Child maltreatment

in Vietnam:
Prevalence and associated
mental and physical health
problems

Huong Thanh Nguyen, BSc, MSc, MPH

A thesis submitted for the Degree of Doctor of Philosophy in the

School of Public Health, Faculty of Health, and Institute of Health
and Biomedical Innovation, Queensland University of Technology
2006
 Key Words
Child abuse/maltreatment 1 Poly-victimization 2
Child sexual abuse/maltreatment Community-based research
Child physical abuse/maltreatment Prevalence
Child emotional abuse/maltreatment Associations
Child neglect Health risk behaviours
Co-occurrence of child maltreatment Mental and physical health
Multiple-type/form maltreatment Cumulative effect

1
In this study, the usage of child abuse and child maltreatment terms is exchangeable (WHO, 1999).
2
In this study, multiple-type maltreatment and poly-victimization terms are exchangeable.

iii
 Abstract
Child maltreatment is not a new issue. It has existed in various forms in every society
since the early days in history. However, it is only in the past four decades that abuse
and neglect of children has attracted widespread interest among health professionals
and the general public. There is now a large body of evidence that identifies four
main maltreatment forms: physical, sexual, emotional maltreatment and neglect.
Child maltreatment is a substantial public health problem, as it is associated with
immediate and long-term health problems.

Most research into child maltreatment has been conducted in English-speaking,

developed countries. Although there has been a small but steady increase in the
number of studies from less developed countries over the past decade, there remains
a relative dearth of research in these populations, especially in Asia. Over the years,
most research projects around the world tend to be focused on only one type of child
maltreatment (usually either child sexual abuse or child physical maltreatment), and
many studies do not examine risk factors in depth, or address the possible outcomes
of various forms of maltreatment.

Children have always held a very important place in the culture and traditions in
Vietnam. In 1989, Vietnam was the first Asian country and the second country in the
world to sign and ratify the United Nations Convention on the Rights of the Child.
Since then Vietnam has adopted various measures to promote children’s rights and
particularly children’s rights to be protected from abuse and exploitation. Despite
strong political support for the rights of children, there is little formal research into
child maltreatment. From the small amount of available evidence and media reports,
it appears that children in Vietnam are vulnerable to maltreatment, just as they are all
over the world. It is clear that information about the extent and health consequences
of different forms of child maltreatment from scientifically sound studies is still far
from sufficient. Thus, more research is essential to ensure effective and culturally
appropriate responses to protect children from maltreatment.

v
The primary aim of this research was to examine the nature and co-occurrence of
four forms of child maltreatment including sexual, physical, emotional maltreatment
and neglect among Vietnamese secondary and high school adolescents in both urban
and rural settings, and determine the extent to which such adverse experiences
impact on self-reported health risk behaviours and physical and mental health.

A mixed methods design including qualitative interviews and focus group

discussions, and a cross-sectional survey was employed in this study. Incorporation
of qualitative inquiry added a cultural dimension on child maltreatment and informed
to develop appropriate quantitative measures.

Following 8 focus group discussions and 16 in-depth interviews as well as a pilot

study of 299 adolescents in Vietnamese schools, a cross-sectional survey of 2,591
adolescents randomly selected from eight secondary and high schools in one urban
district and one rural district was undertaken between 2004 and 2005. Data were
collected by self-administered questionnaires in class rooms. Key information
included demographics, family characteristics and environment, and four scales
measuring sexual abuse, emotional and physical maltreatment and neglect as well as
standard brief assessments of health related risk behaviours, mental and general
physical health.

The study clearly revealed that experiences of different forms and co-occurrence of
child maltreatment among school adolescents were prevalent in Vietnam. The
prevalence estimates of at least one type of physical and emotional maltreatment,
neglect and sexual abuse were 47.5%, 39.5%, 29.3% and 19.7% respectively. A
significant proportion of respondents (41.6%) was exposed to more than one form of
child maltreatment, of which 14.5% and 6.3% experienced three or four
maltreatment forms.

Results from multivariate logistic regression analyses showed that the prevalence of
child physical and emotional maltreatment and neglect among adolescents was not
statistically different between urban and rural districts. However, children from rural

vi
schools were more likely to report unwanted sexual experiences than their
counterparts in urban schools. There was no significant gender difference in reports
of adverse sexual experiences. In contrast, girls were more likely to report emotional
maltreatment and neglect whereas boys were more likely to experience physical
maltreatment. Furthermore, family environment assessed by parental quarrelling,
fighting, perceived quality of parental relationship and emotional support appeared to
be the most consistent factors significantly predicting each form of child
maltreatment.

After controlling for a wide range of potential confounding factors, many significant
correlates between each type of maltreatment, each level of maltreatment co-
occurrence and each health risk behaviour were found. In general, the pattern of
correlations between child maltreatment and health risk behaviours was similar for
females and males. Emotional maltreatment significantly correlated with most
behaviours examined. Physical maltreatment seems more likely to be associated with
involvement in physical fights and being threatened. Sexual abuse was significantly
related to smoking, drinking, being drunk, and involvement in fighting. Statistically
significant associations between neglect and self-harm such as involvement in
fighting, feeling sad and hopeless, suicidal thoughts and attempts were found.
Clearly, co-occurrence of child maltreatment was significantly associated with
almost all examined health risk behaviours and a dose-response relationship was
observed in most of the dependent variables.

Regarding continuous measures of mental and physical health, multivariate

regression analyses revealed that presence of four types of child maltreatment
explained a small but significant proportion of variance (from 5% to 9%), controlling
for a wide range of background variables. Additionally, while each form of child
maltreatment had independent effects on depression, anxiety problems, low self-
esteem and poor physical health emotional maltreatment appeared to be the strongest
influence on mental and physical health of both female and male adolescents.
Analysis of variance also clearly suggested that exposure to increasing numbers of

vii
maltreatment forms significantly increased the risk of mental and physical health
problems in a dose-response fashion.

The present study extends a small body of previous research examining poly-
victimization in developed nations to an Asian country. The data contribute new
knowledge on cross-cultural child maltreatment problems. Considerable
commonalities as well as some differences in the findings in Vietnam compared with
earlier research were found. One important conclusion concerns the significant
independent associations between various types of child maltreatment, as well as the
cumulative effects of poly-victimization on a wide range of health risk behaviours,
depression, anxiety, self-esteem, and general physical health. This pioneering
research in Vietnam provides timely and substantial evidence that can be used to
raise public awareness of the nature of child maltreatment and the harmful effects of
not only sexual and physical abuse but also other forms of emotional maltreatment
and neglect which have not received attention before. These results from a
community-based sample have demonstrated the urgent need for prevention
programs. The current study provides an impetus for more comprehensive research
in this sensitive area in the near future so that culturally and politically relevant
evidence-based responses to child maltreatment can be developed in Vietnam.

viii
 Contents
Key Words …………………………………………………………………...... iii
Abstract ……………………………………………………………………....... v
Contents ……………………………………………………………………….. ix
List of tables …………………………………………………………………… xiii
List of figures ………………………………………………………………….. xvii
Abbreviations ………………………………………………………………….. xix
Statement of original authorship ………………………………………………. xxi
Acknowledgements ……………………………………………………………. xxiii

Chapter 1: Introduction ……………………………………………………... 1

1.1 Background ………………………………………………………... 1
1.2 Research aim and objectives ………………………………………. 4
1.3 Outline of thesis …………………………………………………… 5

Chapter 2: Literature Review ……………………………………………….. 7

2.1 Definition of child maltreatment …………………………………... 7
2.2 International prevalence of child maltreatment ……………………. 10
2.3 Risk factors for child maltreatment ………………………………... 22
2.4 Consequences of child maltreatment ……………………………… 35
2.5 Child maltreatment in Vietnam ……………………………………. 55

Chapter 3: Research Methods and Pilot Study …………………………….. 63

3.1 Methodological considerations in research on child maltreatment ... 63
3.2 Design of this study ………………………………………………... 67
3.3 Study participants ………………………………………………….. 70
3.4 Study sites …………………………………………………………. 71
3.5 Timeline …………………………………………………………… 71
3.6 Instrument development …………………………………………… 72
3.7 Sample selection …………………………………………………... 78
3.8 Data collection …………………………………………………….. 79

ix
 3.9 Data management ………………………………………………….. 79
3.10 Data analysis ……………………………………………………... 80
3.11 Ethics approval …………………………………………………… 84
3.12 The qualitative and pilot studies …………………………………. 85
3.13 Implications of the pilot study …………………………………… 100
3.14 Changes to the questionnaire …………………………………….. 101

Chapter 4: Prevalence and Characteristics of Different Forms of Abuse ... 103

4.1 Sample characteristics ……………………………………………... 104
4.2 Adverse experiences and prevalence of four forms of child
maltreatment …………………………………………………………… 109
4.3 Characteristics of child maltreatment ……………………………… 115
4.4 Correlates of child maltreatment …………………………………... 117
4.5 Summary …………………………………………………………... 132

Chapter 5: Associations between Child Maltreatment and Health Risk

Behaviours ……………………………………………………………………. 133
5.1 Prevalence and correlates of health risk behaviours ………………. 133
5.2 Associations between maltreatment types, multiple forms of
maltreatment and health risk behaviours ……………………………… 137
5.3 Summary …………………………………………………………... 159

Chapter 6: Associations between Child Maltreatment and Mental and

Physical Health ……………………………….................................................. 162
6.1 Descriptive analyses ……………………………………………….. 163
6.2 Bivariate correlations of child maltreatment with mental and
physical health …………………………………………………………. 165
6.3 Impact of co-occurrence exposure to child maltreatment …………. 168
6.4 Relative influence of each type of child maltreatment …………….. 175
6.5 Summary …………………………………………………………... 183

x
Chapter 7: Discussion ……………………………………………………….. 185
7.1 The prevalence of child maltreatment and correlates with
background variables ………………………………………………….. 185
7.2 Correlates of child maltreatment and health risk behaviours ……… 195
7.3 Correlates of child maltreatment and physical and mental health … 202
7.4 Strengths, weaknesses and implications for further research ……… 209
7.5 Conclusion ………………………………………………………… 214

References …………………………………………………………………….. 217

Appendices ……………………………………………………………………. 239
Appendix 1: Summary table of prevalence studies of four forms of
child maltreatment with community-based samples of adolescents and
young adults ………………………………………………………….... 241
Appendix 2: Summary of prior research: Adolescent and early adult
retrospective reports of child maltreatment ……………………………. 269
Appendix 3: Brief demographic profile of Vietnam …………………... 291
Appendix 4: Map of Vietnam and two study sites: Dongda district,
Hanoi city and Chilinh district, Haiduong province …………………... 293
Appendix 5: Guideline for in-depth interview ………………………… 297
Appendix 6: Guideline for focus group discussion ……………………. 299
Appendix 7: Self-administered questionnaire for the major survey …... 301
Appendix 8: Main themes emerging from the qualitative study ………. 319
Appendix 9: Results of confirmatory factor analysis of depression and
self-esteem scale data ………………………………………………….. 327
Appendix 10: Estimated prevalence of each form of child maltreatment
(with confidence intervals) …………………………………………….. 331
Appendix 11: Mean scores of depression, anxiety, self-esteem, and
physical health by levels of maltreatment exposure, age groups and
gender …………………………………………………………….......... 335

xi
 List of Tables

Chapter 2: Literature Review ……………………………………………….. 7

Table 2.1: Rates of various ways of physical punishment in the previous 6
months reported by mothers, WorldSAFE study ……………………………… 15
Table 2.2: Rates of emotional punishment in the previous 6 months as
reported by mothers, WorldSAFE study ………………………………………. 19
Table 2.3: Summary of associations between each form of childhood
maltreatment experiences and common adverse outcomes reported in literature 49
Table 2.4: Ways to conduct physical punishment on children ………………… 59

Chapter 3: Research Methods and Pilot Study …………………………….. 63

Table 3.1: Pilot study: Internal consistency of the scales ……………………... 90
Table 3.2: Pilot study: Rotated loading of the anxiety scale …………………... 91
Table 3.3: Pilot study: Summary of the fit statistics of CES-D and RSES ……. 92
Table 3.4: Pilot study: Frequency of emotional, physical maltreatment acts and
neglect …………………………………………………………………………. 94
Table 3.5: Pilot study: Frequency of sexual abuse acts ……………………….. 96
Table 3.6: Pilot study: Prevalence of different forms of child maltreatment ….. 96
Table 3.7: Pilot study: Prevalence of multiple forms of maltreatment ………... 97
Table 3.8: Pilot study: Correlations between abuse and physical and mental
health outcomes ………………………………………………………………... 98
Table 3.9: Pilot study: Differences between abuse experience groups and
mental health outcomes ……………………………………………………….. 99

Chapter 4: Prevalence and Characteristics of Different Forms of Abuse ... 103

Table 4.1: Demographic characteristics of the sample ………………………... 104
Table 4.2: Family characteristics ……………………………………………… 105
Table 4.3: Family environment ………………………………………………... 108
Table 4.4: Frequency of unwanted emotional acts …………………………….. 110
Table 4.5: Frequency of neglect events ………………………………………... 110

xiii
Table 4.6: Frequency of unwanted physical acts ……………………………… 111
Table 4.7: Frequency of unwanted sexual events ……………………………... 111
Table 4.8: Prevalence of different forms of child maltreatment ………………. 113
Table 4.9: Prevalence of multiple forms of child maltreatment ……………….. 114
Table 4.10: Perpetrators of unwanted physical events ………………………… 116
Table 4.11: Perpetrators of attempted rape and rape …………………………... 117
Table 4.12: Demographic correlates of child emotional maltreatment …........... 118
Table 4.13: Demographic correlates of child physical maltreatment ……......... 119
Table 4.14: Demographic correlates of child sexual abuse ………………......... 120
Table 4.15: Demographic correlates of neglect ……………………………….. 121
Table 4.16: Family characteristic correlates of emotional, physical
maltreatment, sexual abuse, and neglect ………………………………………. 122
Table 4.17: Family environment correlates of child emotional, physical
maltreatment, sexual abuse, and neglect ………………………………………. 125
Table 4.18: Summary of risk factors for emotional maltreatment …………….. 127
Table 4.19: Summary of risk factors for physical maltreatment ………………. 129
Table 4.20: Summary of risk factors for sexual abuse ………………………… 130
Table 4.21: Summary of risk factors for neglect ……………………………..... 131

Chapter 5: Associations between Child Maltreatment and Health Risk

Behaviours ……………………………………………………………………. 133
Table 5.1: Prevalence of health risk behaviours among adolescents by gender 135
Table 5.2: Prevalence of health risk behaviours among adolescents by region 136
Table 5.3: Prevalence of health risk behaviours among adolescents by age ….. 137
Table 5.4: Multivariate models of child maltreatment associated with feeling
sad and hopeless ……………………………………………………………….. 141
Table 5.5: Multivariate models of child maltreatment associated with thought
about attempting suicide ………………………………………………………. 144
Table 5.6: Multivariate models of child maltreatment associated with making
a suicide plan …………………………………………………………………... 146
Table 5.7: Multivariate models of child maltreatment associated with male
cigarette smoking ……………………………………………………………… 147

xiv
Table 5.8: Multivariate models of child maltreatment associated with alcohol
drinking ………………………………………………………………………... 149
Table 5.9: Multivariate models of child maltreatment associated with ever
been drunk ……………………………………………………………………... 150
Table 5.10: Multivariate models of child maltreatment associated with male
injury while drunk ……………………………………………………………... 152
Table 5.11: Multivariate models of child maltreatment associated with female
not eating to lose weight ………………………………………………………. 153
Table 5.12: Multivariate models of child maltreatment associated with male
carrying a weapon ……………………………………………………………... 154
Table 5.13: Multivariate models of child maltreatment associated with being
threatened or injured …………………………………………………………... 156
Table 5.14: Multivariate models of child maltreatment associated with
involving in physical fight …………………………………………………….. 158
Table 5.15: Summary of significant correlations between child maltreatment
and health risk behaviours ……………………………………………………... 161

Chapter 6: Associations between Child Maltreatment and Mental and

Physical Health ……………………………….................................................. 162
Table 6.1: Mean, standard deviation and reliability statistics of mental and
physical health scales ………………………………………………………….. 163
Table 6.2: Mental and physical health scores by gender ……………………… 164
Table 6.3: Mental and physical health scores by region ………………………. 164
Table 6.4: Mental and physical health scores by age groups ………………….. 165
Table 6.5: Bivariate inter-correlations of child maltreatment variables,
physical health and mental health variables (females) ………………………… 167
Table 6.6: Bivariate inter-correlation of child maltreatment scales, physical
health and mental health scales (males) ……………………………………….. 167
Table 6.7: Cumulative impacts of co-occurrence of child maltreatment and age
on health outcomes …………………………………………………………….. 169
Table 6.8: P values of post-hoc comparisons of means across maltreatment
levels for four measures of health status ………………………………………. 175

xv
Table 6.9: Complete results of sequential multiple regression analyses of the
impact of various forms of child maltreatment on mental and physical
health…………………………………………………………………………… 177

xvi
 List of Figures

Chapter 2: Literature Review ………………………………………………… 7

Figure 2.1: Ecologically integrative model of child maltreatment ……………… 24

Chapter 3: Research Methods and Pilot Study ……………………………… 63

Figure 3.1: Mixed methods procedures of the study ……………………………. 69
Figure 3.2: Two-stage cluster sampling ………………………………………… 78
Figure 3.3: Age distribution of pilot sample ……………………………………. 88

Chapter 5: Associations between Child Maltreatment and Health Risk

Behaviours ……………………………………………………………………… 133
Figure 5.1: Percentage of adolescent felt sad and hopeless by occurrence of
multiple types of maltreatment ………………………………………………….. 141
Figure 5.2: Percentage of adolescent thought about attempting suicide by
occurrence of multiple types of maltreatment …………………………………... 143
Figure 5.3: Percentage of adolescent making suicide plan by multiple-type
maltreatment …………………………………………………………………….. 145
Figure 5.4: Percentage of adolescent involved in physical fights by occurrence
of multiple types of maltreatment ………………………………………………. 158

Chapter 6: Associations between Child Maltreatment and Mental and

Physical Health ………………………………………………………………… 162
Figure 6.1: Mean depression scores by number of forms of child maltreatment .. 170
Figure 6.2: Mean anxiety scores by number of forms of child maltreatment …... 171
Figure 6.3: Mean self-esteem scores by number of forms of child maltreatment 172
Figure 6.4: Mean physical health scores by number of forms of child
maltreatment …………………………………………………………………….. 173

xvii
 Abbreviations

CEA Child Emotional Abuse/Child Emotional Maltreatment

CES-D Centre for Epidemiological Studies-Depression Scale
CI Confidence Interval
CN Child Neglect
CPA Child Physical Abuse/Child Physical Maltreatment
CSA Child Sexual Abuse/Child Sexual Maltreatment
FGD Focus Group Discussion
GSO General Statistics Office
MOH Ministry of Health
MOLISA Ministry of Labour, Invalids and Social Affairs
MTM Multiple-Type Maltreatment
n.a Not Available
NA Not Applicable
NS Not Significant
OR Odds Ratio
PFCSI Population, Family and Children Scientific Institute
PTSD Post Traumatic Stress Disorder
RaFH Reproductive and Family Health
RSES Rosenberg Self-Esteem Scale
SAVY Survey Assessment of Vietnamese Youth
SCS Save the Children Sweden
SD Standard Deviation
SIDA Swedish International Development Cooperation Agency
UNESCO United Nations Educational, Scientific and Cultural
Organisation
UNICEF United Nations Children's Fund
WHO World Health Organisation
WorldSAFE World Studies of Abuse in the Family Environment

xix
 Statement of original authorship

The work contained in this thesis has not been previously submitted for a degree or
diploma at any other higher education institution. To the best of my knowledge and
belief, this thesis contains no material previously published or written by other
person except where due reference is made.

Signed: …………………………………………….
Huong Thanh Nguyen, BSc, MSc, MPH

Date: 31 October 2006

xxi
 Acknowledgements

I am forever grateful to the following people:

To my principle supervisor, Professor Michael Dunne, for his inspiration, patience

and intellectual guidance.

To my associate supervisors, Associate Professor Le Vu Anh and Dr. Christine

Eastwood, for their expertise, encouragement and support.

To Dr. Diana Battisttuta, for her understanding and statistical advice, from which I
have learnt so much.

