Factors associated with spousal physical violence in Albania: cross se
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《英国医生杂志》
1 Department of Public Health, Faculty of Medicine, University of Tirana, St "Dibres," N.371, Tirana, Albania, 2 Gender and Health Research Unit, Medical Research Council, Pretoria, South Africa, 3 Unit of Primary Prevention of Addiction, Federal Centre for Health Education, Cologne, Germany, 4 School of Public Health, School of Medicine, University of Belgrade, Serbia and Monte Negro, 5 Section of International Public Health, Faculty of Health Sciences, University of Bielefeld, Germany
Correspondence to: G Burazeri gburazeri@yahoo.com
Objective To describe the prevalence of intimate partner violence and associated factors among married women in Albania.
Design Cross sectional study.
Setting Tirana, the capital city of Albania.
Participants A representative sample of 1039 married women aged 25-65 living in Tirana and recorded in the 2001 census.
Methods Questionnaire on intimate partner violence and social and demographic characteristics of the women and their husbands.
Main outcome measure Women's experience within the past year of being hit, slapped, kicked, or otherwise physically hurt by the husband.
Results More than a third (37%, 384/1039) of women had experienced violence. Risk was greatest among women aged 25-34 (odds ratio 1.47, 95% CI 1.04 to 2.09), women with tertiary education (3.70, 2.04 to 6.67), women in white collar jobs (4.0, 1.59 to 10.0), women with least educated husbands (5.01, 2.91 to 8.64), and women married to men raised in rural areas (3.31, 2.29 to 4.80). Women were at higher risk if they were more educated than their husbands (4.76, 2.56 to 9.09).
Conclusions In transitional Albania, the risk of spousal violence is high, and more empowered women are at greater risk.
Intimate partner violence is present in almost all societies1 2 and is associated with considerable morbidity.1 3 Little is known about the magnitude of intimate partner violence and the factors associated with it in post-communist countries.1 Intimate partner violence is more common in patriarchal societies and settings where violence is commonly used in conflict or to gain ascendance,4 so there has been particular concern about its prevalence in patriarchal transitional countries, where violence has become commonplace and social relations have been disrupted.5
Albania is a small country, and 58% of the population lives in rural areas.6 It has undergone major social and political upheaval in the past decade.5 6 After the collapse of the communist regime in 1990 many people migrated from rural to urban areas.6 7 The population of Tirana, the capital city, increased rapidly from 150 000 in 1991 to more than 500 000 a decade later.6 In the western Balkans there are substantial social and cultural differences between people from urban and rural areas,5 giving rise to an expectation that place of birth (and upbringing) could be an important determinant of attitudes or social norms that might give rise to different behaviour patterns and practices.8 Albania has been described as a particularly patriarchal society.9 10
Intimate partner violence is integrally linked to ideas of male superiority over women.4 These are manifest in different ways in different societies, but violence is usually used to create and enforce gender hierarchy and punish transgressions11-13; to resolve relationship conflict14; and to seek resolution of crisis of masculinity by providing an (often transient) sense of powerfulness.11-13 Different factors influence, and indicate, the status of women and men in a society and so influence these processes. These factors include social and demographic characteristics of the women and men, their economic circumstances, and the characteristics of their relationship.15-20 Other factors, including alcohol consumption, depression, experience of abuse in childhood, and the strength of family and social networks, may additionally influence responses to conflict and a perception of emotional insecurity.1 4 19 20
This study aimed to describe the magnitude of the problem of physical violence among intimate partners in Tirana and the demographic and social factors associated with it.
Methods
We carried out a cross sectional study in Tirana in July-October 2003. At the last census in April 2001, 93 230 women aged 23-63 (at that time) resided in Tirana.7 The sampling frame for this study was the list of these women's names obtained from the National Institute of Statistics. From this list we drew a simple random sample of 1500 women (both married and unmarried), but we included only married women, as cohabiting is unusual in Albania. The study was conducted in 2003 so the women were aged 25-65. Of the 1500 potential respondents, 106 women could not be identified (wrong address or changes of residence), 198 women were excluded as they were not currently married, 129 women were either absent (after two visits), or refused to participate, and 28 questionnaires were incomplete and could not be included in the analysis, giving a response rate of 87% (1039 of 1196).
