00 1.00
Consider Suicide
 Yes 1.55 1.07-2 23 *
 No 1.00 100
Attempted Suicide
 Yes 1.20 0.87-1.66
 No 1.00 1.00
Physical Fight
 2+ Times 2.17 1.53-3.08 ***
 1 Time 1.21 0.90-1.62
 0 Times 1.00 100
Gun Carrying
 1+ Days 1.06 050-2.28
 0 Days 1.00 1.00
Daily Cigarette Smoking
 2+ Cigarettes 1.28 0.91-1.80
 1 Or Less Cigarettes 1.21 0.72-2.05
 0 Cigarettes 1.00 1.00
Days Drank Alcohol
 6+ Days 0.82 0.50-1.34
 1-5 Days 1.05 0.77-1.44
 0 Days 1.00 100
Had 5+ Drinks Alcohol
 6+ Days 1.06 0.58-1.93
 1-5 Days 1.40 0.99-1.98
 0 Days 1.00 1.00
Used Cocaine/inhalants
 Yes 1.22 0.90-1.65
 No 1.00 1.00
Multiple Sex Partners
 2+ People 2.20 1.51-3.20 ***
 1 Person 2.10 1.45-3.03 ***
 Never had sex/None 1.00 100
Alcohol/Drugs Before Sex
 Yes 1.35 0.96-1.91
 Never had sex/No (1) 1.00 1.00
You/Partner Used Condoms
 No 1.70 1.31-2.19 ***
 Never had sex/Yes (1) 1.00 1.00

Note: The last category was used as the reference. * Indicates
significance at p < .05; ** p < .01; *** p < .001

(1) These were combined as the reference category