To my colleagues at the Hanoi School of Public Health, Vietnam, for their ongoing
support. Sincere thanks to Dr. Nguyen Thanh Nghi, Hoang Khanh Chi, Nguyen
Quynh Anh, Nguyen Thai Quynh Chi, Dr. Dang Vu Trung and others for their
significant contribution to the data collection process and overall implementation of
the study.

To the schools and students who participated as anonymous volunteers, for their
time, openness and eagerness for this study that made the research possible.

To fellow PhD candidates and others who I have spent time with in room 604, for
their social and emotional support. Particular thanks to Claire and Chin Chih.

And finally, to my husband, Chinh, my daughter, Ha, my parents and family, without
their never ending love, encouragement, and patience I would have never finished
the challenging journey.

xxiii
 Chapter 1: Introduction

1.1 Background

For a long time in many parts of the world, child maltreatment has been documented
in art and literature. However, the issue did not attract widespread attention from
health professionals and the general public until the early 1960s, with the publication
of an influential article “The battered child syndrome” in the Journal of the American
Medical Association, by paediatrician Henry Kempe and his colleagues (1962). As a
direct impact of this article, before the year 1970, all states in the US had established
child abuse reporting laws (Cicchetti & Carlson, 1989). By the end of the 1960s,
child abuse had emerged as a social problem in other parts of the world, and reports
of child abuse cases flooded the periodical literature (Freeman, 2000).

According to the World Health Organization (WHO), child maltreatment including

child physical maltreatment, emotional maltreatment, sexual abuse, and neglect, is a
public health problem in both developed and developing countries, impairing the
health and welfare of children and adolescents. WHO has estimated that 40 million
children aged 0-14 years around the world suffer from abuse and require health care
and social services (McMenemy, 1999). Consequences of child abuse are often
immediate, impinging on the formative years and can be long lasting, following
victims throughout their lives. Moreover, child abuse affects not only children, but
also other family members and can ruin or contaminate communities, damaging
complex social and familial relations and interactions. Over the past decades, many
researchers have documented the higher frequency of health problems among
maltreated survivors. Possible pathways through which maltreatment might influence
health are behavioural, social, cognitive, and emotional. These four types of
influences form a complex matrix of inter-relationships, impacting on health
(Kendall-Tackett, 2002).

1
This global problem requires both international and local collaborations to design
and implement culturally acceptable ways to alleviate the burden on children,
families, and communities. McMenemy (1999) summarised the international
recommendations to combat the child maltreatment problem as follows:

• Development of worldwide data collection on child maltreatment;

• Sharing of interventions and best practices for prevention;
• Continuing evaluation and research on prevention; and
• Development of national programmes for prevention and provision of social
support for children and families.

While progress in terms of extensive research, development and implementation of

preventive measures and signs of declining abuse rates may have been made in North
America, Australia and Western Europe (Dunne, Purdie, Cook, Boyle, & Najman,
2003; Jones, Finkelhor, & Kopiec, 2001), there remains a significant need to advance
initiatives in the countries of Asia, South America, Eastern Europe, and Africa. The
extent of child maltreatment and its impact in most parts of the developing world is
unknown or not well documented, but there is increasing evidence that problems do
exist and are of growing concern to policy makers, health professionals, researchers
and the general public (D'Antonio, Darwish, & McLean, 1993; Kawewe & Dibie,
1999; Qiao & Chan, 2005).

Over the past decade there has been a small but steady increase in the number of
articles from less developed countries published in English language journals such as
“Child Abuse & Neglect” and “Child Maltreatment” (Lachman et al., 2002).
However, there remains a relative dearth of research on child abuse in developing
countries in general and within Asian cultures in particular. Additionally, a review of
the literature on child maltreatment in less developed world reveals that most
research projects tend to be targeted at the prevalence of only one type of child
maltreatment (usually either child sexual abuse or child physical maltreatment), and
many studies do not examine risk factors in depth, or address the possible outcomes
of maltreatment.

2
When people report that they were maltreated as a child it should be understood that
this often occurs within a complex web of childhood adversity. Often, children are
maltreated in multiple ways (Higgins & McCabe, 2000a; Moeller, Bachmann, &
Moeller, 1993). The co-occurrence of various maltreatment forms may have either a
cumulative or an interactive impact. Wolfe and McGee (1994) argued that different
types of child maltreatment interact in a manner that is more detrimental to
development than the influence of one type alone. However, the majority of child
maltreatment studies have examined the impact of individual types of child
maltreatment in isolation (Higgins & McCabe, 2000b). Evidence from recent
research examining more than one type of child maltreatment has drawn attention to
the fact that co-occurrence of child maltreatment is reported by many respondents
(Benbenishty, Zeira, & Astor, 2002; Meston, Heiman, Trapnell, & Carlin, 1999;
Scher, Forde, McQuaid, & Stein, 2004; Stephenson et al., 2006). Clearly, attempts to
evaluate co-occurrence and a full exploration of the interrelationships of multiple
forms of child maltreatment in a single study are critical to understanding relative
and cumulative effects of child maltreatment.

Although the Vietnamese government has demonstrated commitment to promotion

of children’s rights and child protection most activities implemented across the
country have targeted extreme cases of sexual abuse such as child rape or
commercial sexual exploitation of children (UNICEF, 2002). There is a paucity of
research examining the extent to which Vietnamese children are exposed to child
maltreatment. Furthermore, so far no research investigating the associations between
various types of child maltreatment and health outcomes among the general
population has ever been conducted in Vietnam.

To respond to the compelling need for evidence on the child maltreatment issue in
Vietnam, in this project we conducted a school-based survey of various forms of
child maltreatment among school children from grade 7 to grade 11 (aged from 12-
18 years) in both urban and rural areas in Vietnam. Four different types of child
maltreatment were assessed: physical maltreatment, emotional maltreatment, sexual
abuse, and neglect. The effects of co-occurrence of these types of child maltreatment

3
on adolescents’ self-reported health risk behaviours, mental and physical health were
also explored. This study is among the first of this kind conducted in Asian countries.
On the whole, the study not only contributes evidence to child maltreatment research
in developing countries but also helps to raise awareness and develop culturally
appropriate measures for child maltreatment prevention and intervention in Vietnam.

1.2 Research aim and objectives

Research aim

The primary aim of this research was to examine the nature and co-occurrence of
various forms of child maltreatment reported by Vietnamese school children from
grade 7 to grade 11 in both urban and rural settings and to determine the extent to
which such maltreatment experiences impact on self-reported health risk behaviours
and the physical and mental health of the children.

Research objectives

It follows that the objectives of the research were to:

1. Estimate the lifetime prevalence of sexual abuse, physical maltreatment,

emotional maltreatment and neglect as well as multiple type maltreatment rates,
experienced by school adolescents in one urban district and one rural district.
2. Identify risk factors for each form of child maltreatment from various
background variables including demographic characteristics, family
characteristics and environment.
3. Describe various health risk behaviours of school adolescents.
4. Measure physical and mental health of school adolescents.
5. Examine independent effects of each form of child maltreatment and potential
cumulative impact of co-occurrence of maltreatment on health risk behaviours as
well as on physical and mental health of these adolescents.

4
1.3 Outline of thesis

Chapter 1 has set the background and outlined the purpose of this study.

Chapter 2 reviews the literature related to a wide range of child maltreatment issues.
Initially, while acknowledging the complexity and difficulties of reaching a global
definition of child maltreatment, the review presents widely-used child maltreatment
definitions and classifications by researchers worldwide. The review provides
essential information for selecting the operational definition of child maltreatment to
be used in this research.

The chapter includes a review of estimated prevalence of child sexual abuse, physical
maltreatment, emotional maltreatment, and neglect reported in the international
literature. A wide range of risk factors and possible effects of each form of child
maltreatment and the co-occurrence of multiple types of maltreatment on the victims
are then explored in detail. As enormous child maltreatment research using different
samples have been published worldwide, for the purpose of our study, the review
mainly focuses on the studies among community or school-based adolescents and
early young adult samples. Key information about Vietnam and small body of local
research on child maltreatment is also presented. Based on the literature review, the
chapter ends by proposing the hypotheses of this study.

Chapter 3 The chapter begins by briefly considering significant methodological

issues of child maltreatment research. Then the research methods used for this study
and the main results of the pilot study, focusing on instrument development and
validation are described.

Chapter 4 reports the estimated prevalence of child sexual abuse, physical and
emotional maltreatment and neglect as well as the rates of maltreatment co-
occurrence among adolescents. Demographic variables, family characteristics and
family environment variables that emerged as significant risk factors for each form
of child maltreatment are presented.

5
Chapter 5 reports the rates of various health risk behaviours of adolescents. This
chapter also provides results of analysis of the associations between sexual abuse,
physical and emotional maltreatment, and neglect as well as between multiple-type
maltreatment and each health risk behaviour.

Chapter 6 estimates the relative effects of each form of child maltreatment and
cumulative effects of poly-victimization on depression, anxiety, self-esteem, and
general physical health of adolescents. Significant associations are also reported
between a wide range of background factors and depression, anxiety, self-esteem and
physical health.

Chapter 7 contains a discussion of the main research findings. The strengths,

limitations and the implications of this study are also discussed.

6
 Chapter 2: Literature Review

2.1 Definition of child maltreatment

In 1999, the WHO Report of the Consultation on Child Abuse Prevention proposed
the following definition, which covers a broad spectrum of abuse (WHO, 1999):

Child abuse or maltreatment constitutes all forms of physical and/or emotional

ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other

exploitation, resulting in actual or potential harm to the child’s health, survival,

development or dignity in the context of a relationship of responsibility, trust or

power. (p.15)

While this definition is quite broad, covering various aspects of abuse and neglect,
the vagueness and ambiguity surrounding the definition of this particular complex
problem still make it difficult to operationalise internationally. Awareness of cultural
factors therefore must remain high as these influence all aspects of the problem from
definitions of child abuse and occurrence to its effective prevention.

Behaviours towards children considered as abusive or neglectful vary and the

labelling of behaviours is a contentious issue. World Vision in partnership with the
International Society for the Prevention of Child Abuse and Neglect and Chapin Hall
Centre for Children, University of Chicago designed a five-country study,
interviewing community leaders, caregivers, and children to explore perceptions of
child maltreatment (Dorning, 2002). Despite some cultural differences, a wide range
of behaviours were consistently mentioned in defining child maltreatment by most
respondents and there were some common perceptions in behaviours considered
abusive in all five countries, namely Ghana, Kenya, Thailand, Brazil, and Romania.
However, there are also points of departure between Western and Eastern attitudes

7
on a number of issues closely related to child abuse, especially physical punishment
and emotional expression (Lansford et al., 2005; Michaelson, 2004). Some
definitions focus on the behaviours or actions towards the child while others consider
maltreatment takes place only if there is harm or threat of harm to the child (Dorning,
2002; Straus, Hamby, Finkelhor, Moore, & Runyan, 1998). Given this culturally
variability in the concept of child maltreatment, what definition used to research the
occurrence of different types of child maltreatment cross-culturally?

Within a broad definition of child maltreatment from WHO, a large body of literature
and research on different parts of the world has generally classified child
maltreatment into four major types: physical abuse, sexual abuse,
emotional/psychological abuse, and neglect (Browne, 2002; Clemmons, DiLillo,
Martinez, DeGue, & Jeffcott, 2003; Corby, 2000; D'Antonio et al., 1993; Dong,
Anda, Dube, Giles, & Felitti, 2003; Futterman Collier, McClure, Collier, Otto, &
Polloi, 1999; Goddard, 1996; Meadow & Bamford, 1997; Miller-Perrin & Perrin,
1999; Schwartz-Kenney, McCauley, & Epstein, 2001; Stephenson et al., 2006;
Wolfe, 1999; Zoroglu et al., 2003). In a group meeting of world experts organised by
the WHO and the Global Forum for Health Research, an extensive review and
discussion of different countries’ definitions of child maltreatment provided widely
accepted definitions of sub-categories of child maltreatment as given below (WHO,
1999).

• Physical abuse of a child is that which results in actual or potential physical harm
from an interaction or lack of an interaction.
• Sexual abuse is the involvement of a child in sexual activity that he or she does
not fully comprehend, that violates the laws or social taboos of society. Child
sexual abuse is evidenced by activity between a child and an adult or another
child who by age or development is in a relationship of responsibility, trust or
power, the activity being intended to gratify or satisfy the needs of the other
person.
• Emotional/Psychological abuse may include the failure to provide a
developmentally appropriate and supportive environment, and include acts that

8
 have an adverse effect on the mental health and social development of a child.
Such acts include restriction of movement, denigrating, and threatening, scaring,
discriminating, ridiculing or other forms of hostile or rejecting treatment.
• Neglect is the failure to provide for the development of a child in all aspects such
as: health, education, emotional development, nutrition, safe living conditions etc
in the context of resources reasonably available to the family or caretakers and
causes harm or potential harm for a child.

The above definitions are sound in that they have provided a general framework for
investigation of child maltreatment internationally. The conduct of research on such
sensitive and complex subjects presents practical problems regarding clearly
identifying operational criteria for each type of child maltreatment. No single
definition is likely to be suitable for every purpose; rather it must reflect study
objectives and hypotheses. However, we can conceptualize different types of child
maltreatment experiences as a continuum of behaviours toward the child. Through
comprehensive review of the literature (see Appendix 1) a list of behaviours
commonly placed under each sub-category of child maltreatment has emerged as
follows:

• Physical maltreatment: frequently includes shaking, slapping, punching,

beating, kicking, tying, and burning.
• Sexual abuse: includes non-contact events such as talking in sexual way,
exposing private parts, forcing to watch sexual things, and contact events such
as touching or fondling, attempting to have any type of sexual intercourse and
penetration.
• Emotional/psychological maltreatment: The habitual verbal harassment of a
child by disparagement, criticism, threat and ridicule. Emotional or
psychological abuse includes behaviours that threaten or intimidate a child. It
includes threats, name calling, belittling and shaming.
• Neglect: Failure of caretakers to provide for a child’s fundamental needs
except in the context of unavoidable effects of living in poverty. Although
neglect can include children’s necessary emotional needs, neglect typically
concerns adequate food, housing, clothing, and medical care.

9
In sum, efforts have been made to provide definition and classification of child
maltreatment which can provide a conceptual framework for practitioners and
researchers in the field of child protection. Even though there have been ongoing
debates about cultural variation in different aspects of child maltreatment perception,
a continuum of adverse experiences which are commonly used by researchers to
examine the occurrence and effects of deferent types of child maltreatment has
emerged as generally accepted. Fergusson and Mullen (1999) provided very clear
discussion of these issues and strongly recommend that in order to describe the
extent and the severity of child maltreatment experiences in a systematic and reliable
manner, a list of behaviourally-specific questions should be used.

2.2 International prevalence of child maltreatment

There is wide variation in the estimated prevalence of child maltreatment. The

variation can be attributed to differences in the definition of maltreatment, study
populations, framing of questions about maltreatment, procedures used for collecting
data, the types of maltreatment and the response rate. It is also important to
emphasise that methodological factor only contribute some of the variance. Observed
differences in incidence between cultures, or over different times, may be genuine.
The research into child maltreatment prevalence published so far primarily assesses
sexual abuse and secondly physical maltreatment, and only a small body of extant
studies have assessed emotional maltreatment and neglect. While there are several
published studies reviewing epidemiological data on the prevalence of child sexual
abuse and methodological factors influencing the prevalence estimation (Dunne,
2002; Fergusson & Mullen, 1999; Gorey & Leslie, 1997), we are not aware of any
similar paper reviewing child physical and emotional maltreatment and neglect
prevalence. The reviews reported that the high rates of child sexual abuse are found
among clinical samples, which include participants such as attendees at psychiatric
and child guidance clinics, people coming from criminal justice systems, and
children coming to the attention of welfare agencies (Fergusson & Mullen, 1999).
Reviewing 13 child sexual abuse prevalence studies among female general
population samples and student samples, Dunne (2002) found the average prevalence

10
rates to be remarkably similar in these two types of sample (27.7% vs. 29.8%
respectively). He suggested that deviation from random population sampling per se
might not necessarily be the cause of the significant degree of prevalence variation
among studies. In an integrated review of 16 cross-sectional surveys among non-
clinical populations about child sexual abuse from North America, Gorey and Leslie
(1997) found definition of abuse and response rate had a profound effect (50% of the
prevalence variance) on these estimates. The higher the response rate and the
narrower the abuse definition the lower prevalence estimated. However, neither
sampling method, type of sample nor data collection method explained significant
proportions of the prevalence variation.

As mentioned earlier, the studies among clinical populations suggest higher

prevalence rates than maltreatment prevalence estimations among the general
population and student samples. As a result, it would be unreasonable to conclude
that these estimates from clinical samples fairly represent the problem in the general
population. For the purpose of this project therefore, the review will focus on studies
conducted among non-clinical samples, especially among young adults, university
and college students and school-based samples of adolescents.

Prevalence studies with community-based samples mainly rely on retrospective

reports by adults about their childhood experiences. The adult groups studied most
frequently include samples from the general population, college or university
students. There has been much less research on child maltreatment among
adolescents from school-based samples.

Child physical abuse/maltreatment (CPA)

Studies with young adults and older adults in the United States and other developed
countries reveal self-reported childhood physical abuse prevalence rates from 10% to
34% in males and 6% to 40% in females (Dube, Anda, Felitti, Edwards, & Croft,
2002; MacMillan et al., 1997; May-Chahal & Cawson, 2005; Meston et al., 1999;
Springer, Sheridan, Kuo, & Carnes, 2003). Studies in some Chinese societies and

11
other developing countries tend to yield higher rates of CPA. Apart from the
differences due to inconsistencies in study definitions and methodology, the
differences in prevalence of CPA between Western and Asian countries may be
mainly rooted in cultural attitudes towards physical punishment in child rearing.

Hahm and Guterman (2001) reviewed literature on CPA in South Korea and found
relatively high rates documented in recent studies. The authors listed 7 main studies
on CPA conducted during 1994-1998 with school children and/or parents as sample
populations and using Conflict Tactics Scale or modified versions of Conflict Tactics
Scale as study instruments. The results varied from 23.2% to 81.5% reporting
moderate violence and from 8.2% to 76.8% reporting severe forms of violence
including kicking, beating, throwing or threatening with a knife or a gun. In Hong
Kong, it has been shown in a recent survey among randomly selected parents of
children under the age of 16 that 46.1% of children were subjected to severe violence
and 52.6% subjected to minor violence during the preceding year (Tang, 1998).

A comparative study of school children’s experience of violence in China and Korea

found that family violence during the preceding year was experienced by 70.6%
Chinese children (42.2% minor, 22.6% serious and 5.8% no classification) and
68.9% Korean children (9.4% minor, 51.3% serious and 8.2% no classification)
(Kim et al., 2000). Another study in Hong Kong limiting the reported time to 3
months and using different violence classifications among a random sample of
secondary school students found different figures. According to this study,
prevalence rates of being beaten to injuries by family members in the past 3 months
was 1.1%, being beaten by parents for no apparent reason was 2.0%, corporal
punishment was 4.9%, and any of the above three was just 6.6% (Lau, Liu, Cheung,
Yu, & Wong, 1999).

Lau and colleagues (2005) used secondary data from a large-scale cross-sectional
survey among 95,788 secondary school students in Hong Kong to determine the
prevalence of physical maltreatment. Physical maltreatment was measured by two
indicators. First, indicators of students who had experienced corporal punishment by

12
their family members in the last 6 months were measured. Second, whether or not
respondents had been injured during a beating without provocation by parents in the
last 6 months were measured. Study results show that similar proportions (4.1%) of
males and females reported corporal punishment during the preceding 6 months.
Nearly three per cent (2.9%) of the sample reported being injured by family members
from a beating occurring without provocation, and this prevalence was slightly
higher in males (3.1%) than females (2.7%). The estimated prevalence of CPA in this
study corroborates those results revealed by the previously mentioned study by Lau
et al. in 1999.

A cross-cultural comparison of four post-communist bloc countries (Latvia,

Lithuania, Macedonia, and Moldova) with more than one thousand students aged 11-
14 years old was conducted between 1998 and 2000 (Sebre et al., 2004). In this
study, CPA was measured using the 10 physical abuse items of the Conflict Tactic
Scale measured during the past year. Respondents were identified as being physical
abused if they marked “sometimes”, “often” or “always” for any items or at least
“rarely” for the more severe items. Significant differences in the incidence of
physical abuse were noted across countries (Latvia: 17.4%; Lithuania: 26.0%;
Macedonia: 12.1%; and Moldova: 29.7%). The authors accounted for the variation in
CPA prevalence among countries in three ways. First, there are real differences in
overall parental behaviour. Second, CPA may be conceptualized differently by
students in these countries. Children may consider parent behaviours, viewed as
abusive by experts, as “normal” therefore not report these behaviours. Third, children
may differ in willingness to report their parent’s behaviours due to social-cultural
traditions and prohibition.