A structured questionnaire was administered by an interviewer to married women who agreed to participate in the survey after an informed consent form had been signed. The questionnaire included questions on age, education, religion, occupation, place of birth (rural or urban) and age of move to Tirana (if any) of the woman and of her husband. It asked about number of children, household size, and household disposable income (from all sources, after rent is paid). It asked about whether the husband was "violent and constantly jealous," was drunk (almost) every day, and whether the woman knew if he had been abused by his parents during childhood or had witnessed violence between his parents. Women's recent experience of spousal violence was measured by a question asking whether in the past year she had been "hit, slapped, kicked, or physically hurt" by her husband. Those answering "Yes" were asked how many times this had happened.
We computed income per capita as the ratio of disposable income per family member living in the home (partner, children, parents, inlaws) and categorised as low (< 80 (￡54; $95) per capita/month), middle (80-150 per capita/month), and high (> 150 per capita/month). Educational attainment of women and their husbands was classified as high if they had a university degree (or other post-school qualification), middle if they had a formal education of 9-12 years, and low if formal education lasted no more than eight years. For profession we used the self reported main occupation, categorised as "white collar" (clerk or business occupations), "blue collar" (industry and agriculture), housekeeping (for women), or unemployed or retired.
Data analysis
After calculating descriptive statistics for the prevalence of physical spousal violence and social and demographic variables, we used logistic regression to examine bivariate associations between these variables and Student's t test to compare the mean number of children in a household and number of household members in the two abuse categories. We then constructed two multiple variable logistic regression models. We first modelled factors associated with reporting spousal violence for 945 women who had no missing data, using a backwards stepwise elimination procedure with a P value to exit > 0.10. The model tested the age of the husband, age difference between spouses, place of origin of women, income level, difference in educational level between spouses, difference in employment level between spouses, number of children, number of household members, employment status of men, male jealousy, alcohol misuse, and male experience of abuse in childhood. Colinearity between educational status of men and women and educational discrepancy between spouses prevented all of these being retained in one model. As all seemed to be important in different ways, we built a second model showing educational discrepancy, but not men's and women's education level, otherwise using the same backwards stepwise elimination procedure and candidate variables. The fit of the logistic regression models was tested by likelihood ratio and Hoshmer-Lemeshow goodness of fit tests. All statistical analyses were done with SPSS 10.0 for Windows.
Results
The mean age of the women was 42.3 (median 41.0, interquartile range 33.0-50.0) years, and their husbands' mean age was 46.6 (45.0, 37.0-55.0) years. Of the women interviewed, 384 (37%) reported at least one episode of spousal violence in the past year, and 267 (26%) reported three or more episodes (655 (63%) reported none; 72 (7%) reported one episode, 45 (4%) two, 97 (9%) three, 39 (4%) four, 104 (10%) five to nine, 27 (3%) 10 or more).
The prevalence of violence was highest among women aged 25-34, those with more than 12 years of education, those employed in white collar positions, women who were more educated than their spouse, in households where there were more children and more household members, and in couples where the wife was the only one employed (table 1).
Table 1 Prevalence of spousal physical abuse, Tirana, Albania. Values are numbers (percentages) unless stated otherwise
Husbands who had been violent towards their wives were more likely to be aged 25-34, to have less than nine years of schooling, to have come from a rural area (especially doing so at, or after, 10 years of age), and to have witnessed their mothers being abused and to have been beaten in childhood (table 2).