Recently, two studies on child maltreatment in Middle Eastern societies reported

remarkably different figures on prevalence of CPA. About ninety per cent of female
students aged 14-18 years old in a Bedouin-Arab in Southern Israel community had
experienced some act of CPA (Elbedour, Abu-Bader, Onwuegbuzie, Abu-Rabia, &
El-Aassam, 2006). In contrast, Stephenson and colleagues (2006) reported that the
prevalence of CPA among school adolescents (11-18 year olds) in Kurdistan

13
province, Iran was 38.5% at home and 43.3% at school (with male: 45% at home and
55.7 at school; female: 28.0% at home and 22.6% at school). Differences in research
definitions of CPA was one of the main reasons explaining the difference of reported
prevalence of these two studies. The latter study used a much narrower definition of
CPA with only two questions. The first question was a general screening item
regarding self-perception of physical abuse experience of the respondent asking
whether the child had ever been physically maltreated at home or school. The second
question asked about the degree of physical maltreatment including bleeding,
scratching, or bruising; broken bones; burning; tying; the need for medical care, if
children responding “yes” to the first question. The children who endorsed any of
these experiences were classified as CPA.

Very few researchers have attempted to study the prevalence of different forms of
child maltreatment across cultures. So far, cross-culturally comparable data on CPA
come from the World Studies of Abuse in the Family Environment (WorldSAFE)
project (Hunter & Bangdiwala, 2004). This was an international multi-site study,
conducted in Chile, Egypt, India and the Philippines. In these countries, a core
instrument has been used to survey population-based samples of mothers, aged 15-49
years about various discipline practices, including harsh punishment that might be
considered abusive. Table 2.1 presents the study results from four countries on
prevalence of self-reported parental abusive discipline. The findings are compared to
those from a national survey conducted in the United States using the same
instrument.

Clearly, harsh punishment is quite common in these countries. Parents in Egypt,

India and the Philippines more frequently reported harsh punishment of their children
than their counterparts in Chile and the United States. Recently, Lansford et al.
(2005) found significant difference in mother reported frequency of using physical
discipline in a cross-cultural study in 6 countries. The rank order from high to low
frequency of mother reporting using physical discipline was Kenya, India, Italy,
Philippines, China and Thailand. Appendix 1 documents the findings of some

14
childhood physical abuse prevalence studies worldwide with population-based
participants at adolescent and early adult ages.

Table 2.1: Rates of various ways of physical punishment in the previous 6

months reported by mothers, WorldSAFE study

Prevalence (%)
Type of punishment
Chile Egypt India Philippines USA
Slapped the child’s face 13 41 58 21 4
or head
Hit the child with object 4 26 36 21 4
Kicked the child 0 2 10 6 0
Burned the child 0 2 1 0 0
Bit the child 0 25 n.a 3 0

Adapted from Runyan, Wattam, Ikeda, Hassan, & Ramiro (2002)

Note: n.a: not available

Child sexual abuse/maltreatment (CSA)

Estimates of prevalence of childhood sexual abuse vary widely between studies

depending upon the operationalized definitions, study samples, the ways in which
data are collected, the age cut-off for childhood, and the age difference between
victims and perpetrators. Many studies among non-clinical samples of adults in the
United States (US) estimate self-reported childhood sexual abuse rates of 2.2 % to
29% in men (Ambuel, Butler, Hamberger, Lawrence, & Guse, 2003; Dong et al.,
2003; Scher et al., 2004) and 7% to 43% in women (Ambuel et al., 2003; Dong et al.,
2003; Scher et al., 2004; Walker et al., 1999; Wise, Zierler, Krieger, & Harlow,
2001).

Finkelhor (1994) reviewed more than 20 epidemiological surveys with large non-
clinical populations from the US, Canada and 19 other countries, including 10
national probability samples. The studies showed sexual abuse histories in at least
7% of the females and 3% of the males, ranging up to 36% of women in Austria and

15
29% of men in South Africa. Another review of reports from Europe indicated that 6-
36% girls and 1-15% boys under the age of 16 experienced some type of sexual
abuse (Lampe, 2002).

Various studies conducted in the US among school-based adolescents reveal CSA

rates ranging from 3 % to 8% of boys and 10% to 30% of girls (Bensley, Spieker,
Van Eenwyk, & Schoder, 1999; Grossman, Milligan, & Deyo, 1991; Harrison,
Fulkerson, & Beebe, 1997; Lodico, Gruber, & Diclemente, 1996; Riggs, Alario, &
McHorney, 1990). In contrast to North America, less research on the prevalence of
CSA has been conducted in Europe and other developed countries with school
samples. Two studies carried out in Switzerland and Sweden among school children
aged 17 or younger showed relatively different figures of 33.8% for girls and 10.9%
for boys in Switzerland whereas 11.2% for girls and 3.1% for boys in Sweden having
experienced at least one sexual abuse event. However, the latter study excluded peer
abuse in its CSA definition (Edgardh & Ormstad, 2000; Halperin et al., 1996). These
figures are higher than findings from another school-based sample conducted by
Martin et al. (2004) in Australia reporting 2.0% males and 5,4% females experienced
CSA. Importantly, the differences might be explained by variation in the question
used to assess sexual abuse. The two former studies used a list of sexual abuse events
while the latter used only one question “have you ever been sexually abused?”.

Studies conducted among adolescent samples in some Asian countries shows that
CSA’s prevalence seems to be at the lower point of the range in comparison to other
parts of the world. Diverse findings on CSA prevalence rates have been revealed in
several empirical studies with high school or college students carried out in China,
Hong Kong, and Malaysia. These studies used similar broad definitions of CSA
including non-contact and contact events however there were differences in the age
cut-off for events in childhood. The participants were asked to report their childhood
sexual experiences occurring before age 16 in China, 17 in Hong Kong, and 18 in
Malaysia studies. CSA rates ranged from 2.1 – 4% for boys and from 7 – 25% for
girls (Chen, Dunne, & Wang, 2002; Chen, Dunne, & Han, 2004; Singh, Yiing, &
Nurani, 1996; Tang, 2002). Of those studies, Chen et al. (2002) found the highest

16
rate of around 25% of high school Chinese female students subjected to any of ten
forms of CSA. However, non-penetrative forms accounted for the majority of the
cases.

A study among more than two hundred female school students in Israel revealed that
more than half of respondents (53.3%) reported experiencing at least one sexual
abuse event (Elbedour et al., 2006). Using a different definition of CSA (touching
and/or intercourse), Alikasifoglu and colleagues (2006) found that among nearly
2,000 Turkish female students (mean age: 16.3; SD: 1.05) 11.3% reported touching
sexual abuse, 4.9% reported forced intercourse, and 3.0% experienced both types of
CSA. Again, it is clear that due to the large differences in definition, data gathering
techniques, the wording of individual questions and cultural differences between
respondents in the ways they interpret the questions, it is impossible to establish
more precise conclusions about the prevalence of CSA. A more exhaustive summary
of studies that attempt to estimate childhood sexual abuse prevalence among
community-based adolescent samples from various countries is given in Appendix 1.

Child emotional abuse/maltreatment (CEA) and child neglect

(CN)

Professionals working in the area of child abuse have found it extremely difficult to
operationally define CEA and CN. There is considerable uncertainty regarding legal
definitions. In comparison to CPA and CSA, child emotional abuse and neglect is
under-recognized. Behl et al. (2003) reviewed 2,090 articles pertained to child
maltreatment published from 1977-1998 in six specialty journals and found that the
major proportion of articles addressed specific types of child maltreatment were
32.7% for CSA, 20.2% for CPA, 9% for CN and only 4.2% for CEA. Most estimates
of CEA and CN prevalence have been obtained from clinical samples or case reports
(Jellen, McCarroll, & Thayer, 2001). There has been a dearth of figures based on the
general population in most countries.

17
So far, most epidemiological studies documenting rates of CEA and CN with
samples from the general population have been done in North America and some
other developed countries such as the United Kingdom. Again, rates vary
considerably depending on definitions, methodologies and samples recruited. Walker
et al. (1999) reported prevalence among women for CEA of 24%, prevalence of
physical neglect and emotional neglect were 12% and 21%, respectively. A study by
Dong et al. (2003) showed lower prevalence rates among a sample of adult health
plan members. Child emotional abuse was reported by overall 10.6% of the study
population with 13.1% of women and 7.6% of men reporting CEA. May-Chahal and
Cawson (2005) estimated CEA and CN prevalence using mid point score of seven
emotional dimensions defined on a continuum of behaviours and three level
definition of CN severity measured different neglect events. This study found that
among nearly three thousand young adults (18-24 year olds) randomly selected
throughout the United Kingdom, 6.0% reported CEA, 6.0% experienced serious
absence of care, 9.0% experienced intermediate level of neglect, and 2.0% reported
neglect at the level of cause of concern.

Studying a sample of high school students in Mpumalanga, a poor province in South

Africa, Madu (2001) found the considerably higher rate of CEA (35.3%) compared
to those reported in studies conducted in the developed countries mentioned above.
However, lower rate of CEA (26.9%) among South African university students was
also reported by the same author (Madu, 2003). The inconsistency of these two
prevalence rates in South Africa may stem from differences in socio-economic
backgrounds of the two samples.

Child emotional abuse prevalence also varied significantly among the four former
communist bloc countries indicating rates of 10% to more than 30% in a school-
based study (Latvia: 28.8%; Lithuania: 33.3%; Macedonia: 12.5%; and Moldova:
32.1%) (Sebre et al., 2004). Child emotional abuse and neglect prevalence at home
and school was examined in a school-based study in Iran (Stephenson et al., 2006).
Strikingly high rates of students reported experiencing at least one emotional abuse

18
event at home (female: 64.7%, male: 74.5%) and one neglect event at home (female:
71.1%, male: 86.5%).

International estimates of prevalence of CEA have emerged from the WorldSAFE

project (Runyan et al., 2002). Table 2.2 shows the findings of emotional punishment
from surveys across five countries in this project.

Table 2.2: Rates of emotional punishment in the previous 6 months as reported

by mothers, WorldSAFE study

Prevalence (%)
Emotional punishment
Chile Egypt India Philippines USA
Yelled or screamed at the child 84 72 70 82 85
Call the child names 15 44 29 24 17
Cursed at the child 3 51 n.a 0 24
Refused to speak to the child 17 48 31 15 n.a
Threatened to kick the child out
of the household 5 0 n.a 26 6
Threatened abandonment 8 10 20 48 n.a
Lock the child out of the house 2 1 n.a 12 n.a

Adapted from Runyan et al., (2002)

Note: n.a: not available

There is evidence to suggest that most CEA acts are more common in Egypt than
other study countries. The practices of threatening children with abandonment,
kicking the child out of the household, and being locked out of the house, however
vary greatly among the countries. Cultural factors seem to strongly influence how
parents choose emotional punishment strategies toward their children.

Unfortunately, research on CEA and CN with general population samples seems to

be neglected in most developing countries. It is therefore difficult to delineate a clear
picture on these problems. However, it is believed that the problems exist and are of
growing concern to policy makers, health workers, researchers, and the general
public (Hildyard & Wolfe, 2002; Jinadu, 1986). (Appendix 1 summarised several
recent studies on CEA and CN).

19
Multiple-type maltreatment (MTM)

The experience of child maltreatment is complex at the individual level, as a child

may suffer more than one form of maltreatment in a given abuse episode, or may
experience different forms of abuse at different times. Multiple-type maltreatment
refers to the co-occurrence of one or more forms of child maltreatment. It is
important to distinguish between individuals who have experienced only one
maltreatment form and those who have experienced two, three, or more types of
child maltreatment because of cumulative effects of MTM (Higgins & McCabe,
2001b). However, there are few research reports the prevalence rates of co-
occurrence of child maltreatment and almost all are conducted in developed
countries.

A growing body of empirical evidence shows that co-existence of more than one
form of maltreatment is not uncommon. Higgins and McCabe (2000a) examined the
co-occurrence of CSA, CPA, CEA, CN and childhood exposure to family violence
reported by a community sample of 175 Australian men and women. Overall, 43.4%
of participants reported experiencing more than one form of child maltreatment,
while 15.4%, 11.4%, 9.7%, and 6.9% of the total sample were classified as
experiencing two, three, four and five forms of maltreatment respectively. Moeller et
al. (1993) found a similar pattern among a large community sample in the US with
45% of the participants reporting two or three types of child maltreatment (i.e.,
physical, sexual, or emotional abuse). In a very large study among 8629 adult Health
Maintenance Organisation members in the United States, Dube et al. (2001)
examined 10 categories of adverse childhood experiences (ACEs) including
emotional, physical, sexual abuse, emotional and physical neglect, battered mother,
household substance abuse, mental illness in household, parental separation or
divorce, and incarcerated household member. Nearly forty per cent (38.1%) of all
participants reported having experienced more than one type of ACEs and over; 17%
of women and 11% of men reported four or more of these ACEs. In a survey of a
representative population-based sample in the metropolitan Memphis, US, Scher et
al. (2004) found a lower proportion of adults (13.5%) who met criteria for

20
experiencing more than one form of child maltreatment classified as emotional,
physical, sexual abuse, emotional and physical neglect.

To date the only school-based study reporting the prevalence of MTM including 4
types (CPA, CEA, CSA, and CN) of child maltreatment was conducted in Turkey
(Zoroglu et al., 2003). This study involved 862 students (mean age: 15.9; SD: 1.8) of
four high schools in Istanbul. Nearly fourteen per cent (13.8%) of respondents
reported having experienced two or more types of child maltreatment, of which 8.7%
reported two types, 3.8% three types and 1.3% all four forms of trauma.

Although estimates vary, it is nevertheless clear that a significant proportion of

individuals experience multiple forms of child maltreatment. Given the accumulating
evidence of co-occurrence of maltreatment types, it appears important for researchers
to explore and document co-existence among different forms of maltreatment and to
examine the possible cumulative effects of MTM on health and well-being
(Clemmons et al., 2003; Kinard, 1994; Simpson & Miller, 2002).

Overall, the main conclusions from reviewing research worldwide on prevalence of

child maltreatment are:

First, child maltreatment has been found in all countries where it has been measured
(Fergusson & Mullen, 1999). However, the prevalence of child maltreatment varies
widely from study to study depending largely on research definitions, sample
characteristics, response rate (Gorey & Leslie, 1997) and cultural characteristics
(Meston et al., 1999). Definitional and methodological inconsistencies, differences in
study population and timing of investigation across epidemiological studies on child
abuse have made it extremely difficult to draw firm conclusions regarding the rates
of different forms of maltreatment as well as the extent to which these forms have
co-existed in the general population (Simpson & Miller, 2002).

21
Second, most child maltreatment prevalence is reported from the United States and
other developed countries. There is a dearth of child maltreatment research in
developing countries in general and in Asian developing countries in particular.

Third, despite the need for information on all types of child maltreatment and
multiple types of maltreatment, most research worldwide mainly focuses on CSA
and CPA. As a result, relatively little is known about CEA, CN and MTM.

2.3 Risk factors for child maltreatment

Why does child maltreatment occur? This is a complex question. A variety of

theories have been developed to answer this question and research has generated
various frameworks for observing, understanding, explaining, and intervening in
child maltreatment. Discussed below are the main theories as to why child
maltreatment occurs. Each theory emphasizes particular aspects, and none provides,
on its own, comprehensive account.

Attachment theory (Rutter, 1982) emphasises that nature and quality of attachment
between parents or other caretakers has considerable impact on ability to protect the
child from aggression or neglect. A failure of attachment may therefore not only be
consequence of abuse, it may contribute to it. Poor infant-caretaker attachment must
be considered as a risk factor for child maltreatment. The theory focuses on the
personal dynamics of attachment, rather than stress factors such as unemployment,
marital discord or financial difficulties. This theory focuses on personal
relationships, rather than social circumstances.

Psychopathology theories (Miller-Perrin & Perrin, 1999) propose that various forms
of child maltreatment are committed by individuals who are seriously disturbed by
some types of mental illness or personality disorders. However, many experts argue
that psychopathology is observed in only a small percentage of child abuse
perpetrators (Groff & Hubble, 1984; Williams & Finkelhor, 1990). Yet, from the
psychological perspective (Wilson-Oyelaran, 1989) it is presumed that the

22
psychologically malfunctioning parents or caretakers may be potential child
maltreatment offenders. Those people can be identified by a series of contributory
characteristics such as low self-esteem, a history of childhood abuse and intolerance
for frustration and criticism.

Social learning theory (Elliott, Thomas, Chan, & Chow, 2000; Miller-Perrin &
Perrin, 1999), a widely accepted explanation of how socialization plays a role in
child maltreatment, emphasizes that child abuse is a problem not derived from
personality traits or lack of attachment, but through inappropriate reinforcement or
modelling. Modelling is a process in which a person learns social and cognitive
behaviours by simply observing and imitating others. Social learning theory rests on
several observations. First, maltreatment tends to perpetuate itself from one
generation to the next (Frias-Armenta, 2002; Morton & Browne, 1998; Newcomb &
Locke, 2001); second, a large number of studies have successfully linked exposure to
violence in childhood, either directly or through observation, to violence in
adulthood (Bensley, Van Eenwyk, & Wynkoop Simmons, 2003; Williams &
Finkelhor, 1990).

Sociological models (Corby, 2000), also known as socio-cultural or environmental

models (Browne, 2002), focus on the social environment and other cultural patterns
which would interfere with parents’ or caregivers’ ability to cope with the day-to-day
environment. Within these models, child maltreatment is examined in terms of the
social context in which it occurs. Factors associated with abuse from this perspective
include: cultural attitudes toward violence; social stress arising from inadequate
housing, unemployment, family size; social isolation, and other financial stresses and
pressures.

Maltreatment is multifaceted and children in families are embedded in complex and

interrelated social systems that affect conditions within families (Macdonald, 2001).
Each of these theories has explanatory power with a restricted range of variables, but
they are not able to successfully integrate divergent viewpoints and provide a holistic

23
framework for arranging a large body of knowledge about the causes and
perpetuation of the problem.

A broader, more comprehensive model can be found in the ecological mode. This is
the most widely adopted model, providing a multidimensional perspective and helps
to understand the multifaceted nature of child maltreatment (Belsky, 1993; Corby,
2000; Hecht & Hansen, 2001; Korbin, 2003; Krishnan & Morrison, 1995; , 2002;
Leventhal, 2003; Wilson-Oyelaran, 1989). The ecological model of child
maltreatment has origins in models for human development; in which children are
seen to live within a series of interconnected systems conceived as ever widening
concentric circles or inter-nested spheres. This model has been used to conceptualise
the problem as a multifaceted phenomenon based on an interplay between personal,
situational and socio-cultural factors. These factors are nested in four different levels
labelled from the innermost to the outermost as the individual, micro-system:
relationship or family, the exo-system: community, the macro-system: societal
(Ellsberg, Pena, Herrera, Liljestrand, & Winkvist, 2000) (Figure 2.1).

Societal
(Macro-system)
Community
(Exo-system) Relationship
(Micro-system) Individual

Figure 2.1: Ecologically integrative model of child maltreatment

Adapted from: Krug et al. (2002)

A large body of studies has examined the risk factors of CSA and CPA while CEA
and CN have received comparatively little research attention (see Black et al.). While
no specific causes definitively have been identified leading parents or caregivers to

24
abuse or neglect children, epidemiological research conducted over the past four
decades suggests that some factors belonging to different layers of the model are
fairly consistent over a range of contexts. Children within families and environments
in which these factors exist have a higher probability of experiencing maltreatment.
However, it is important to note that a risk is not a certainty. The factors mentioned
below may be only statistically associated and not causally linked.

Individual level

A number of characteristics related to child and adult factors may be associated with
risk of maltreatment: for example, characteristics of the child (such as gender, age,
temperament, disabilities etc); adult attitudes, attributions, and cognitive factors;
prior history of abuse; alcohol and drug abuse; and demographic factors (such as
young marital age, marital status, and family size) (Black, Smith Slep, & Heyman,
2001; Brown, Cohen, Johnson, & Salzinger, 1998; Dietz, 2000; Krishnan &
Morrison, 1995; Madu, 2003; Madu & Peltzer, 2000; Moore, 1992; Paavilainen,
Astedt-Kurki, Paunonen-Ilmonen, & Laippala, 2001; Salter et al., 2003; Schumacher,
Smith Slep, & Heyman, 2001).

Child factors

With any type of child maltreatment, research shows that victims may possess certain
characteristics associated with increased risk for child abuse. However, these factors
should not be taken as evidence that these victims cause the maltreating behaviours
to which they are subject.

Gender: There are significant gender differences in risk of some forms of abuse and
neglect, especially child sexual abuse. The literature on child maltreatment among
adolescent community-based samples (see Appendix 1) shows that there is no clear
pattern of gender differences in CEM and CN. However, boys seem to be at risk of
being physically abused more than girls (Benbenishty et al., 2002; Hibbard,
Ingersoll, & Orr, 1990; Lau, Chan, Lam, Choi, & Lai, 2003; Meston et al., 1999;

25
Youssef, Attia, & Kamel, 1998a, , 1998b; Zoroglu et al., 2003). Conversely, girls are
more likely to be victims of sexual abuse than boys; this essentially reflects the fact
that they account for about 60% - 70% of the child sexual abuse victims (Chen,
Dunne et al., 2004; Edgardh & Ormstad, 2000; King et al., 2004; Pedersen &
Skrondal, 1996; Singh et al., 1996; Tang, 2002). However, recent studies in different
cultures among college and school-based samples have shown unexpected
equivalence in the rate of CSA among boys and girls (Haj-Yahia & Tamish, 2001;
Madu & Peltzer, 2000). Interestingly, a study conducted by Zeira et al. (2002) on
sexual harassment experiences of Arab and Jewish students occurring at a school
setting in Israel found sexual harassment to be much more common among boys than
girls in all measures. These findings suggest different patterns of maltreatment
vulnerability for boys and girls, which have implications for further research.

Age: National Incidence Studies in the United States and population-based studies
have consistently found that gender and age are related to risk of abuse
(HealthCanada, 2001; Jones & McCurdy, 1992; Lau et al., 2005; Windham et al.,
2004). Toddlers, preschool children and young adolescents are the most frequent
victims of physical and emotional maltreatment. Although child physical abuse
affects a sizeable proportion of all age groups, the highest rate of injuries due to
physical abuse is found among older children (12-17 years of age), probably because
of increasing parent-adolescent conflict. Neglect may occur more often in the early
childhood with incidence declining with age (Belsky, 1993). In contrast, sexual
abuse is relatively constant from age 3 onwards, with children’s vulnerability from
early preschool years throughout childhood. The mean age of onset of sexual abuse
appears to be about 11-12 years, and this has been reported by studies in both
Western and Asian cultures (Chen, Dunne, & Han, 2006; Kogan, 2004; Oaksford &
Frude, 2001; Tang, 2002).

Disabilities: Generally, children who have special needs, including children with
disabilities and children with chronic illness or with difficult temperaments, low birth
weight/small for gestational age may be at greater risk of maltreatment (Black,
Heyman, & Smith Slep, 2001a; Brown et al., 1998; , 2002; Macdonald, 2001;

26
Windham et al., 2004). A large population based epidemiological study among
50,278 participants from 0-21 years of age conducted by Sullivan and Knutson
(2000) in the United States showed that overall rate of maltreatment among children
who had an identified disability for which they were receiving special education
services were more than three times more likely to be abused than were children
without an educationally relevant disability. In addition, the study also revealed that
children with a behaviour disorder or language impairment and mentally retarded
children are among much higher risk groups of being abused than children with
visual impairments, learning disabilities or autism.

Adult factors

Research also shows that adult factors potentially contribute to maltreatment. Over
the past decades a number of the characteristics of child maltreatment perpetrators
have been documented.

Demographic factors: Demographic factors are among the most common

variables studied as potential risk factors for different forms of child maltreatment.
All researchers are emphasising that most demographic variables are markers, not
causal, variables. Demographic variables influencing risk of child maltreatment may
include age, gender, ethnicity, religion, education, employment status, socio-
economic status, marital status, and size of family.

Black et al. (2001a) reviewed studies on risks of CPA and found that several
perpetrator demographic variables including young maternal age, low parental
education, mother’s employment status (unemployment or part-time job) and length
of residence of less than 14 years in a community were significantly associated with
minor and/or severe CPA. However, parents’ age was the only variable that had a
medium effect size. Mother’s age was also found to be a significant risk factor of
physical maltreatment in a female school adolescent sample of the Bedouin-Arab
community in Southern Israel. The older the mother, the less likely the girl was to be
subjected to physical abuse (Elbedour et al., 2006).

27
The relationships between perpetrators of CSA and demographic factors have been
explored in a large body of literature and a number of risk factors have emerged.
Finkelhor and Baron (1986) reviewed community studies and found that a child is at
higher risk of sexual abuse when he or she lives without one of the biological parents
or the child reports having a stepfather. A study among high school students in
grades 9 and 10 in three schools in Northern Province South Africa found that three
demographic factors proved to be significant discriminators of childhood sexual
abuse: ethnicity (not Northern Sotho), mother employed at above the level of a
labourer, and having a stepparent present during childhood (Madu & Peltzer, 2000).
Calculating effect sizes for several child sexual abuse studies in the United States,
Black et al. (2001) noted that moderate to strong effect sizes were found for
perpetrators who were less educated, poorer, and from outside the child’s family.

As far as child emotional abuse and neglect are concerned, according to Schumacher,
Smith Slep, and Heyman (2001) the only demographic variable playing a role as a
risk factor for child neglect with moderate or strong effect size was fertility (greater
number of live births, more pregnancies, and more unplanned conceptions). No
socio-demographic risk factors for child emotional abuse were found to have
moderate effect sizes (Black, Smith Slep et al., 2001). However, several studies
conducted in Western countries have found that low-income families, younger
parents and Asian ancestry also significantly increased the potential risk of neglect
(Chaffin, Kelleher, & Hollenberg, 1996; Jones & McCurdy, 1992; Meston et al.,
1999; Sedlak, 1997). Family income and ethnicity are also reported to be
significantly related to child emotional maltreatment (Meston et al., 1999; Sedlak,
1997).

Personality and adjustment factors: No set of characteristics or personality

traits has consistently been associated with maltreatment by parents or caregivers
(Belsky, 1993). Comprehensive reviews indicate that studies of underlying
personality traits have been unable to identify clear patterns associated with child
maltreatment (Wolfe, 1985). In contrast, Friederich and Wheeler (1982) argued that
there is a considerable amount of evidence that personality does play a role as a

28
determinant of child abuse. Various reviewers of the relevant literature draw
different conclusions regarding the role of personality and psychological resources.
This may arise because of the inconsistencies apparent in the available data.
However, recent studies seem to be more consistent in reporting some adjustment
factors in those who are physically abusive or neglectful such as low self-esteem,
more emotionally reactive and avoidance-focused problem-solving, stressful life
events and parenting stress, emotional distress, loneliness, anxiety, depression,
interpersonal problems (Black, Heyman et al., 2001a; Brown et al., 1998;
Schumacher et al., 2001)

History of maltreatment: Childhood abuse history appears to strongly influence

subsequent parenting. Individuals with poor parental experiences or those who did
not have their own needs met in childhood may find it very difficult to meet the
needs of their own children.

Child maltreatment studies have commonly found that some parents or caregivers
maltreated as children are at higher risk of abusing their own children or having
abused children (Finkelhor, Moore, Hamby, & Straus, 1997; Hemenway, Solnick, &
Carter, 1994; Ozturk Ertem, Leventhal, & Dobbs, 2000). One study investigated the
relationship between parent’s history of prior sexual victimization in a nationally
representative sample (Finkelhor et al., 1997). Parents were interviewed about their
sexual victimization experiences in childhood with two items (e.g. “before the age of
18, were you ever forced to have sex by an adult or older child, including who was
member of your family, or outside your family?”). The result shown that parents’
history of child sexual abuse was strongly associated with having a sexually abused
child (odds ratio = 10.2). Black and colleagues (2001a) reviewed child physical
abuse studies, which have the richest risk factor research literature for any form of
child maltreatment, and found support for the concept of intergenerational
transmission of child physical abuse.

Substance abuse: Parental substance abuse is reported to be a contributing factor

in between one- and two-thirds of cases of child maltreatment that reach the US child

29
welfare system (Magura & Laudet, 1996) and among court samples (Murphy et al.,
1991). Research provides ample empirical evidence for the link between parental or
caregiver substance abuse and increased risk for all forms of child maltreatment
(Chaffin et al., 1996; Dube et al., 2001; Famularo, Kinscherff, & Fenton, 1992;
Jaudes, Ekwo, & Van Voorhis, 1995; Kelleher, Chaffin, Hollenberg, & Fischer,
1994; Walsh, MacMillan, & Jamieson, 2003; Windham et al., 2004). For example, a
retrospective study of maltreatment experience in Chicago found children whose
parents misused alcohol and other drugs were almost three times more likely to have
been abused and more than four times more likely to be neglected than children of
parents who did not misuse substances (Jaudes et al., 1995). A recent comprehensive
population survey among more than 8000 participants in Canada (Walsh et al., 2003)
reveals that prevalence of physical and sexual abuse was significantly higher, with
more than two times increased risk among those reporting parental substance abuse
histories. There was a trend toward risk increasing with only parental, only maternal
and both parent substance abuse, respectively. A longitudinal study concerned with
the sequelae of parental substance abuse among Child Protective Service cases
closed after investigation found parental substance abuse greatly increases the
likelihood of poorer family functioning and re-reports for maltreatment to the Child
Protective Service agencies (Wolock & Magura, 1996).

Substance abuse can interfere with a parent’s mental functioning, judgment,

inhibitions, and protective capacity. Parents significantly affected by the use of drugs
and alcohol may neglect the needs of their children, spend money on drugs instead of
household expenses or get involved in criminal activities that jeopardize their
children’s health and safety. Additionally, studies suggest that substance abuse can
influence parental discipline choices and child-rearing styles (Magura & Laudet,
1996).

Knowledge and attitude toward child development: Negative attitudes and

attributions about a child’s behaviour and inaccurate knowledge about child
development may play a contributing role in child abuse (Dukewich, Borkowski, &
Whitman, 1996; Zuravin & Taylor, 1987). For example, Dukewich et al. (1996)

30
found maternal knowledge and expectancies about child development are more
predictive of abuse potential than is maternal psychological adjustment among
adolescent mothers. Other studies have also found that mothers who physically abuse
their children have both more negative and higher than normal expectations of their
children, as well as less understanding of appropriate developmental norms
(Twentyman & Plotkin, 1982; Williamson, Borduin, & Howe, 1991).

Relationship level (micro-system)

Relationship level factors associated with increase risk of child maltreatment include:
family environment; parenting styles; interactions among family members such as
anger; conflict; and social isolation (Bagley & Mallick, 2000; Black, Smith Slep et
al., 2001; Coohey & Braun, 1997; Gracia & Musitu, 2003; Jones & McCurdy, 1992;
Kasim, Shafie, & Cheah, 1994; Kellogg, 2002; Moore, 1992; Schumacher et al.,
2001). While these factors alone may not directly cause maltreatment, they
frequently contribute to negative patterns of family functioning.

Domestic violence has been reported as a risk factor at the micro-system level.
Strikingly, Osofsky (2003) noted that in 1990 the rates of physically abused and
neglected children in homes where domestic violence occurs weree 15 times higher
than the national average in the United States. According to published studies, in 30
to 60 percent of families where spousal abuse takes place, child maltreatment also
occurs (Appel & Holden, 1998; Edleson, 1999). Children in violent homes may
witness parental violence, may be victims of physical abuse themselves, and may be
neglected by parents who are focused on their partners or unresponsive to their
children due to their own fears.

A cohort study among married couples with children having at least one spouse on
active duty in the US Army during 1989-1995 reported that families with identified
spouse abuse were 5 times as likely as families without identified spouse abuse to
have a subsequent substantiated case of child abuse. After adjusting for rank of
soldier and parental age, families with spouse abuse were still twice as likely to have

31
a report of child abuse compared to other military families (Rumm, Cummings,
Krauss, Bell, & Rivara, 2000).

McGuigan and Pratt (2001) conducted a longitudinal study investigating the effects
of domestic violence during the first 6 months of child rearing on 3 forms of child
maltreatment (CPA, CEA and CN) up to the child’s first 5 years. The logistic
regression models established a significant relationship between domestic violence
and physical abuse, emotional abuse and neglect. Furthermore, beyond the effect of
known risk factors, domestic violence during the first 6 months of child rearing more
than tripled the likelihood of physical abuse and more than doubled the likelihood of
emotional abuse and neglect occurring during the child’s first 5 years.

This pattern was also found with child physical abuse of spouse-abusing parents in a
study of a large and nationally representative sample of American couples conducted
by Ross (1996). The study shows that marital violence is a statistically significant
predictor of child physical abuse after controlling for five demographic variables
(age of the respondent; age of selected child; socio-economic status of the family;
race of the respondent; and gender of the child), and corporal punishment of the
respondent as a teenager. The possibility of physical child abuse increases in
accordance with the amount of the violence against a spouse.

Very little research in developing countries has examined the risk factors for child
maltreatment at the micro-system level. Recently, a study conducted in Iran among
school adolescents has shown that quality of parental relationship was one of several
factors significantly associated with all types of child maltreatment examined (CPA,
CEA and CN) after controlling for other factors, including child’s age, region,
gender, birth order, school performance, mother’s education and employment, and
other household members’ use of addictive substances (Stephenson et al., 2006).
Odds of reporting physical maltreatment, emotional maltreatment, and neglect
increased with the severity of conflicts between parents. Relative to children whose
parents had no conflicts, children whose parents had any form of conflict reported
greater odds of physical maltreatment (less severe conflict OR = 3.46 and severe

32
conflict OR = 5.67), emotional maltreatment (less severe conflict OR = 3.53 and
severe conflict OR = 7.14), and neglect (less severe conflict OR = 2.07 and severe
conflict OR = 3.35) at home.

Community level (exo-system)

The third level includes the community contexts in which social relationships are
embedded, such as workplaces, neighbourhoods, school and peer groups. It is
important to determine the extent to which these factors are correlated with being a
victim or a perpetrator of abuse. Although interest in community/neighbourhood
influences on child maltreatment has increased recently, research seeking to uncover
the relationship between this level and child maltreatment has lagged behind research
into individual and family correlates. There is consensus that growing up in
neighbourhoods with high levels of unemployment, concentrated poverty, excessive
numbers of children per adult resident, and high population turnover are associated
with higher risk than that for children from wealthier and more stable communities.
This holds true for severe CN, CEA and CPA as well as CSA victimization (Coulton,
Korbin, & Su, 1999; Coulton, Korbin, Su, & Chow, 1995; Hadi, 2000; Hunter, Jain,
Sadowski, & Sanhueza, 2000; Korbin, Coulton, Lindstrom-Ufuti, & Spilsbury, 2000;
Molnar, Buka, Brennan, Holton, & Earls, 2003; Schumacher et al., 2001).

It is not clear why socio-economic characteristics of neighbourhoods are correlated

with child maltreatment. Attributes of the individual families living in a
neighbourhood and characteristics of the neighbourhood have contributed to the
variation in different forms of child maltreatment. Distinguishing different factors is
complex in child maltreatment research (Korbin, 2003). Most contextual studies do
not investigate multilevel factors. For example, they may focus on neighbourhood
features without incorporating family factors.

A recent study in the US examined whether differences among neighbourhoods on

parent-to-child physical aggression remain significant after family characteristics are
taken into account. This study used a unique study design incorporating data from

33
individuals and families living in 80 diverse neighbourhoods in Chicago (Molnar et
al., 2003). The study found differences in parent-to-child physical aggression
between families are greater than differences between neighbourhoods, based on
intraclass coefficients of .54 versus .02 respectively. No other multilevel study exists
therefore, it is suggested that further research on the multidimensional nature of child
maltreatment is needed using a clear definitions of neighbourhood and community.

Societal/ Structural level (macro-system)

The final level of risk factors includes the larger societal factors affecting the
occurrence of child maltreatment. Factors thought to be influential are dominant
cultural views and attitudes permeating the society at large such as laws, health,
educational systems, social and economic policies, and cultural norms (for instance,
norms that give priority to parental rights over child welfare, norms valuing boys
over girls etc.) (Ferrari, 2002; Johnson, 2002; Kim et al., 2000; Schumacher et al.,
2001). Krug et al. (2002) suggested the factors at this level as follows but to date
they have not been investigated as risk factors for child maltreatment in most
countries.

• The role of cultural values and economic forces;

• Inequalities related to gender and income;
• Cultural norms regarding gender role, parent-children relationship;
• Child and family policies;
• The nature and extent of health care system for infants and children;
• The strength of the social welfare system;
• The nature and extent of social protection and the responsiveness of the criminal
justice system;
• Larger social conflicts and war.

In summary, the value of ecological theory for child maltreatment lies in its capacity
to generate perspectives accommodating the influence of environmental context.
Before applying this model, researchers tended to confine their analysis of

34
environmental influences in close proximity to the child only. The ecological
model’s strength lies also in its ability to build a bridge between the fields of
psychology and sociology accounting for multilevel risk factors from individual to
societal levels.

An ecological model, like any other theory, is far from perfect. An ecological theory
is unable to depict how and why certain influences become powerful and come to
dominate the ecological system in certain circumstances. Additionally, the
interactions among these levels and factors are poorly understood and further in-
depth longitudinal research is required.

2.4 Consequences of child maltreatment

Child maltreatment is a heinous act. These acts are not only hurtful at the time they
occur; they are also detrimental to the child’s growth and development and may
affect their entire life and the lives of following generations (Walker et al., 1999).
Multiple, varied and substantial are terms that can be used to describe the effects of
childhood maltreatment on its victims. Multiple means that a wide array of
symptoms can emerge from maltreatment. Varied, since there is no clear or
consistent set of victim responses associated with the severity or type of
maltreatment. Substantial is used because childhood maltreatment may alter the
course of the victims’ lives in negative ways.

Among the most common types of research conducted to assess the effects of child
maltreatment are retrospective studies with or without comparison groups, follow-up
testing of maltreated and non-maltreated groups among various clinical samples, or
population-based samples including university students, school students and adults in
the general population. Variation exists across studies in the definition of child
maltreatment as well as the length of time elapsed from the time of the maltreatment
occurred.

35
Child fatality and burden of ill health

Children die from maltreatment in all countries in the world. However, accurate
statistics are difficult to find. In the United States, New Zealand and Australia
(among others), there are multi-disciplinary death-review teams that analyse the
causes of child deaths. The reliability of these data varies depending upon the
definitions, diligence, and data organisation. Child abuse was the second leading
cause of death in children in the US (Johnson, 2002). The national estimate of the
child abuse and neglect fatality rate in the US in 2004 was 2.03 per 100,000 children
and the youngest children suffered the highest rates of fatalities (Child maltreatment
2004). In New South Wales, Australia, 2.9% of deaths in children aged 1-17 years
were found to be due to homicide or non-accidental injury in 1988-1999. Between
1991 and 2003, 112 children and young people died from homicide, fatal assault
and/or neglect in Queensland, Australia. The fatalities rates have fluctuated from
year to year of approximately 0.3 to 1.7 per 100,000 (Annual Report Deaths of
children and young people Queensland 2004-05). However, one study conducted by
US Centre for Injury Control found that 85% of the deaths from child abuse in the
United States were recorded as due to other causes (Johnson, 2000). A study in New
Zealand reviewing reported death cases of children 16 years of age or under during
the period 1978-1987 revealed the same pattern: fatal child abuse is substantially
under-diagnosed in official sources of mortality data (Kotch, Chalmers, Fanslow,
Marshall, & Langley, 1993). Therefore such figures of child maltreatment fatalities
need to be treated with caution.

Survivors of child maltreatment often suffer from health problems both short term
and long-term. Some consequences can be easily observed in the form of physical
trauma such as bruises and welts, burns and scalds, fractures, and other physical
injuries. Keshavarz and colleagues (2002) found in their study that bruises were the
most frequently observed injury in 25% of cases, reported for child abuse from 1996-
1998, hospitalised at a New York metropolitan Paediatric Emergency Department.