Table 2 Prevalence of spousal physical abuse, Tirana, Albania. Values are numbers (percentages) unless stated otherwise
The multiple variable logistic regression model (table 3) of factors associated with physical violence showed greatest risk for the youngest women (aged 25-34). Risk increased with increasing educational level for women, with decreasing educational level for men, and with men being of rural origin and having left rural areas at age 10 or later. Risk of violence reduced with decreasing employment status of women: women in blue collar work, housekeepers, and unemployed women were at lower risk than those in white collar occupations.
Table 3 Multiple variable logistic regression models of factors associated with spousal physical violence experienced by 945 married women in Tirana, Albania
The model with educational discrepancy (table 3) showed least risk of violence when women were married to a more educated spouse. Women were protected (but less so) if their spouse had the same educational level, and they were most at risk if they were more educated than their spouse. There was substantial confounding between the educational discrepancy variable and most factors in the first model. The only variable that showed no change in effect size was men's rural origin. After adjustment for education discrepancy, women's age was not independently associated with risk of violence; women's employment status was protective only if women were unemployed; and a variable not in the first model, men's employment status, is seen in the model with increased risk associated with men being unemployed (table 3).
Discussion
World Health Organization. World report on violence and health. Geneva: WHO, 2002. www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf (accessed 27 Jun 2005).
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002;359: 1232-7.
Campbell JC. Health consequences of intimate partner violence. Lancet 2002;359: 1331-6.
Jewkes R. Intimate partner violence: causes and prevention. Lancet 2002;359: 1423-9.
Rechel B, McKee M. Healing the crisis: a prescription for public health action in South Eastern Europe. New York: Open Society Institute Press, 2003.
Nuri B, Tragakes E (eds). Health care systems in transition: Albania. Copenhagen: European Observatory on Health Care Systems, 2002. www.who.dk/document/E80089.pdf (accessed 11 Jul 2005).
Institute of Statistics of Albania. The population of Albania in 2001. Tirana: INSTAT, 2002.
Unicef. Multiple indicator cluster survey report. Tirana: UNICEF-Albania, 2000. www.childinfo.org/MICS2/natlMICSrepz/Albania/mics_final_report.pdf (accessed 5 Jan 2005).
Young A. Women who become men: Albanian sworn virgins. New York: Berg, 2001.
Pritchett Post SE. Women in modern Albania: first hand accounts of culture and conditions from over 200 interviews. London: McFarland, 1998.
Bourgois P. In search of respect: selling crack in El Barrio. Cambridge: Cambridge University Press, 1996.
Moore H. A passion for difference: essays in anthropology and gender. London: Polity Press, 1994.
Wood K, Jewkes R. "Dangerous" love: reflections on violence among Xhosa township youth. In: Morrell R, ed. Changing men in Southern Africa. Pietermaritzburg: University of Natal Press, 2001.
Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. New York: Anchor, 1980.
Kantor GK, Jasinski, JL, Aldarondo E. Socio-cultural status and incidence of marital violence in Hispanic families. Violence Vict 1994;9: 207-22. (Special issue: Violence against women of colour.)
Sorenson SB, Upchurch DM, Shen H. Violence and injury in marital arguments: risk patterns and gender differences. Am J Public Health 1996;86: 35-40.
Martin SL, Tsui AO, Maitra K, Marinshaw R. Domestic violence in northern India. Am J Epidemiol 1999;150: 417-26.
Kantor GK, Straus MA. Substance abuse as a precipitant of wife abuse victimizations. Am J Drug Alcohol Abuse 1989;15: 173-89.
Jewkes R, Penn-Kekana L, Levin J. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med 2002;55: 1603-17.
Ellsberg MC, Pena R, Herrera A, Liljestrand J, Winkvist A. Wife abuse among women of childbearing age in Nicaragua. Am J Public Health 1999;89: 241-4.
Schuler SR, Hashemi SM, Riley AP, Akter S. Credit programmes, patriarchy and men's violence against women in rural Bangladesh. Soc Sci Med 1996;43: 1729-42.