36
Recently, a study in the US evaluating cause of injury and patient outcomes in young
children with abdominal injuries reported that among 927 cases of children aged 0-4
years extracted from the National Paediatric Trauma Registry, child abuse accounted
for 15.75%. Additionally, patient outcomes were more severe in abused children.
Child abuse is independently associated with a 6-fold higher rate of in-hospital
mortality compared to falls caused by other childhood activities (Trokel, DiScala,
Terrin, & Sege, 2004).

Furthermore, researchers and professionals working in this field from different parts
of the world have not only documented data on mortality and easily observable
physical injuries but also examined the long-term effects of child maltreatment.
Examples include studies finding that abuse survivors are sick more often and more
likely to seek health care (Arnow, Hart, Hayward, Dea, & Barr Taylor, 2000;
Mammen, 1996). McCauley and colleagues (1997) reported the various symptoms
were significantly related to a history of childhood physical or sexual abuse in
women in primary care practices: nightmares, back pain; frequent or severe
headaches, pain in the pelvic, genital, or private areas, eating binges or self-induced
vomiting, frequent tiredness, problems sleeping, abdominal or stomach pain, vaginal
discharge, breast pain, choking sensation, loss of appetite, problems urinating,
diarrhoea, constipation, chest pain, face pain, frequent or serious bruises, and
shortness of breath. Others studies also noted that adult subjects who suffer multi-
types of adverse childhood events are at increased risk of wide range of health
problems including cancer, stroke, diabetes, hepatitis, ischemic heart disease, chronic
pain syndromes, binge eating disorder (Grilo & Masheb, 2002; Lampe et al., 2003).
There is also ample evidence that abuse in childhood is associated with an increased
incidence of adult mental health problems such as depression, anxiety, anger, self-
esteem, fear, personality disorder and sexual dysfunction (Frias-Armenta, 2002;
Jumper, 1995; Najman, Dunne, Purdie, Boyle, & Coxeter, 2005; Nelson et al., 2002;
Paolucci, Genuis, & Violato, 2001; Roberts, O'Connor, Dunn, & Golding, 2004;
Springer et al., 2003; Ullman, 2004).

37
Current methods of collecting statistics on health and mortality are not adequate
measures of the burden of disease and ill health resulting from child maltreatment
(Djeddah, Facchin, Ranzato, & Romer, 2000). It is estimated, however, that the
burden of ill health caused by child abuse accounts for a significant portion of the
global burden of disease (WHO, 1999).

Over the past decades the correlations between childhood maltreatment, especially
CSA and CPA, and a wide range of adverse adult health outcomes have been well
established (Fergusson & Mullen, 1999; Springer et al., 2003). For the purpose of
this project, the following section will focus on reviewing the literature on common
child maltreatment effects according to four types of child maltreatment and the co-
occurrence of child maltreatment mainly among community-based adolescent and
young adult samples. The intention is not to be exhaustive; as such review would be
very lengthy. Rather, the aim is to illustrate the diversity of problems associated with
each form of maltreatment. Then, the collective pattern is summarised in Table 2.3 to
show the similarities and differences in possible outcomes for each type of abuse.
The review in the remainder of this chapter is limited to community-based studies in
developing countries. In this respect, the collection of research is considerably
exhaustive. Occasionally, studies from the United States and other western countries
are cited, usually because there is no comparable study in developing countries. A
more exhaustive compilation of studies worldwide is given in Appendix 2.

Physical maltreatment consequences

Physical health

Physical maltreatment can vary from minor to severe and in extremely severe cases it
can cause fractures, brain injury or even death. However, when studies conducted
among population-based samples consider the initial impact of physical maltreatment
on children then it will be the immediate pain and suffering and medical problems
caused by the physical injury. A school based study with more than 3,000
adolescents (13-19 year olds) in Hong Kong found more than 1 per cent of the

38
adolescents reported being beaten to injury by family members in the preceding 3
months (Lau et al., 1999). More recently a large-scale study among more than 90,000
secondary students also in Hong Kong estimated relatively similar rate of
respondents (2.9 %) who reported being beaten to injury by family members during
the preceding 6 months (Lau et al., 2005). Perkins and Jones (2004) reported that
20.1% of students from a large-scale school based survey (16,313 adolescents from
43 public schools in Michigan, the United States) conducted in 1993-1994, had ever
experienced physical abuse from adults causing a scar, black and blue marks, welts,
bleedings, or broken bones. The large difference in figures from Hong Kong and the
US may be mainly due to the differences in assumption of physical maltreatment
time and perpetrators.

Regarding physical health consequences of physical maltreatment at home (Youssef

et al., 1998a) and in school settings (Youssef et al., 1998b), Youssef and colleagues
found striking results from a school-based study with more than two thousands
students enrolled in secondary and high public schools in Alexandria, Egypt during
the scholastic year 1996-1997. Among 37.5% students who reported having physical
maltreatment at home, 25.5% had experienced inflicted physical injuries including
bumps and contusions (61.4%), wounds (53.3%), fractures (5.7%), loss of
consciousness (6.7%), concussion (0.5%), and loss of vision in one eye (0.5%). More
than one fifth of the injury cases reported seeking medical care. In school settings,
the consequences of physical maltreatment by teachers were even worse. More than
one thousand boys (79.9%) and five hundred girls (61.5%) reported having
experienced physical maltreatment at school during the scholastic year. The
estimated prevalence of inflicted physical injuries among reported physical
maltreatment cases at school was 26.5% for boys (bump, contusions: 67.4%,
wounds: 40.4%, fractures: 7.1%, loss of conscious and concussion: 2.1%) and 18.5%
for girls (bumps or contusions: 72.6%, wounds: 30.5%, fractures: 6.3%).

In Hong Kong, Lau and colleagues (1999) found much lower rate (1.1%) of
secondary school students reported having been injured due to being beaten by
family member in the proceeding 3 months in comparison with Egyptian students.

39
Additionally, the authors also found an association between physical maltreatment
and other physical health consequences. Students who had experiences of physical
maltreatment by family members during the proceeding 3 months were generally
more likely to report somatic conditions, asthma, epigastric pain, dizziness,
headache, burn, cuts or other accidents, and stays in hospital in the past thee months.
Many of these correlations were statistically significant.

Mental health

Making links between physical maltreatment and psychological health is an

important step in examining the consequences of child physical maltreatment.
Psychological symptoms that often have been found to correlate with child physical
maltreatment include depression, anxiety, aggression, dissociation, posttraumatic
stress disorders (PTSD), paranoid ideation (Hanks & Stratton, 2002; Lansford et al.,
2002; Malinosky-Rummell & Hansen, 1993)

Quite a few studies have examined the relationship between physical maltreatment
and mental health outcomes among community children and adolescent samples. In a
twelve-year prospective study with data collected annually from 1987 to 1999 among
a community-based sample of 585 children in the US, Lansford et al. (2002) found
that physical maltreatment in the first five years of life significantly predicts
psychological problems (level of aggression, anxiety, depression, dissociation,
PTSD) controlling for the effects of other factors associated with physical
maltreatment. Results of this study provided evidence that effects of early physical
maltreatment may persist over a long period (at least 12 years). A special advantage
of that prospective study is that, the findings are not inflated by retrospective biases
which most studies in child maltreatment area could not overcome.

Further insight into associations between physical maltreatment and mental health
emerged from a survey of nearly 500 secondary school students in Hong Kong (Lau
et al., 2003). Psychological outcomes were measured by Teacher’s Report Form and
the Child Behaviour Checklist (CBCL) completed by parents and teachers

40
(Achenbach CBCL). Lau et al. found that students who reported experiencing two
forms of physical maltreatment (being beaten for no reason by family members in the
last 6 months and ever beaten to injury by family members), had poor mental health.
Correlates between physical maltreatment and anxiety and stress were also reported
in another school-based study in Hong Kong conducted by Lau and colleagues
(1999).

Studies in other countries also showed correlations between physical maltreatment

and several psychological symptoms in school and community adolescent samples. A
lifetime prevalence of Generalized Anxiety Disorder was found to be associated with
experiences of physical abuse among 119 young people (aged 18-21 years) in Japan
(Yamamoto et al., 1999). Similar significant associations (Pearson correlations)
between physical abuse and psychosocial symptoms including depression, anxiety,
dissociation, PTSD, anger, sexual concerns, and somatic problems were reported in a
school-based, cross-cultural study in 4 post-communist bloc countries (Latvia,
Lithuania, Macedonia, and Moldova) (Sebre et al., 2004). The strongest association
found in these countries was between physical abuse and anger, with the highest
correlation in Macedonia [r(275) = .54, p<.001].

Behavioural and academic problems

Physical maltreatment is linked to a wide range of risky behaviours in adolescents

such as self-injurious behaviours, suicidal thoughts and attempts, substance use, and
academic difficulties (Malinosky-Rummell & Hansen, 1993). Lansford et al. (2002)
found in the prospective study mentioned above that adolescents physically
maltreated early in their lives were absent from school more than 1.5 times as many
days, and were significantly less likely to anticipate attending college, compared with
non-maltreated counterparts, controlling for other covariates (socioeconomic status,
family stress, maternal social support, single-parent status, child exposure to
violence, child temperament, and harsh parental treatment during adolescence).

41
Findings from several other studies among population-based adolescent or early
adulthood samples in different countries also support the significant correlations
between CPA and increase in the likelihood of health risk behaviours including
smoking, drinking, other drug use, suicide attempts, involvement in physical fights,
self-mutilation, running away from home, and poor academic achievement (Csoboth,
Birkas, & Purebl, 2003; Fergusson & Lynskey, 1997; Lau et al., 1999; Lau et al.,
2003; Lau et al., 2005; Youssef et al., 1998a). In one of the most comprehensive
studies to date Fergusson and Lynskey (1997) found that among a cohort of 1,025
New Zealand-born children in a 18-year longitudinal study, young people reporting
exposure to childhood physical maltreatment had significantly increased rates of
violent offending, suicide attempts, violent victimization and alcohol abuse, even
after adjusting for various confounding factors (gender, exposure to sexual abuse,
family history of offending, change of parents, exposure to family life events,
maternal age, parental illicit drug use, family income, socioeconomic status,
childhood disadvantages, and family arrangement).

Sexual abuse consequences

Of the published studies with population-based samples of adolescents and young

adults, most measure variables such as depression, anger, anxiety, self-esteem, fear,
and personality disorders. A number of studies examined health risk behaviours,
including substance use, anorexia and bulimia, unsafe sex and teenage pregnancy,
sexual revictimization, and poor school performance (Fergusson & Mullen, 1999;
Hanks & Stratton, 2002; Kenney, Reinholtz, & Angelini, 1997; Krahe, Scheinberger-
Olwig, Waizenhofer, & Kolpin, 1999; Saewyc, Magee, & Pettingell, 2004). There is
a complex pattern of putative effects of sexual abuse, and there are many unresolved
controversies (Haj-Yahia & Tamish, 2001). Some researchers suggest that CSA
almost always leads to short-term and long-term detrimental consequences in
survivors, while others argue that a considerable number of CSA victims do not
report any symptoms at all (Kendall-Tackett, Williams, & Finkelhor, 1993; Rind,
Tromovitch, & Bauserman, 1998).

42
Mental health

Most studies to date have examined correlation between CSA and mental health in
isolation from other concurrent forms of child maltreatment. Overall, the data show
that many CSA victims suffer both acute and chronic psychological problems. The
findings from many studies have been summarised elsewhere (Fergusson & Mullen,
1999). However, it is important in this brief review to focus mainly on studies
conducted outside of North America. A cross-sectional survey was conducted among
a convenience sample of 652 Palestinian undergraduate students (mean age = 20.64
years, SD =2.28 years) to explore correlations of CSA with a wide range of
psychological symptoms (Haj-Yahia & Tamish, 2001). Comparison (t test) of abused
and nonabused participants was examined for nine psychological symptoms:
psychoticism, hostility, anxiety, somatisation, phobic anxiety, paranoid ideation,
depression, obsessive-compulsive, and psychological distress, according to sexual
abuse age (under 12 year olds, 12-16 year olds, and over the age of 16), and
perpetrators (family members, relatives and strangers). The study found that
respondents who were sexually abused by any perpetrators at any age reported
significantly higher levels of all nine psychological symptoms compared with their
nonabused participants.

Similar observation of the relationship between CSA and mental health (depression)
was also found among school-based adolescents in China (Chen et al., 2006; Chen,
Dunne et al., 2004; Chen, Han, & Dunne, 2004). Child sexual maltreatment was
categorized as contact and non-contact abuse experiences that occurred against the
respondents’ will before the age of 16. Depression was significantly higher among
self-reported sexually abused male and female students. However, there was no
significant correlation between CSA and self-esteem, measured by the Rosenberg
scale. Similar findings emerged from a cross-sectional survey of 892 female students
of a medical school in China. Compared to respondents who had no experience of
CSA, sexually abused females (contact and noncontact events) had higher levels of
depression (Chen, Han et al., 2004).

43
Bal et al. (2003) examined correlations between self-reported sexual abuse and
trauma symptoms in nearly a thousand adolescents (aged from 11 to 19 years old)
from a general secondary school, a technical secondary school and vocational
training in Belgium. Trauma symptoms were measured by the Trauma Symptom
Checklist for Children, which includes assessment of: Fear, Depression, Post-
traumatic stress, Dissociation, Anger, and Sexual problems. Multivariate analysis
including gender as a covariate was performed to compared trauma symptom score
between adolescents who reported experiences of sexual abuse and those who
reported different stressful events in her or his life such as exposure to disaster, fire
or explosion, serious accident, being attacked, street fights or war, physical neglect,
abduction, serious disease, death of someone close, witnessing serious injury to
someone, and other events. The authors reported that sexually abused adolescents
significantly reported more fear, depression, post-traumatic stress, dissociation
complaints, anger, and more sexual problems. The research also found that avoidant
coping strategies can be seen as mediator between sexual abuse event and
consequent trauma symptoms.

Adolescent problem behaviours and poor school performance

Quite a few studies have explored the possible effects of childhood sexual
victimization upon various adolescent health risk behaviours. Researchers from
different parts of the world consistently find that adolescents who experienced CSA
were more likely to report smoking, drinking, substance use, suicidal thinking and
attempts, involvement in physical fighting, anti-social behaviours such as stealing
property or causing physical damage to property (Anteghini, Fonseca, Ireland, &
Blum, 2001; Champion et al., 2004; Chen et al., 2006; Chen, Dunne et al., 2004;
King et al., 2004; Martin et al., 2004; Pedersen & Skrondal, 1996; Tomori, Zalar,
Kores Plesnicar, Ziherl, & Stergar, 2001). Various studies indicate that adolescents
who are sexually abused are more likely to begin early consensual sexual activity,
engage in sexual risk taking, or have a teenage pregnancy and revictimization
(Chandy, Blum, & Resnick, 1996; Fergusson, Horwood, & Lynskey, 1997; Kenney
et al., 1997; Krahe et al., 1999; Saewyc et al., 2004).

44
In a large and comprehensive study of 2,946 students in grade 8 and 11 in Cape
Town, South Africa, using ordinal logistic regression, controlling for several
background factors such as race, age, social amenities, family living arrangement,
King et al. (2004) found that students who had ever consumed alcohol were two
times higher than abstainers to report attempted rape or actual rape experience.
Respondents who reported being a victim of sexual violence had significantly
engaged in increasing level of anti-social behaviours in comparison to non-abused
participants (OR = 1.44). Rape and attempted rape were also significant predictors of
suicidal ideation (OR = 2.48) and attempted suicide (OR = 3.20). Stratification by
gender revealed that among girls, alcohol consumption (OR = 2.7), suicide attempts
(OR = 3.13) and anti-social behaviours (OR = 1.47) were significantly related to
sexual abuse. In the contrary, for boys suicidal behaviours were only marginally
significantly correlated with sexual victimization.

Higher rates of early onset of consensual sexual activity, multiple sexual partners,
unsafe sex, teenage pregnancy, sexually transmitted disease, and sexual
revictimization were reported from a long-term study of female adolescents in New
Zealand when various potential confounders had been controlled for (Fergusson et
al., 1997). According to Fergusson, Horwood, and Lynskey (1997) CSA victims had
greater sexual vulnerability during adolescence, perhaps because of many childhood
and family characteristics associated with CSA also were correlated with increased
sexual risk behaviour during adolescence. Fergusson et al. (1997) also suggested that
childhood sexual abuse may encourage victims into early engagement in sexual
activity which, in turn, heightens the sexual risks during adolescence.

Gender differences in the impacts of CSA on various health risk behaviours and
school performance were examined in the Adolescent Health Survey conducted in
Minnesota during the 1986-1987 school year with a sample of more than 36,000
students from grade 7 to 12 in public schools (Chandy et al., 1996). Among 370
males and 2,681 females who self-reported a history of sexual abuse, females were
more likely to engage in internalizing behaviour while males were more likely to
engage in externalizing behaviours. Male adolescents with a sexual abuse history

45
tended to report school performing below average and had higher drop out risk,
delinquency, and sexual risk-taking behaviours compared to abused female
adolescents. In contrast, sexually abused females were more likely to report suicidal
thinking and behaviours, eating disorders and frequent use of alcohol than their male
counterparts. However, males who reported sexual victimization exhibited more
extreme alcohol drinking and more frequent and extreme use of marijuana.

Emotional maltreatment and neglect consequences

In comparison to research into physical and sexual maltreatment, there is a relative

dearth of information on the consequences of emotional maltreatment and neglect
(Hildyard & Wolfe, 2002; Trickett & McBride-Chang, 1995). However, some
experts believe that child emotional maltreatment and neglect is not uncommon and
perhaps has higher prevalence than other forms of maltreatment, and that it has
destructive on health and well-being of the young victims (Crosson-Tower, 2005;
Crosson -Tower, 1999; Egeland, Sroufe, & Erickson, 1983; Glaser, 2002; Hildyard
& Wolfe, 2002; O'Hagan, 1993). Emotional maltreatment may result in a myriad of
long-term impacts. A chronic pattern of maltreatment might destroy a child’s sense
of self and personal safety (Briere & Runtz, 1990). There is also consensus among
child psychiatrists and psychologists that early emotional security is of paramount
importance for later emotional maturity and that even though resilient children and
adolescents may be found to have survived a great degree of emotional deprivation,
the long term consequences of CEA tend to prevail (Corby, 2000; Miller-Perrin &
Perrin, 1999). Neglect, unlike physical maltreatment or sexual abuse which are
usually incident-specific, is often a chronic problem and less obvious so it is more
difficult to identify (Hildyard & Wolfe, 2002). Literature indicates that neglect is
closely linked to emotional maltreatment in that they may lead to similar adverse
consequences (Hanks & Stratton, 2002; Kairys & Johnson, 2002). Some possible
effects of these two forms of maltreatment are:

• Feelings low self-esteem, negative emotional or life view, anxiety, depression,

and suicidal thought and behaviour.

46
• Poor emotional health, including emotional instability, impulse control problems,
anger, self-injury, eating disorders, and substance use.
• Impaired social skills, including antisocial behaviours, attachment problems, low
social competency, low sympathy for others, self-isolation, aggression, and
delinquency.
• Reduced learning ability, including poor school performance and impaired moral
reasoning.
• Poor physical health, including failure to thrive, somatic complaints, poor adult
health.

One study which specifically examined child emotional maltreatment among a

community-based adolescent sample, was conducted in Palestine (Khamis, 2000).
One thousand school children aged from 12-16 years were interviewed at school and
available parents were interviewed at home. Emotional maltreatment was measured
by a 20-item scale consisting of three factors (1: Emotional Abuse - verbal or
emotional assault, close confinement and threatened harm; 2: Emotional Neglect -
inadequate nurturance and affection, child isolation and neglect; 3: Corrupting -
encouraging child maladaptive behaviours such as lying and cheating). After
adjusting for the effects of different variables including child characteristics, parents’
socio-demographics, economic hardship, and family characteristics, emotional
maltreatment was significantly correlated with poor academic performance. In a
cross-cultural comparison of self-report emotional maltreatment among school
students aged 10-14 years old from four post-communist bloc countries, Sebre et al.
(2004) found that emotionally abused respondents in all countries reported
significantly higher psychological symptoms (depression, anger, dissociation, PTSD,
anxiety, sexual concerns and somatic problems) than nonabused participants. The
largest correlation was observed between emotional abuse and anger in four
countries.