Hotaling GT, Sugarman DB. An analysis of risk markers in husband to wife violence: the current state of knowledge. Violence Vict 1986;1: 101-24.
Ellsberg M, Heise L. Bearing witness: ethics in domestic violence research. Lancet 2002;359: 1599-604.(Genc Burazeri, lecturer in epidemiology )
Correspondence to: G Burazeri gburazeri@yahoo.com
Objective To describe the prevalence of intimate partner violence and associated factors among married women in Albania.
Design Cross sectional study.
Setting Tirana, the capital city of Albania.
Participants A representative sample of 1039 married women aged 25-65 living in Tirana and recorded in the 2001 census.
Methods Questionnaire on intimate partner violence and social and demographic characteristics of the women and their husbands.
Main outcome measure Women's experience within the past year of being hit, slapped, kicked, or otherwise physically hurt by the husband.
Results More than a third (37%, 384/1039) of women had experienced violence. Risk was greatest among women aged 25-34 (odds ratio 1.47, 95% CI 1.04 to 2.09), women with tertiary education (3.70, 2.04 to 6.67), women in white collar jobs (4.0, 1.59 to 10.0), women with least educated husbands (5.01, 2.91 to 8.64), and women married to men raised in rural areas (3.31, 2.29 to 4.80). Women were at higher risk if they were more educated than their husbands (4.76, 2.56 to 9.09).
Conclusions In transitional Albania, the risk of spousal violence is high, and more empowered women are at greater risk.
Intimate partner violence is present in almost all societies1 2 and is associated with considerable morbidity.1 3 Little is known about the magnitude of intimate partner violence and the factors associated with it in post-communist countries.1 Intimate partner violence is more common in patriarchal societies and settings where violence is commonly used in conflict or to gain ascendance,4 so there has been particular concern about its prevalence in patriarchal transitional countries, where violence has become commonplace and social relations have been disrupted.5
Albania is a small country, and 58% of the population lives in rural areas.6 It has undergone major social and political upheaval in the past decade.5 6 After the collapse of the communist regime in 1990 many people migrated from rural to urban areas.6 7 The population of Tirana, the capital city, increased rapidly from 150 000 in 1991 to more than 500 000 a decade later.6 In the western Balkans there are substantial social and cultural differences between people from urban and rural areas,5 giving rise to an expectation that place of birth (and upbringing) could be an important determinant of attitudes or social norms that might give rise to different behaviour patterns and practices.8 Albania has been described as a particularly patriarchal society.9 10
Intimate partner violence is integrally linked to ideas of male superiority over women.4 These are manifest in different ways in different societies, but violence is usually used to create and enforce gender hierarchy and punish transgressions11-13; to resolve relationship conflict14; and to seek resolution of crisis of masculinity by providing an (often transient) sense of powerfulness.11-13 Different factors influence, and indicate, the status of women and men in a society and so influence these processes. These factors include social and demographic characteristics of the women and men, their economic circumstances, and the characteristics of their relationship.15-20 Other factors, including alcohol consumption, depression, experience of abuse in childhood, and the strength of family and social networks, may additionally influence responses to conflict and a perception of emotional insecurity.1 4 19 20
This study aimed to describe the magnitude of the problem of physical violence among intimate partners in Tirana and the demographic and social factors associated with it.
Methods
We carried out a cross sectional study in Tirana in July-October 2003. At the last census in April 2001, 93 230 women aged 23-63 (at that time) resided in Tirana.7 The sampling frame for this study was the list of these women's names obtained from the National Institute of Statistics. From this list we drew a simple random sample of 1500 women (both married and unmarried), but we included only married women, as cohabiting is unusual in Albania. The study was conducted in 2003 so the women were aged 25-65. Of the 1500 potential respondents, 106 women could not be identified (wrong address or changes of residence), 198 women were excluded as they were not currently married, 129 women were either absent (after two visits), or refused to participate, and 28 questionnaires were incomplete and could not be included in the analysis, giving a response rate of 87% (1039 of 1196).