Two studies in the United States employed robust design including a case-control
study (Kendall-Tackett & Eckenrode, 1996) and a longitudinal study (Kurtz, Gaudin,
Wodarski, & Howing, 1993). These studies examined the effects of child neglect

47
with school aged samples. Kendall-Tackett & Eckenrode (1996) compared academic
achievement and disciplinary problems between 324 neglected children and
adolescents and 420 matched non-maltreated children and adolescents. Results
revealed that neglected participants had poorer academic performance, had lower
grades, more suspensions, more disciplinary referrals, and more repeated classes
when controlling for gender and socio-demographic status. Kurtz, Gaudin, Wodarski,
and Howing (1993) found that in comparison to the non-maltreated group, neglected
children marginally differed on the measures of socio-emotional development in
school, at home, in the community and with peers after taking into account the
effects of socio-economic status. Notably, neglected students showed severe
academic delays.

Reflections on the broad patterns in evidence linking child

maltreatment to health

From the review of the available literature it is evident that the widespread
prevalence of child physical maltreatment, emotional maltreatment, sexual abuse and
neglect as well as the numerous developmental issues and mental health
consequences associated with them has also been recognized (Hanks & Stratton,
2002; Hildyard & Wolfe, 2002; Staudt, 2001; Trickett & McBride-Chang, 1995).
Table 2.3 summarises a number of consequences correlated with each form of child
maltreatment. There is considerable overlap of a wide range of negative outcomes of
individual maltreatment types. However, this literature has been segmented, with
researchers focusing their efforts only on particular forms of maltreatment, which
does not reflect the lived experience of child maltreatment victims.

48
 Table 2.3: Summary of association between each form of childhood
maltreatment experiences and common adverse outcomes reported in literature

Adverse outcomes CSA CPA CEA CN

Physical health
Physical injuries √ √
A number of physical health √ √ √ √
symptoms: pain, severe headaches,
etc. and overall poor physical health
Sexually transmitted diseases √
Mental health
Depression √ √ √ √
Anxiety √ √ √ √
Aggression/anger √ √ √ √
Posttraumatic stress disorders √ √
Low self-esteem √ √ √ √
Behavioural problems
Suicidal thoughts and attempts √ √ √ √
Smoking, drinking and substance use √ √ √ √
Eating disorders √ √ √ √
Involving in fighting √ √ √ √
Self-injury √ √ √ √
Antisocial behaviours √ √ √ √
Dating violence √ √
Teenage pregnancy √
Sexual risk taking behaviours √
Learning ability
Poor school performance √ √ √ √

Children who suffer one type of maltreatment are at risk of other forms of
maltreatment (Clemmons et al., 2003; Higgins & McCabe, 2001b). Studies have
found that different forms of child maltreatment clearly are correlated with each
other and with many background factors such as child and parent characteristics,
socio-economic status, family environment, and community characteristics etc
(Berger, Knutson, Mehm, & Perkins, 1988; Fontes, 2005; Newcomb & Locke, 2001;
Newcomb, Locke, & Goodyear, 2003; Turner, Finkelhor, & Ormrod, 2006). There
are two important implications for research into the effects of child maltreatment.
First, examining effects of only one form of child maltreatment may substantially
underestimate the cumulative impacts of a spectrum of maltreatment exposure on

49
young people. Second, focusing on effects of only one form of child maltreatment
and failure to take into account the effect of various confounding factors and
concurrent maltreatment forms may result in overestimation of the relative impact
upon health of the single maltreatment form that is measured. To fill this gap, studies
have begun to document the effects of the co-occurrence of various forms of
maltreatment and a small body of research has been able to partition the effects of
other maltreatment domains while examining the potential influence of individual
forms of child maltreatment on adverse outcomes (see Appendix 2).

Consequences of co-occurrence of child maltreatment

In recent years there has been growing interest in measuring the consequences of co-
occurrence of various forms of child maltreatment (Ambuel et al., 2003; Clemmons
et al., 2003; Dong et al., 2003; Dube, Felitti, Dong, Giles, & Anda, 2003; Dube et al.,
2006; Hobfoll et al., 2002; Locke & Newcomb, 2004; Newcomb & Locke, 2001;
Walker et al., 1999). Higgins and McCabe (2000a) examined the co-occurrence of
adverse childhood experiences including sexual abuse, physical abuse, emotional
abuse, neglect, and exposure to family violence reported by a community sample of
175 Australian men and women. It was found that 43% of participants reported
experiencing more than one type of maltreatment, while 15.4%, 11.4%, 9.7% and
6.9% of the sample were classified as suffering two, three, four and five types of
maltreatment as a child, respectively. Greater mental health problems significantly
correlated with reports of a larger number of different child maltreatment types.
Moeller, Bachmann and Moeller (1993) reported similar results in their study in the
USA among a sample of 668 middle class females in a gynaecological practice. Half
(53%) of the sample reported childhood abuse (physical, sexual and emotional),
28.9% exposure to one type, 18.7% to two types and 5.4% to three types. This study
also found that the greater the amount of child abuse the poorer one’s health (both
physical and psychological well-being) and the more likely one was to have suffered
abuse as an adult.

50
These early findings have been extended by larger studies. Edwards and colleagues
(2003) conducted a study among 8,667 adult members of a health maintenance
organisation in the USA, to explore the relationship between the combination of
various forms of child maltreatment and adult mental health. Using the mental health
scale of the Medical Outcomes Study 36-item Short-Form Health Survey, the authors
found that lower mean mental health scores were associated with higher numbers of
abuse categories. Both an emotionally abusive environment and the interaction of an
emotionally abusive environment with the various maltreatment types had a
significant effect on mental health scores. A dose-response relationship was found
between the number of forms of maltreatment reported and mental health scores.

Much less research has been conducted to examine the concomitance of different
types of child maltreatment and its impacts among community-based samples of
adolescents in not only developing countries but also in developed nations. Most
studies have considered the combination effects of different forms of maltreatment
focusing only on the combination of two forms at a time and mainly on the
consequences of physical maltreatment and sexual abuse. Additionally, many studies
examined the relative impacts of individual types of child maltreatment have
typically failed to account for possible effects of other forms. Appendix 2 documents
studies on various forms of child abuse and outcomes among adolescents and early
young adults from different parts of the world. This appendix includes a summary of
the form of maltreatment examined, confounding factors controlled, information on
sample size and characteristics, the nature of data collection method, the outcomes
examined, and whether the effects of each type of child maltreatment was
partitioned. In total, 78 studies were summarized, of which 45 studies examined
more than one form of maltreatment with 38 studies exploring the association
between maltreatment and specific health and health risk behaviour outcomes.
However, less than half of the studies (14 out of 38 studies) used multivariate
analysis to partition the effects of each type of child maltreatment. Only 7 studies
examined the concomitance of more than three forms of abuse, and 2 out of 7
reported the cumulative impacts of multiple forms of child victimization. From the
literature review it can be seen that there is no comprehensive study of multiple

51
forms of child maltreatment and its impacts on physical, mental health and health
risk behaviours among adolescent and early young adulthood samples in Asian
countries.

Some research from America among adolescents and young adulthood on the various
consequences of multiple forms of child abuse has also found significant dose-effect
relationships between indices of abuse severity and likelihood of several health
outcomes as well as health-related behaviours (Back et al., 2003; Diaz, Simatov, &
Rickert, 2000; Moran, Vuchinich, & Hall, 2004; Newcomb et al., 2003; Turner et al.,
2006).

Most recently, Turner, Finkelhor and Ormrod (2006) conducted one of the most
comprehensive studies to date among a national representative sample of more than
two thousand US children aged from 2 to 17 years. Telephone interviews were
conducted with the selected child if he/she was 10-17 years old and with an adult
caregiver (usually a parent) if the selected child was 2-9 years old. This sophisticated
study examined a wide range of child life-time victimization and its relative impacts
of each type and cumulative effects of multiple forms of victimization on child
mental health (depression and anger/aggression). Controlling for age, the study
results clearly showed a significant dose-response in comparing mean levels of
depression and anger/aggression across groups with varying levels of victimization
from no victimization to more than four types including physical abuse and neglect,
sexual victimization, witnessing family violence, and other direct and indirect
violence. A hierarchical regression analysis was performed to examine the relative
impacts of each form of victimization on depression and anger/aggression in this
study. After controlling for age, gender, race, socio-economic status, family
arrangement and non-victimization adversity, and other victimization domains, the
study found that every victimization form had its independent effects on the mental
health of victimized children. The findings emphasise that focusing only on recent
adverse experiences and only on one or two forms of child victimization cannot
describe the full picture of the effects on mental health.

52
Through the literature review (Appendix 2), it is clear that there is increasing
evidence regarding significant associations between different types of child
maltreatment as well as their concomitance and health risk behaviours among
adolescents and young people from non-clinical settings. Results of a study
conducted among high school students in the US showed that after controlling for
effects of gender, age and family configuration, all four categories of child
maltreatment (CPA, CSA, CEA and CN) were associated with increased levels of
tobacco, alcohol and illicit drug use. Physical and sexual abuse more than doubled
and tripled the odds respectively of all three substance-use types. Furthermore, the
effect of experiencing the combination of physical and sexual abuse was especially
pronounced (Moran et al., 2004).

In a cohort study of the development of behavioural problems among a thousand US

urban youth who were followed from age 13 to adulthood, Smith, Ireland and
Thornberry (2005) explored the correlations between adolescent maltreatment
experiences and antisocial behaviours including arrest, self-reported general and
violent offending, and illicit drug use at late adolescence (16-18 year olds) and early
adulthood (20-22 year olds). Maltreatment information including sexual abuse,
physical abuse, and emotional abuse and neglect based on substantiated maltreatment
reports. The study found that short-term and long term effects of adolescent
maltreatment varied by the type of maltreatment when controlling for the effects of
parent education, race, caregiver changes, early adolescent offending, and
community poverty. The most consistent pattern was that neglect and emotional
maltreatment significantly increased the odds of arrest (OR = 4.37), general
offending (OR = 3.23), and violent crime (OR = 3.59) in late adolescence in
comparison to non-maltreated participants. Physical maltreatment increased the odds
of violent crime (OR = 2.54) and illicit drug use (OR = 3.66). However, results of
this study revealed adolescents who experienced sexual abuse were not significantly
different from those never maltreated at least in relation to the three antisocial
outcomes examined in late adolescence. On the contrary, antisocial behaviours in
early adulthood were related to sexual abuse during adolescence, especially for
general offending (OR = 5.04) and drug use (OR = 5.07). Neglect significantly

53
increased the risk of arrest (OR = 2.36) and drug use (OR = 2.55) but not general
offending while physical abuse only correlated with violent offending (OR = 2.17) in
early adulthood.

Kendall-Tackett and Eckenrode (1996) examined the effect of child neglect, alone
and in combination with other types of abuse on academic achievement and school
disciplinary problems for elementary, junior high and senior high students.
Recruiting matching samples of abused and non-abused children in a city in New
York State, the study found that the combination of neglect and abuse (physical and
sexual) had particularly strong effect on the number of disciplinary referrals and
grade repetitions, even when controlling for gender of child and SES.

So far only one available study conducted outside the United States examined the
cumulative and relative impacts of four forms of child maltreatment (CPA, CEA,
CSA, CN). A survey of Turkish adolescent students assessed suicide attempts and
self-mutilation (Zoroglu et al., 2003). Logistic regression models supported the
significant contribution of each type of child maltreatment and increases in the
likelihood of suicide attempts and self-mutilation. The study also found significant
relationships between increasing number of maltreatment types and suicide attempts
and self-mutilation. However, this study did not adjust for the effects of possible
related background variables.

From the literature review it is difficult at this stage to interpret the relative effects of
each type of child maltreatment. Some would suggest that emotional abuse and
neglect cause the most damage whereas others point to the strong impact of physical
and sexual abuse. It is not possible to determine the maltreatment-specific impact of
different forms without considering a range of child maltreatment types and wide
range of outcomes and confounding factors. Consistent finding is that co-occurrence
of more than one type of child maltreatment is more traumatic and correlated with
more negative health outcomes than a single form of abuse. This suggests an additive
model of trauma (Fox & Gilbert, 1994). The emphasis of these few studies has
shifted social epidemiological work in the child maltreatment in an important new

54
direction. It seems clear that research in maltreatment field must move beyond the
simple compilation of new survey data gathered from ever more diverse sections of
global population as we know already that child maltreatment is common and
harmful wherever it has been measured. The new findings about the cumulative
impacts of multiple forms of child maltreatment are important but at present limited
to Western, affluent, English speaking populations, except the small study in Turkish
adolescents. There is a need to understand the generalisability of these findings.

2.5 Child maltreatment in Vietnam

Introduction

Children have always held a very important place in the culture and traditions of
Vietnam (Appendix 3 summarizes the country’s profile). In 1989 Vietnam was the
first country in Asia and the second in the world to ratify the UN Convention on the
Rights of the Child (Salazar-Volkman, 2004). The Vietnamese government’s second
National Programme on Action for Children 2001- 2010 sets forth clear policy goals
in the areas of health, nutrition, education, child protection, water, sanitation, culture
and recreation (UNICEF, 1999).

At present, Vietnam does not have a specific body of legislation concerning child
maltreatment. There are, however, many laws that have been introduced with
components aimed at protecting children from harm and exploitation. More than 110
laws and regulations relevant to children were issued by the National Assembly, the
Prime Minister and Government bodies during the period from 1998 to 2002 alone.
These legal documents mainly focused on promoting education for children,
strengthening services for children, and improving protection from violence through
more stringent punishment of perpetrators (Salazar-Volkman, 2004). The Law on the
Protection, Care and Education of Children passed in 1991, which was revised in
2004, was the most important document in the aftermath of the UN Convention on
the Rights of the Child. In the revised law one chapter relating to disadvantaged
children was added, however other important dimensions regarding child

55
maltreatment were not covered except for extremely severe cases such as child rape,
child prostitution, or severe injuries and death (PFCSI & SCS, 2005). On the one
hand, many laws and regulations relevant to children were issued as an indicator of
increasing awareness of the Government on the importance of child protection. On
the other hand, this does not mean that child protection in Vietnam has significantly
improved, because of obstacles in implementation and enforcement of these many
legal documents. Many challenges remain for the Vietnam Government during this
period of social and economic transition before the rights set forth in the UN
Convention on the Rights of the Child can be exercised and enjoyed by all
Vietnamese children.

Research on child maltreatment in Vietnam

There is a serious dearth of research on the exposure of children in Vietnam to

maltreatment, especially research on the general population. As a consequence, it is
impossible to obtain accurate figures on the extent of child maltreatment problems in
this country. Numerous factors may explain the paucity of research and inability to
obtain precise figures. These include under-recognition of the issues by stakeholders,
a traditional reluctance to discuss issues related to child abuse (especially sexual
abuse), reluctance to intervene in family lives of others, and no mandated reporting
system. Further, there may also be influential perceptions that other health and social
problems demand more urgent attention. However, it is widely believed that the
actual rate of child abuse is rising (MOLISA, 1999) and this increase exceeds the rise
in cases documented in official government statistics reported by police and court
(child abuse cases recorded by police and courts are only child rape or sexual
exploitation) (SIDA, 2000). Available data show that before 1990, child rape
accounted for only 6% of all rape cases. By 1996, this figure has increased to 30%.
In the first 6 months of 1999, the number of child rape cases increased by 25%
compared to that number for the same period of 1998 (Hoang, 1998; RaFH, 2002).

No paper specifically relating to child maltreatment in Vietnam has ever been

published in international academic journals. Most of the research carried out so far
in Vietnam in this field has employed qualitative methods and mainly focused on

56
CSA, including child prostitution and child sexual exploitation among convenience
samples of disadvantaged children such as street children, child prostitutes and
children in rehabilitation centres or government shelters (Le, 2002; MOLISA, 1999;
Ngo & Flamm, 1997; Nguyen, Phan, & Duong, 1997).

There have been several quantitative community-based studies conducted among

children that include some data related to child physical maltreatment. In a survey
carried out by Hoang and colleagues (2001) the researchers explored the kinds of
methods parents use to educate their children. They interviewed a sample comprising
50 girls, 50 boys (from 4 to 18 years old) and their parents. Results showed that
parents often used physical punishment as a method to “educate” their children, and
the following methods were used: slapping or knocking on the child’s head (26.0%),
hitting on the buttocks (22.0%), beating with a rod (21.8%), slapping on the thigh
(20.1%), slapping on the buttocks (19.8%), pinching (19.6%), beating the child with
uncontrolled anger (19.5%), shaking the child (15.0%), rushing and hitting the child
(11.7%) and kicking the child (5.3%). However, the researchers did not ask the
parents about the frequency of acts and if they considered any of the above acts to be
physically abusive to children. A large-scale survey among a randomly selected
sample of 2400 adolescents (aged from 13-22) conducted in 7 provinces representing
7 ecological and socio-economic regions in the country revealed little information
relevant to child maltreatment. Regarding corporal punishment there were 26% of
boys and 20% of girls who reported being physically punished by their teachers. This
was more common in the rural than urban areas (25% and 18% respectively)
(Mensch, Dang, & Clark, 2000).

A survey of 1240 Vietnamese children undertaken by the Youth Research Institute in

1998 showed an alarming figure on the situation of physical punishment against
children (Le, 1999). About 90% of children reported being regularly beaten by their
parents with about 50% claiming that the reasons were unjust. Children who reported
being severely beaten accounted for 65%. Roughly 70% of regularly beaten children
said that they felt very sad about being hit by their parents and about 28% said that
they were very angry with their parents. This figure on physical punishment seems to
be quite high. However, physical punishment in this study was defined generally in

57
terms of beating children and may not includes other acts commonly considered to
constitute physical maltreatment. Therefore it may not provide a valid estimate of the
extent to which Vietnamese children are exposed to severe physical maltreatment.

Very recently, the Population, Family and Children Scientific Institute-National

Committee on Population, Family and Children in collaboration with Save the
Children, Sweden, have conducted a survey on corporal and emotional punishment.
The participants included 571 parents or adults in families, teachers, child protection
staff and 514 children mainly aged 6-18 years old in four provinces in the North,
Centre, Centre Highlands, and the South of Vietnam (PFCSI & SCS, 2005). The
study employed a multi-method approach, including a quantitative survey with
parents and children, in-depth interviews with child protection staff, children and
adults, focus group discussions with teachers, and feedback letters from children
aged 11-18 years. This study revealed important and interesting information to set a
baseline for the Save the Children Alliance in Vietnam to launch a campaign against
corporal punishment in 2005.

When asking parents and adults “what did they do if a child made a mistake?” a
significant proportion (37.3%) reported shouting at a child, nearly one third (28.6%)
reported using corporal punishment, and one fifth (20.2%) said insulting a child or
trying to make a child feel guilty as the “methods” employed. They also reported
hitting with a rod and hand to the bottom of children is the only ways they have done
when conducting corporal punishment to “educate” children. Yet the information
revealed by children in this survey was somewhat different with more than half
saying they have been beater, kicked, tied or locked in house. Adolescents reported
more emotional punishment such as being threatened to be sent out of their home,
which made them very disappointed in their parents. Table 2.4 summarises the
experiences of corporal punishment reported by children in this study. Whether
parents and adults under reported what they actually practiced or whether children
over reported their experiences is unknown. However, parents and adults had
reported that they knew neighbours punished children in such a way that caused blue
marks, welts, injuries, and forced children to run away from home.

58
Most children in this study (69.3%) reported that they felt sad when being physically
or emotionally punished by adults mainly due to their mistake, but also because their
parents and adults did not listen and understand them and sometimes punished them
without any reason. More than sixty per cent of children said that they felt ashamed,
less confident, and frightened because of parent and adult punishment. Especially, a
small group of children felt very angry and wanted to take revenge. Approximately
fifty per cent of children participants completely disagreed with the current used
physical and emotional punishment by parents and adults.

Table 2.4: Ways to conduct physical punishment on children

Per cent Rarely Sometimes Often

Implements (n =514) of total (%) (%) (%)

Rod, cane (n = 126) 24.5 46.1 48.7 5.2

Hand applied to face and bottom (n = 94) 18.1 51.1 46.8 2.1
Beat and kick (n = 44) 8.6 79.5 18.2 2.3
Twist ear or nose and pull hair (n = 53) 10.3 67.9 30.2 1.9
Used whatever had in hand (n = 49) 9.5 65.3 32.7 2.0
Tie or chain (n =23) 4.5 91.3 8.7 0.0
Lock in house (n = 33) 6.5 75.8 24.2 0.0

Adapted from PFCSI & SCS (2005)

In 2003, the most substantial community-based research on child maltreatment topic

in Vietnam was conducted by Michaelson (2004), a UNICEF Vietnam consultant.
The study was a comprehensive investigation into the concept, nature and extent of
all forms of child abuse in Vietnam, including sexual abuse, emotional and physical
maltreatment, and neglect, the impact of domestic violence on children, commercial
sexual exploitation of children, trafficking of children, and child labour. The research
was undertaken in Hanoi (capital), Angiang (in the South), and Laocai (mountainous
province in the North) among 2,800 participants (aged from 8-35 years old) for a
quantitative survey, and 178 children and young people (aged 8-25 years old) and

59
134 adults (aged 27-63 year olds) for a qualitative study. The participants represented
a diversity of backgrounds, including children and young people from primary,
secondary and high schools, universities, reform school and social protection centres,
and children on the street, adults working as teachers, consultant/street educators,
social protection centre staff, government representatives, academics, non-
government organisation staff, private sector representative and community parents.
Even though the information presented in this study’s report was basically
descriptive, it provided a base of preliminary evidence relating to concepts, nature
and extent of various forms of child abuse from a diversity of respondents. There are
five important findings of the study.

First, violence is not an unfamiliar experience of children and young people growing
up in Vietnam. The vast majority of respondents reported having experienced some
form of physical punishment (70% experienced spanking with a hand; 51.5%
reported physically punishment with an implement; 16.2% experienced physical
attack from adults). More than one third of the participants (35.7%) reported having
experienced emotional abuse. Nearly eight per cent (7.9%) of respondents
experienced unsafe touching of private parts and 2.7% reported having been raped or
experiencing another form of sexual assault as a child. Surprisingly, males were
twice as likely as females to report having a sexual abuse experience. Physical
bullying by other children was also very common (71.5%) and about one in three
participants (29.3%) reported having witnessed physical violence between adults in
their family. Traditional forms of neglect i.e. failure to take care a child’s basic needs
had been reported by respondents in the qualitative study. Parental deprivation of a
child’s right to education and emotional neglect of children by parents who spend a
lot of time at work emerged as a common form of neglect mentioned by participants.

Second, older participants were less likely to view “physical punishment for
education” as child abuse, while the majority of the younger generation believed that
it is abusive, on the ground that there are better and more humane ways of educating
children. Third, the cultural practice of adult male relatives fondling penises of
young boys was raised as an experience disliked by many young males. Fourth,

60
“education pressure” is a relatively new phenomenon but emerged as problem facing
youth. This issue was most commonly reported by young people from urban rather
than rural areas. Fifth, the research results demonstrated a high awareness among
participants in relation to child prostitution and trafficking and child sex tourism but
much less to child pornography and internet related child abuse.

So far there is no single quantitative study exploring the issues of emotional, physical
maltreatment, sexual abuse and neglect as well as examining the relative effects of
each form of child maltreatment and cumulative impacts of co-occurrence of various
forms of child maltreatment on health related behaviours, mental and physical health
problems in Vietnam. There is a need therefore for specific research investigating the
prevalence and effects of all forms of child maltreatment in order to provide relevant
evidence for Vietnamese public health solutions.

To sum up, through limited research evidence, media reports and observations it is
widely believed that child maltreatment in Vietnam is as serious a social and public
health issue as in other countries. During the past several years a great deal of
attention has been given to the topic of child maltreatment in the media in Vietnam.
However, there is still a lack of community-based research evidence to provide a
more comprehensive understanding of the concepts of various forms of child
maltreatment, the extent to which the problem exists, and its potential effects on the
health and well-being of victimised children. Without scientifically sound research it
is impossible to set firm foundations for future prevention, intervention and treatment
strategies. The main purpose of the present study therefore was to meet, to some
extent, this compelling need, so that we may contribute to collective and long-term
endeavours to combat child maltreatment in Vietnam.

After reviewing a relatively substantial body of international research and the little
available evidence on child maltreatment in Vietnam, the gaps in child maltreatment
literature have been identified. As a result, the following hypotheses of this study
were proposed:

61
1. The prevalence of physical maltreatment, emotional maltreatment, sexual abuse
and neglect is different between school boys and girls.
2. The prevalence of physical maltreatment, emotional maltreatment, sexual abuse,
and neglect among school adolescents is different between urban and rural
districts.
3. Physical maltreatment, emotional maltreatment, sexual abuse, and neglect
experiences independently increase risk of engaging in various health risk
behaviours of adolescents.
4. Each form of child maltreatment independently increases the risk of having
depression, anxiety, and physical health problems, and decreasing self-esteem of
adolescents.
5. There are dose-response relationships between increasing number of types of
child maltreatment experiences and the likelihood of taking health risk
behaviours, and poor health among adolescents.

62
 Chapter 3:
Research Methods and Pilot Study

3.1 Methodological considerations in research on

child maltreatment

Studying child maltreatment in the general population is difficult due to factors such
as the sensitivity of the topic, the related legal, ethical, and practical restrictions and
the difficulty in determining the reliability and validity of retrospective data (Kinard,
1994). Although child maltreatment research has become more methodologically
sophisticated over time, it has often been subjected to criticism for methodological
deficiencies. Many questions have been raised about the validity, comparability, and
generalisability of findings regarding prevalence and consequences of child
victimization. The main methodological issues that need to be taken into
consideration include: definitions of child maltreatment; source of study population
and method of sampling; and potential bias associated with measurement (Creighton,
2002; Edwards et al., 2001; Hecht & Hansen, 2001).

Definition of child maltreatment

As discussed earlier, there is the lack of a clear, generalizable definition of child

maltreatment. Research definitions of child maltreatment within a certain culture
cannot be drawn without carefully considering the nature of the parent-child
relationship and the nature of other relationships affecting the child in his/her social
context (Haj-Yahia & Shor, 1995). Specifically, Crosson-Tower (1999) argued that
there are cultural dissimilarities in attitudes regarding what are acceptable or
unacceptable practices towards children.

Definitions are promulgated for multiple purposes and may vary between different
legal, social service, clinical, and scientific contexts. Definitions created for clinical

63
purposes might not be easy applied in research based on the general community.
There have been various questions that should be raised before deciding on the
operational definition for the study. For example, what constitutes dangerous or
unacceptable practice towards children? What should be included in classification
systems about maltreatment subtypes, severity, frequency, and consequences?
Should the definition be based on adult behaviours or subjective outcomes for the
child? Should the presumed intent of the perpetrator be included in definitions?
Which aspect of the context of the maltreatment should be included and how?
(Dubowitz et al., 2005; Socolar, Runyan, & Amaya-Jackson, 1995). There are no
clear answers to these questions. However, it is suggested that operational definitions
of child maltreatment must be as concrete and specific as possible using simple,
behaviourally specific language (Hamby & Finkelhor, 2000). Operational definitions
must also take into account cultural appropriation to select adequate samples and
facilitate comparisons across studies.

Keeping these principles in mind, in this project, child maltreatment was categorised
into four types measured by four scales including a continuum of behaviours towards
children. Operational definitions of each type of child maltreatment and measuring
scales are presented in detail later in this chapter. The development of definitions and
scales was based on the following steps:

• Identifying the different definitions used by researchers through literature search

internationally and locally. The focus was on defining maltreatment in terms that
are behaviourally specific, culturally acceptable, appropriate for the age of
research participants, and to some extent comparable with other research.
• In-depth discussion with experts
• Testing qualitatively and quantitatively with potential study participants in a pilot
study.

64
Sources of research population and sampling method

It appears that child maltreatment prevalence rates and the extent to which child
mistreatment correlates with health status are affected by variation in research
samples (Goldman & Padayachi, 2000). Studies in this field often select convenience
samples from clinics or hospital patients, or from the criminal justice system,
shelters, and special intervention services. These sources of research population often
include more severe abuse cases. Data obtained from these populations, as Pope and
Hudson (1995) indicated, are vulnerable to biases, including information bias, which
is a major threat to internal validity of findings.

Over time the number of published articles on child maltreatment using college and
outpatient samples has increased (Behl et al., 2003). Yet, Ryan and colleagues (2000)
questioned the representativeness of college samples regarding the assessment of the
impact of child maltreatment on adjustment problems. They argue that college
students have better coping skills, so this could diminish differences between the two
groups of maltreated and non-maltreated students in adjustment problems.

However, as far as maltreatment prevalence is concerned, Dunne (2002) in his

review of 13 studies on CSA experiences of females included 7 general population-
based and 6 student-based samples. He found considerable similarity in terms of
average child sexual maltreatment prevalence rates. He suggested that samples
selected from different segments of population do not always result in significant
differences in prevalence rates. Gorey and Leslie (1997) also found that the sources
of the research populations (general sample or college sample) and sampling
methods (probability or convenience sample) did not significantly explain the
prevalence variation in their review of 16 CSA cross-sectional studies among a non-
clinical population in North America whereas response rate and abuse definition
explained half of the variability of abuse prevalence estimates.

65
Measurement bias

Measurement of variables related to child maltreatment, either as an outcome or a

risk factor, is problematic. Retrospective survey data are subjected to recall bias,
particularly in studies in which the abusive events may have occurred many years
before. Because of the sensitive nature of this topic, disclosure problems also
jeopardise measurement (Socolar et al., 1995). The method of collecting data is also
another important issue, but there is little evidence available on the effects of
assessment mode on reporting maltreatment experiences. Different suggestions have
been provided by research groups. Interview methods did not significantly explain
much variance in CSA prevalence estimates in Gorey and Leslie’s (1997) integrative
review of 16 surveys. However, Socolar and colleagues (1995) suggested that self-
administered surveys are more likely to be accurate. Self-administration
questionnaires are often used to collect data in school settings and in group
administrations. In contrast, Goldman and Padayachi (2000) indicated that face-to-
face interviews are likely to produce more accurate data by trained interviewers who
have the capacity to encourage respondents to uncover their personal matters. These
researchers also demonstrated how the content and structure of questions on child
maltreatment in any method of data collection result in inconsistencies in research
findings. They concluded that fairly low rates of child maltreatment were revealed by
those studies using only limited screening questions. Among 20 recommendations
for assessment and instrument development used in a child victimization study,
Hamby & Finkelhor (2000) suggested that it is possible to collect self-report data
with children as young as 7 years old, but to date there is no conclusive evidence
available supporting a major advantage of any one data collection method.

Research on child maltreatment must be not only methodologically rigorous, but also
practically feasible. When trying to obtain accurate findings for child maltreatment,
researchers have encountered various practical problems in implementing even well-
designed studies that make it difficult to conduct research in this area. A research
design that appears both ethically and scientifically sound would involve longitudinal
study of a large and representative sample of children followed up at regularly

66
scheduled intervals from childhood to adulthood. By this design some major
methodological pitfalls mentioned above could be avoided. Unfortunately, this
design is not feasible to implement in many contexts and to date few studies have
been able to use this approach such as a study in New Zealand (Fergusson et al.,
1997; Fergusson & Lynskey, 1997) and LONGSCAN (LONGitudinal Studies of
Child Abuse and Neglect) in the US (Runyan et al., 1998). It is important that
investigators be aware of potential constraints and equip themselves with various
mechanisms to minimise these barriers.

3.2 Design of this study

A mixed methods design (Creswell, Clark, Gutmann, & Hanson, 2003), including
qualitative and quantitative methods was employed. Creswell and colleagues (2003)
argue that mixed methods designs allow researchers to develop a more
comprehensive understanding of the complexity of human behaviours and
experiences. The incorporation of the qualitative method in the present study adds an
important cultural dimension on child maltreatment problems, in turn helping to
develop appropriate quantitative measures. The mixed methods design applied in this
study is depicted in Figure 3.1 and is discussed in more detail later in the chapter.

Stages of study: The study was conducted in Vietnam in three stages as

follows:

Stage 1: Qualitative in-depth interviews and focus group discussions

Qualitative research based on ethnographic methods attempts to interpret and present

findings from a cultural perspective. As discussed in the literature review, child
maltreatment is a complex, multifaceted, multi-determined and, to some extent,
culturally-specific issue. Haj-Yahia and Shor (1995) argue that we should take into
account the social and cultural components, to ensure a comprehensive approach to
this sensitive topic. Qualitative methods were employed in stage 1 as a useful

67
exploratory tool providing insight into how people perceive child maltreatment and
make sense of their experience in a way that could not be easily provided by other
methods (Grbich, 1999; Rice & Ezzy, 1999). Stage 1 of the present study included
two steps:

Step 1: In-depth interviews with teachers, parents and students themselves.

The aims of this step were to:

• explore how teachers, parents and students perceive child maltreatment as a
concept;
• discover the nature of the child maltreatment phenomenon through interviewees’
experiences; and
• examine how to use culturally appropriate terminologies/words in research
questionnaires for this study population, especially when investigating child
sexual abuse.

Interviews were completed with 16 participants, including 4 teachers, 4 parents and 8

students (see guideline for in-depth interview in appendix 5).

Step 2: Focus group discussions (FGD): Eight FGDs, 6-8 students for each FGD,
were conducted in urban and rural study sites (4 FGD for each site) and with students
from both lower and upper secondary schools. Given the sensitivity of the topic,
gender homogeneity of each FGD was taken into account (4 girl FGDs and 4 boy
FGDs) (see guideline for focus group discussion in appendix 6).
The purposes of this step were to:
• inform researchers about young people’s familiarity with the child maltreatment
problem;
• have feedback from students on structure, content and wording of study
instruments in order to revise them (students completed the self-administered
questionnaire individually then discussed their general comments in the group);
and
• gain suggestions from participants about questions that could be included.

68
 Qualitative
Stage 1 research
16 interviewees: 4
In-depth interviews teachers; 4 parents and 8
students

Text analysis
Data analysis

Focus group 8 FGDs: each with 6-8

discussion students

Data analysis to Text analysis

revise quantitative
instruments

Self-administered
Pilot quantitative questionnaires with 299
Stage 2 research students

Data analysis to Using SPSS 12;

revise instruments AMOS 5.0; and SUDAAN
and adjust survey 7.5.2a
sample size

Self-administered
Stage 3 Main survey questionnaires with 2,591
students

Data analysis to Using SPSS 14

produce quantitative
findings

Figure 3.1: Mixed methods procedures of the study

69
Stage 2: Pilot quantitative study

One class of each grade 7, 9 and 11 was recruited from 1 lower secondary school and
1 upper secondary school for each study site (2 lower secondary schools, 2 upper
secondary schools with 6 classes in total for 2 study sites – Dongda urban district and
Chilinh rural district). The main findings of the pilot study will be presented later in
this chapter.

The aims of this stage were threefold, to:

• check that the management procedures for survey implementation were

appropriate and successful;
• re-examine the strengths and weakness of the questionnaires and to amend them
where necessary; and
• get preliminary prevalence data on various types of child maltreatment that could
be used to calculate the sample size for the stage 3 survey.

Stage 3: Conduct main survey to test study’s hypotheses

3.3 Study participants

The school-based population comprised students from Vietnamese public lower

secondary schools (grade 7 to grade 9, age generally ranges from 13-15 years) and
upper secondary schools (grade 10 and grade 11 aged 16 and 17 years). Four
teachers, 4 parents and 64 students were recruited for qualitative interviews and
focus group discussion. In total there were 326 and 2,737 students invited to
participate in the pilot and the main study respectively.

70
3.4 Study sites

The study was conducted in two districts in the North of Vietnam selected (see map
in Appendix 4). One urban area and one rural area were purposively selected.

Urban area: The urban area selected was Dongda district, Hanoi capital city,
with 5 public upper secondary schools and 17 public lower secondary schools.
Dongda was chosen because it is one of the nine districts of Hanoi city. It has an
estimated population of 336,000 people in comparison to three other inner districts,
Hoankiem, Badinh and HaiBaTrung with smaller populations of 159,761; 191,611
and 347,400 respectively, according to the 1999 census. Dongda is a typical
municipal district including many common living quarters. It has average socio-
economic development and investment (Vu, 2000).

Rural area: The rural area selected was Chilinh district, Haiduong province. This
district is approximately 60 kilometres Northeast of Hanoi with two public upper
secondary schools and 20 public lower secondary schools. Chilinh was selected
because it is the field-lab of the Hanoi School of Public Health namely CHILILAB–a
Demographic Epidemiologic Surveillance System with establish management
procedures and locally capacity to use trained research assistants as data collectors
for this project. CHILILAB is a member of INDEPTH, an International of field sites
with continuous Demographic Evaluation of Population and Their Health in
developing countries, network. It has a focus on studying adolescent health. Chilinh
is located in both the Plains (35%) and Midlands (65%) areas of Vietnam. Socio-
economic development and urbanisation processes are similar to that of Haiduong
province (Chilinh People's Committee, 2003).

3.5 Timeline

This study was conducted through 2004 and 2005:

• the qualitative study took place between January and March 2004;

71
• the pilot study (n = 299) was conducted in May and June 2004; and
• the major survey (n = 2591) was undertaken between December 2004 and May
2005.

3.6 Instrument development

In this study the following definitions of 4 forms of child maltreatment were used.
These definitions were developed based on reviewing literature and the results of
qualitative study.

Definition of child maltreatment of the study: Child maltreatment is

any forms of sexual, physical and emotional abuse and neglect. In this study,
different forms of child maltreatment were conceptualized as a continuum of
behaviours toward a child aged less than18 year olds.

Physical abuse: Frequency of violence of any adult (in a family and outside a
family) toward a child (under 18 years old) including spanking, pushing, grabbing,
shoving, locking, tying or chaining, kicking or hitting, beating up.
Sexual abuse: Frequency of sexual behaviours between any adult family member
or non-family member and a minor (under 18 years old) against child’s will
including talking in a sexual way, exposing adult’s private part to a child, forcing a
child see sexual scene, touch or fondle adult’s private parts, touching or fondling
child’s private parts, attempted intercourse or intercourse.
Emotional abuse: Frequency of verbal or psychological threats of any adult in
family toward a child (under 18 years) including yelling, insulting, making a child
feel guilty, embarrassing and humiliating a child.
Neglect: Failure of parents or caretakers to provide for a child’s physically and
emotionally fundamental needs including adequate food, clothes, care when child’s
sick, close and sources of strength to a child.

72
Instrument development process

Three instruments were developed for use in this study: a guideline for in-depth
interviews (see Appendix 5); a guideline for focus group discussion (see Appendix
6); and a self-administered questionnaire for the quantitative survey (see Appendix
7). The following steps were applied to develop and finalise the questionnaire as the
key instrument for this research:

• Examination of previous literature;

• Discussions with experts;
• Compilation of draft questionnaire;
• In-depth interview with children, parents and teachers;
• Focus group discussion with children to record their comments on a preliminary
questionnaire;
• Questionnaire modification in response to comments made during the focus
groups and results of the in-depth interviews;
• Pilot survey in both urban and rural districts; and
• Questionnaire finalisation based on results from pilot survey data analysis.

The questionnaire was originally developed in English and then translated into
Vietnamese by two bilingual Vietnamese public health professionals. Back-
translation was then undertaken by another bilingual Vietnamese person with post
graduate qualifications in social science. The back-translation version was reviewed
by an English native speaking expert to confirm its equivalence with the original.

The same version of the questionnaire was administered to juniors in lower

secondary schools (grades 7, 8 and 9) and the senior cohort in upper secondary
schools (grades 10 and 11).

73
Main contents of the questionnaire

The questionnaire for the pilot study consists of the following sections:

• Demographics
• Family environment
• School and work
• Childhood experiences: It includes 4 scales measuring four forms of child
maltreatment (physical, emotional maltreatment sexual abuse, and neglect), and 4
scales measuring physical health problem and mental health (depression, anxiety,
self-esteem). This section also consists of 11 items measuring health risk
behaviours.

Child maltreatment scales:

In the childhood experiences section, questions measuring four forms of child

maltreatment were developed. Mostly, these were modified from various sets of
questionnaires previously used internationally and demonstrated to have good
internal consistency (α coefficient) including: the Revised Conflict Tactics Scale
(Straus, Boney-McCoy, & Sugarman, 1996); the Juvenile Victimization
Questionnaires (JVQ) (Hamby & Finkelhor, 2001); and the Childhood Trauma
Questionnaire (Bernstein et al., 2003). As well, several other scales developed and
used in countries such as Australia (Higgins & McCabe, 2001a), South Africa (Madu
& Peltzer, 1999) and China (Chen, Dunne et al., 2004) were used. In constructing the
items, words reflecting abstract categories or value judgements (e.g., abuse,
perpetrator, victim) were avoided in favour of descriptions that were behaviourally
specific such as “kicking”, “yelling at you”, and “exposing their private parts”. These
4 maltreatment scales were:
• Emotional maltreatment included seven items using a 5-point scale ranging from
never, rarely, sometimes, often, and always.
• Neglect included seven items using a 5-point scale ranging from never, rarely,
sometimes, often, and always.