A structured questionnaire was administered by an interviewer to married women who agreed to participate in the survey after an informed consent form had been signed. The questionnaire included questions on age, education, religion, occupation, place of birth (rural or urban) and age of move to Tirana (if any) of the woman and of her husband. It asked about number of children, household size, and household disposable income (from all sources, after rent is paid). It asked about whether the husband was "violent and constantly jealous," was drunk (almost) every day, and whether the woman knew if he had been abused by his parents during childhood or had witnessed violence between his parents. Women's recent experience of spousal violence was measured by a question asking whether in the past year she had been "hit, slapped, kicked, or physically hurt" by her husband. Those answering "Yes" were asked how many times this had happened.
We computed income per capita as the ratio of disposable income per family member living in the home (partner, children, parents, inlaws) and categorised as low (< 80 (￡54; $95) per capita/month), middle (80-150 per capita/month), and high (> 150 per capita/month). Educational attainment of women and their husbands was classified as high if they had a university degree (or other post-school qualification), middle if they had a formal education of 9-12 years, and low if formal education lasted no more than eight years. For profession we used the self reported main occupation, categorised as "white collar" (clerk or business occupations), "blue collar" (industry and agriculture), housekeeping (for women), or unemployed or retired.
Data analysis
After calculating descriptive statistics for the prevalence of physical spousal violence and social and demographic variables, we used logistic regression to examine bivariate associations between these variables and Student's t test to compare the mean number of children in a household and number of household members in the two abuse categories. We then constructed two multiple variable logistic regression models. We first modelled factors associated with reporting spousal violence for 945 women who had no missing data, using a backwards stepwise elimination procedure with a P value to exit > 0.10. The model tested the age of the husband, age difference between spouses, place of origin of women, income level, difference in educational level between spouses, difference in employment level between spouses, number of children, number of household members, employment status of men, male jealousy, alcohol misuse, and male experience of abuse in childhood. Colinearity between educational status of men and women and educational discrepancy between spouses prevented all of these being retained in one model. As all seemed to be important in different ways, we built a second model showing educational discrepancy, but not men's and women's education level, otherwise using the same backwards stepwise elimination procedure and candidate variables. The fit of the logistic regression models was tested by likelihood ratio and Hoshmer-Lemeshow goodness of fit tests. All statistical analyses were done with SPSS 10.0 for Windows.
Results
The mean age of the women was 42.3 (median 41.0, interquartile range 33.0-50.0) years, and their husbands' mean age was 46.6 (45.0, 37.0-55.0) years. Of the women interviewed, 384 (37%) reported at least one episode of spousal violence in the past year, and 267 (26%) reported three or more episodes (655 (63%) reported none; 72 (7%) reported one episode, 45 (4%) two, 97 (9%) three, 39 (4%) four, 104 (10%) five to nine, 27 (3%) 10 or more).
The prevalence of violence was highest among women aged 25-34, those with more than 12 years of education, those employed in white collar positions, women who were more educated than their spouse, in households where there were more children and more household members, and in couples where the wife was the only one employed (table 1).
Table 1 Prevalence of spousal physical abuse, Tirana, Albania. Values are numbers (percentages) unless stated otherwise
Husbands who had been violent towards their wives were more likely to be aged 25-34, to have less than nine years of schooling, to have come from a rural area (especially doing so at, or after, 10 years of age), and to have witnessed their mothers being abused and to have been beaten in childhood (table 2).
Table 2 Prevalence of spousal physical abuse, Tirana, Albania. Values are numbers (percentages) unless stated otherwise
The multiple variable logistic regression model (table 3) of factors associated with physical violence showed greatest risk for the youngest women (aged 25-34). Risk increased with increasing educational level for women, with decreasing educational level for men, and with men being of rural origin and having left rural areas at age 10 or later. Risk of violence reduced with decreasing employment status of women: women in blue collar work, housekeepers, and unemployed women were at lower risk than those in white collar occupations.
Table 3 Multiple variable logistic regression models of factors associated with spousal physical violence experienced by 945 married women in Tirana, Albania
The model with educational discrepancy (table 3) showed least risk of violence when women were married to a more educated spouse. Women were protected (but less so) if their spouse had the same educational level, and they were most at risk if they were more educated than their spouse. There was substantial confounding between the educational discrepancy variable and most factors in the first model. The only variable that showed no change in effect size was men's rural origin. After adjustment for education discrepancy, women's age was not independently associated with risk of violence; women's employment status was protective only if women were unemployed; and a variable not in the first model, men's employment status, is seen in the model with increased risk associated with men being unemployed (table 3).
Discussion
World Health Organization. World report on violence and health. Geneva: WHO, 2002. www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf (accessed 27 Jun 2005).
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002;359: 1232-7.
Campbell JC. Health consequences of intimate partner violence. Lancet 2002;359: 1331-6.
Jewkes R. Intimate partner violence: causes and prevention. Lancet 2002;359: 1423-9.
Rechel B, McKee M. Healing the crisis: a prescription for public health action in South Eastern Europe. New York: Open Society Institute Press, 2003.
Nuri B, Tragakes E (eds). Health care systems in transition: Albania. Copenhagen: European Observatory on Health Care Systems, 2002. www.who.dk/document/E80089.pdf (accessed 11 Jul 2005).
Institute of Statistics of Albania. The population of Albania in 2001. Tirana: INSTAT, 2002.
Unicef. Multiple indicator cluster survey report. Tirana: UNICEF-Albania, 2000. www.childinfo.org/MICS2/natlMICSrepz/Albania/mics_final_report.pdf (accessed 5 Jan 2005).
Young A. Women who become men: Albanian sworn virgins. New York: Berg, 2001.
Pritchett Post SE. Women in modern Albania: first hand accounts of culture and conditions from over 200 interviews. London: McFarland, 1998.
Bourgois P. In search of respect: selling crack in El Barrio. Cambridge: Cambridge University Press, 1996.
Moore H. A passion for difference: essays in anthropology and gender. London: Polity Press, 1994.
Wood K, Jewkes R. "Dangerous" love: reflections on violence among Xhosa township youth. In: Morrell R, ed. Changing men in Southern Africa. Pietermaritzburg: University of Natal Press, 2001.
Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. New York: Anchor, 1980.
Kantor GK, Jasinski, JL, Aldarondo E. Socio-cultural status and incidence of marital violence in Hispanic families. Violence Vict 1994;9: 207-22. (Special issue: Violence against women of colour.)
Sorenson SB, Upchurch DM, Shen H. Violence and injury in marital arguments: risk patterns and gender differences. Am J Public Health 1996;86: 35-40.
Martin SL, Tsui AO, Maitra K, Marinshaw R. Domestic violence in northern India. Am J Epidemiol 1999;150: 417-26.
Kantor GK, Straus MA. Substance abuse as a precipitant of wife abuse victimizations. Am J Drug Alcohol Abuse 1989;15: 173-89.
Jewkes R, Penn-Kekana L, Levin J. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med 2002;55: 1603-17.
Ellsberg MC, Pena R, Herrera A, Liljestrand J, Winkvist A. Wife abuse among women of childbearing age in Nicaragua. Am J Public Health 1999;89: 241-4.
Schuler SR, Hashemi SM, Riley AP, Akter S. Credit programmes, patriarchy and men's violence against women in rural Bangladesh. Soc Sci Med 1996;43: 1729-42.
Hotaling GT, Sugarman DB. An analysis of risk markers in husband to wife violence: the current state of knowledge. Violence Vict 1986;1: 101-24.
Ellsberg M, Heise L. Bearing witness: ethics in domestic violence research. Lancet 2002;359: 1599-604.(Genc Burazeri, lecturer in epidemiology )