74
• Physical maltreatment included four items using a 5-point scale ranging from
never, rarely, sometimes, often, and always.
• Sexual abuse consisted of nine items using a 3-point scale (never, once, more
than once).

Physical health problem scale: Self-reported physical health problem scale was
developed including eight items asking about various physical illnesses using a 3-
point scale (never, sometimes, often).

Mental health scales: Self-reported mental health problems included anxiety,

depression, and self-esteem scales.

• Anxiety scale: To the best of my knowledge, no validated or locally

developed anxiety scale is currently available to use for screening in population
based adolescent samples in Vietnam. A review of recent literature reveals that
some published anxiety measures have been validated with normal adolescent
samples in Western countries and show satisfactory psychometric quality.

The State-Trait Anxiety Inventory (STAI) was validated in the United States
among Asian/Pacific Islander in Hawaii and in Belgium (Hishinuma et al., 2001;
Muris, Merckelbach, Ollendick, King, & Bogie, 2002). Muris et al. (2002), in the
same study also tested the quality of five other anxiety scales including the
Revised children’s Manifest Anxiety Scale (RCMAS), the Fear Survey Schedule
for Children - Revised (FSSC-R), the Multidimensional Anxiety Scale for
Children (MASC), the Screen for Child Anxiety Related Emotional Disorders
(SCARED), and the Spence Children’s Anxiety Scale (SCAS) in a large sample
of school adolescents. Psychometric properties of SCAS, MASC, the Social
Anxiety Scale for Adolescents (SAS-A), the Social Phobia and Anxiety
Inventory for Children (SPAI-C), and the Anxiety Sensitivity Index for Children
(ASIC) have also been evaluated in Australia and the United States (March,
Sullivan, & Parker, 1999; Myers, Stein, & Aarons, 2002; Spence, Barrett, &
Turner, 2003; Storch, Masia-Warner, Dent, Roberti, & Fisher, 2004; Valentiner,

75
 Gutierrez, & Blacker, 2002). Generally, these anxiety scales consist of between
20 to 80 items except for SAS-A, and ASIC. Even though we understand that
choosing instruments used internationally will enable systematic comparison
with available data from other countries, after thoroughly reviewing these
validated anxiety measures, no instrument was selected for several reasons. First,
in the context of our project the participants have to answer numerous other
questions in a 35-minute timeframe. It is therefore necessary that the anxiety
measure should be short and succinct. The ASIC, which is brief, was considered
for use in the present study. However, as Stallings and March (1995) suggested in
their comprehensive review of childhood anxiety measures, instruments should
provide reliable and valid ascertainment of symptoms across multiple symptom
domains. With this in mind, although the ASIC consists of 12 items, it is not the
option of choice as it measures only the anxiety sensitivity construct which is
insufficient for the purpose of this study. Second, when using an instrument
originally developed in another language in a new cultural group, it is crucial to
ensure cultural congruence of a construct. The original instruments must use
language and wording in a way that makes sense when translated to the new
study population. None of the brief anxiety scales could completely be translated
into Vietnamese with equivalent meaning.

In the light of these decisions and based on the reviewed literature on anxiety
measures, a short anxiety scale including items measuring various anxiety
symptoms such as separation anxiety, generalized anxiety, social anxiety,
perfectionism, and physical symptoms was developed (Muris et al., 2002; Myers
et al., 2002). This anxiety scale was originally drafted with 16 items using a 3-
point scale (never, sometimes, often). After consulting two bilingual Vietnamese
experts, it was shortened to 14 items. This scale was tested in the pilot study to
determine its quality before using to screen anxiety symptoms in the main survey
of school-based adolescents. Results of exploratory factor analysis and reliability
in terms of internal consistency of this scale are presented in the pilot study
section of this chapter.

76
• Depression scale: The Centre for Epidemiological Studies-Depression Scale
(CES-D) (Radloff, 1977) has been shown to be a reliable measure for assessing
depressive symptoms across race, gender, and age categories. High internal
consistency has been reported with Cronbach’s alpha coefficient ranging from
0.85 to 0.90 in the general population samples tested (Radloff, 1977). The 20-
items have a 4-point scale for most or all of the time to rarely or none of the time
reported for the previous week. It was designed to measure depression symptoms
in community surveys, and has been used extensively with adolescents (Chen,
Dunne et al., 2004; Lam et al., 2004; Radloff, 1991). Cumulative scores can
range from 0 to 60; the higher the score, the higher the depression. The standard
cut-off point of the CES-D for community sample is sixteen (Turk & Okifuji,
1994).

• Self-esteem scale: The Rosenberg self-esteem scale (RSES) (Rosenberg,

1965) has been used. This scale is a 10-item questionnaire that was originally
developed to measure adolescents’ global feelings of self-worth or self-regard.
Five of the 10 items are worded in the positive and the other five items are
worded in the negative. The RSES is commonly administered using a 4-point
response format ranging from strongly agree to strongly disagree. A cumulative
score can range from 0 to 30 (higher scores indicate higher self-esteem). The
scale generally has favourable reliability, test-retest correlations are typically in
the range of 0.82 to 0.85 after a 1-week interval or a 2-week interval respectively,
and Cronbach’s alpha coefficient for various samples are in the range of 0.77 to
0.88 (Miyamoto et al., 2000).

Health risk behaviour measure: Health risk behaviours are actions people
take that can be harmful to their health and well-being such as substance use and
drug abuse, binge drinking, fighting, and suicide (Zweig, Lindberg, & McGinley,
2001). In this study, eleven items measuring health risk behaviours have been
adapted from the Questionnaire of Youth Risk Behaviour Survey (YRBS) developed
by the Centres for Disease Control and Prevention in the United States in 1990. The
questionnaire originally included approximately 88 items and has demonstrated good

77
reliability (Brener, Collins, Kann, Warren, & Williams, 1995; Grunbaum, Lowry,
Kann, & Pateman, 2000). Eleven adapted items refer to severe sadness or
hopelessness, suicidal attempt, suicide planning, cigarette smoking, alcohol drinking,
eating disorders and violence-related behaviours using Yes/No response options.
YRBS had been widely used in various studies among adolescents in Asian countries
such as China (Chen, Dunne et al., 2004) and Thailand (Ruangkanchanasetr,
Plitponkarnpim, Hetrakul, & Kongsakon, 2005).

3.7 Sample selection

A two-stage cluster sampling technique was employed. The sampling procedure is

depicted in the following chart (see Figure 3.2). Districts were purposely selected.
Schools within districts were randomly selected. Then classes within schools were
randomly chosen. All students in randomly selected classes were invited to
participate in this study.

Two districts Chi Linh

purposively
Dong Da
selected

Stage 1 2 secondary 2 high 2 secondary 2 high

(randomly-selected
schools schools schools schools
schools)

Stage 2*
(randomly- 18 classes 12 classes 18 classes 12 classes
selected classes) (6 for each (6 for each
(6 for each (6 for each
grade) grade)
grade) grade)

* Each randomly selected school had 3 classes per grade taking part in the
research. All students in each randomly selected class were invited to participate
in the study.
Figure 3.2: Two-stage cluster sampling

78
3.8 Data collection

The questionnaires were self-administered in school classrooms in single sessions

during regular school hours in the pilot study and the main survey. At the time of the
survey, the study purposes were explained to students. They were told that
participation was voluntary, their responses would be anonymous, there were no
right or wrong answers, and they could stop or withdraw from participation at any
time. To protect confidentiality and to ensure standard administration procedures,
anonymous questionnaires were administered by trained researchers without the
presence of class teachers. Students were asked to focus on their own responses
without any discussion. Study participants put completed questionnaires in sealed
envelopes. The field manual for collecting data was developed to provide practical
information necessary to ensure that standard methods were used to collect data in all
participating sites.

3.9 Data management

Qualitative data

All in-depth interviews (16 interviews) and focus group discussions (8 FGDs with an
average of 6-8 students for each FGD) were audio taped and trained researchers also
took manual notes. All audio taped interviews and FGDs were transcribed into
Vietnamese.

Quantitative data
In order to ensure data integrity, the following steps were taken:
• A coding manual was developed for the pilot survey and modified for use in the
major survey.
• Two experienced researchers cleaned all the returned questionnaires for
inconsistent responses and non-responses before conducting data entry.

79
• It was ensured there were no double-ups in ID numbers and all ID numbers were
in range. The IDs for the pilot survey ranged from 1 to 299 and for the major
survey ranged from 1 to 2591.
• Data was entered into Microsoft Access database by two experienced research
assistants. Double entry verification was used on a random sample of 10% of the
returned survey questionnaires.
• Frequency distributions of all variables were generated and checked for invalid
response codes and the degree of missing data.
• Inconsistent responses were again checked with the original questionnaire.

All data were kept in a locked cabinet and on a password-protected computer.

3.10 Data analysis

Qualitative data: Data analysis was done thematically using open coding,
which is the process of breaking down, examining, comparing, and conceptualizing
data (Strauss & Corbin, 1998) to identify common major themes and sub-themes.
Thematic analysis (Morse & Field, 1996) was chosen as the analytic approach
because the qualitative study stage in this project is exploratory, rather than being
aimed at testing a particular hypothesis about child maltreatment.

Quantitative data: Appropriate statistical analysis was performed using Survey

Data Analysis – SUDAAN 7.5.2a; Analysis of Moment Structures - AMOS 5.0 and
the Statistical Package for Social Sciences - SPSS (version 12 and 14) for Windows.
SUDAAN 7.5.2a was used for calculating design effect to estimate sample size for
the major survey. AMOS 5.0 was used to perform confirmatory factor analysis for
scales measuring depression (CES-D) and self-esteem (RSES). Other specific tests as
described below were undertaken using SPSS version 12 and 14.

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• Prevalence estimates of different types of child maltreatment and other indices of
interest were provided as the proportion of the entire sample of respondents as
well as for groups of interest, for example, male/female; rural/urban; age groups
and different levels of severity of maltreatment etc.
• Estimates of the magnitude of association between different levels of severity of
various types of maltreatment and risky behaviours were reported as Odd Ratios
(ORs) correlation coefficients (r) for the relationship with physical health and
mental health measures (depression, anxiety, self-esteem).
• Chi-square tests (χ2) and independent t-tests were used to compare the
differences between two groups (for example, gender, region, and age) for
dichotomous and continuous dependent variables respectively.
• Analysis of variance was used to examine the cumulative impact of multiple type
maltreatment experiences on mental and physical health outcomes.
• Logistic Regression modelling was performed to control for possible
confounding to examine the relative impact of each type of maltreatment and
assessment of dose-response relationships between the number of types of
maltreatment and health risk behaviours.
• Multiple Regression modelling was employed to control for possible background
variables to explore the relative effects of child maltreatment on physical and
mental health measures.

Derivation of Variables

• Estimates of participants’ family economic status: We used a proxy measure

asking participants: “In total, how many vehicles (belong to your parent, you and
siblings) does your family have?” Based on their answers we divided their family
economic status into three groups as follows:

ƒ High: if families had at least one car.

ƒ Medium: if families had one or more motorbikes and no car; and
ƒ Low: if families had only one or more bicycles, no motorbike and no car.

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• Prevalence estimates for particular types of child maltreatment: From the
literature review it is clear that researchers studying child maltreatment continue
to struggle with an optimal operational and compatible definition of each type of
child maltreatment (Manly, 2005). No single definition is likely to be appropriate
for every purpose. Some studies have reported prevalence of various forms of
maltreatment based on response to only a few questions, such as “Being beaten
up, hit with an object, kicked, or some other form of physical force”; “Someone
is intentionally trying to hurt you emotionally with words or actions”; “Someone
in your family or another person does sexual things to you or makes you do
sexual things to them that you don’t want to” (Moran et al., 2004). However,
Bolen and Scannapieco found in their meta-analysis of prevalence of CSA that
such brief measures tend to produce artificially low estimates. Some researchers
have attempted to define severity of maltreatment based on experts’ judgement.
These judgements vary in the importance they place on either frequency of
maltreatment events or a combination of different abusive acts endorsed by
respondents (Arnow et al., 2000; Chen, Dunne et al., 2004; MacMillan et al.,
1997; May-Chahal & Cawson, 2005; Meston et al., 1999; Scher et al., 2004;
Sebre et al., 2004).

Researchers have used a cut–off point (in child maltreatment scales) to classify
maltreated and non-maltreated groups as well as the levels of severity of
maltreatment. Walker and colleagues (1999) identified a cut-off point for the 28-
item short form of the Childhood Trauma Questionnaire for adult sample in the
US using receiver operating characteristic methods with clinician interviews as
the criterion. Other authors used mean score for the cut-off point for each type of
maltreatment (Clemmons et al., 2003; Higgins & McCabe, 2000a; Varia, Abidin,
& Dass, 1996). Gauthier et al. (1996) also used mean as a threshold and mean
plus .55 standard deviation to distinguish between those who experienced low
maltreatment and those who had high maltreatment. To date, the selection of cut-
points has been arbitrary when classifying maltreated groups and levels of
severity in these studies. It may be preferable to give greater weight to
experiences that are considered as more damaging to the victims when defining

82
maltreatment. For example, being kicked or stabbed would be expected to be
worse than being slapped, or a parent saying they wish “you were never born”
would be considered more severe than a parent yelling at you in anger.
Unfortunately, there is not enough empirical evidence to reach consensus on the
differential impacts of these acts for various forms of maltreatment (Bremner,
Vermetten, & Mazure, 2000; Finkelhor, Hamby, Ormrod, & Turner, 2005).

At present, what defines maltreatment is a matter of vigorous debate. There is no

universally accepted criterion for researchers studying child maltreatment in
different countries and study populations to classify severity in estimates of
maltreatment prevalence. One reason is that it is extraordinarily difficult (if not
impossible) to determine a single criterion for severity that is “culture free”. One
imperfect but nevertheless practical alternative is to judge “severity” (e.g.
distinguish between nil, minor, and severe maltreatment) in the basis of variation
in samples drawn from within the population(s). In Vietnam at this time it is not
yet possible (without very extensive further study) to know if there is consensus
among the general public or among the (few) local child protection experts
regarding which combination of events and frequency of acts defines
maltreatment.

In this study, we used the mean score as cut-off point to estimate maltreatment
prevalence as follows: adolescent respondents who scored above the mean and
scored above the mean + 1.0 standard deviation (SD) on the subscales measuring
child emotional maltreatment, physical maltreatment, sexual abuse, and neglect
were classified as having minor maltreatment/unpleasant experience or more
severe level of that type of maltreatment. For example, in the major survey we
used the 5-point physical maltreatment scale with 6 items ranging from never,
rarely, sometimes, often, and always and coded as 1, 2, 3, 4, and 5 respectively.
As a result, the total scores of this scale can range from 6 (if participant
responded never for all 6 items) to 30 (if respondent endorsed always for all
items). The results of mean and SD of this scale in the major survey were 7.85
and 1.95 respectively. Then, physical maltreatment prevalence was estimated as

83
 follows: respondents who had mean score equal or higher than 8 but less than or
equal to 10 (10≥mean score≥8) were classified as minor physical maltreatment.
Those with a mean higher than 10 (>10) were considered to have more severe
physical maltreatment. As a result, physical maltreatment prevalence was the
sum of the number of respondents classified as minor and more severe physical
maltreatment.

This approach to defining maltreatment is not perfect. However, one benefit is

that it takes into account the presence of the abusive events and the frequency of
each event. As a result, this could reduce the problem of inclusion of too many
false positives in the maltreated group in comparison with the approach of using
“event/non event” in previous studies. For example, a study in Israel that used the
“event/non event” approach reported more than half of the sample experienced
psychological maltreatment and nearly 90% experienced physical abuse
(Elbedour et al., 2006). In the present study, if we adopted the same approach, the
proportion of adolescents classified at having any experience of at least one event
type (emotional, physical and neglect domains) are also very high (90%, 70%
and 50% respectively, see chapter 4, page 112). In addition, as mentioned earlier,
the use of mean scores as the cut-off point to estimate maltreatment prevalence
takes into consideration the norms of the local population.

In sum, it is recognised that although there are limitations of using the mean (and
mean plus 1.0 SD) as cut-off points for classifying maltreatment, this approach
does at least incorporate a balance between event exposure and severity, and thus
overcomes some measurement problems identified in previous research.

3.11 Ethics approval

Approval to conduct the research was granted from Queensland University of

Technology, Australia and the Hanoi School of Public Health, Vietnam.

84
Before data collection at the two study sites written approval from the Hanoi
Education Bureau, Dongda district Education Department and Chilinh Education
Department was achieved. Information on the research was provided to participating
principals and class teachers and all gave their permission to conduct the study in
their schools and classes. Participants were recruited on a voluntary basis following
informed consent of children, teachers and parents (in the qualitative research stage)
as well as passive consent of parents, whose children voluntarily participated in the
quantitative study. All were advised they could withdraw at any time, and that refusal
or withdrawal would not have an effect on them in any way.

There was the potential for distress among participants during or after data collection
sessions, especially for those who experienced child maltreatment. They could
contact available persons from schools (Youth Union) or Women Union, as the local
communities belonged to a support network for social issues, including children and
women’s issues. The principal investigator contacted the network in advance to
ensure the availability and accessibility of the support service and provided contact
details for participants.

3.12 The qualitative and pilot studies

Qualitative study

The qualitative study included in-depth interviews with teachers, parents and
students (4 teachers: 1 male and 3 females; 4 parents: 2 males and 2 females and 8
students – 4 boys and 4 girls in both lower secondary schools and upper secondary
schools) in both study sites and 8 FGDs (4 FGDs for each study site: 2 groups of
boys and 2 groups of girls from both lower secondary schools and upper secondary
schools) with 6-8 students in each FGD. This work was conducted from January to
March 2004. In-depth interviews lasted between 45 and 60 minutes and the FGDs
lasted about one and a half hours.

85
Eight major themes emerging from accounts provided by students, parents and
teachers including:

• Perception/meaning of child abuse

• Types of abuse

• Different thinking about child physical punishment

• Child maltreatment examples

• Potential perpetrators

• Perceived trend of child abuse prevalence in Vietnam

• Sources of information on child abuse

• Expected measures to prevent child abuse

More details of these common themes are provided in Appendix 8.

The main modifications of the questionnaire following the qualitative study were to:

• Add examples for several questions to help participants to better understand such
as questions about their fathers and mothers occupation (Q12), emotional support
(Q 16) and risky behaviours (Q36 - item g and i).

• Add a clear instruction sentence in section 5 asking about physical abuse (Q43-
Q50).

• Add more detailed options for Q51.6.1 and Q52.7.1 asking about perpetrators
who tried to have, or had sexual intercourse with respondents.

• Change wording in Vietnamese language for Q51 (item a, f, and g) but ensure the
equivalent meaning in the English language version.

The results of the qualitative analysis and comments by children in the draft
questionnaire from FGDs were taken into account to ensure the cultural
appropriateness and clarity of structure, content and wording used in the

86
questionnaire and for interpreting and discussing major study findings from a cultural
perspective.

The pilot study

The pilot study took place at four schools including one lower secondary school and
one upper secondary school in each study site in May and June 2004. All students, in
one grade 7 class and one grade 9 class in each secondary school as well as one grade
11 class in each upper secondary school, resulting 6 classes in total, were invited to
participate in the study. For the pilot study, on the agreed dates with the schools,
research assistants distributed a questionnaire to all students in the selected classes.
To protect confidentiality and to ensure standard administration procedures,
anonymous questionnaires were administered without the presence of class teachers.
First of all, researchers explained the purpose of the research to the children who
were allowed to ask questions related to the research. Then they were asked to
complete the questionnaire to the best of their knowledge. Respondents were
encouraged to participate but it was also made clear to them beforehand that those
who did not want to participate should feel free to decline or could skip portions of
the questionnaire with which they were not comfortable. All participants completed
the questionnaire within 30 minutes. The completed questionnaires were put in blank
envelopes by students. These four schools also participated in the major study.
However, all of the classes that participated in the pilot study were excluded from the
list of classes selected randomly for the major survey.

The pilot study was conducted among 326 participants. Twenty-seven returned
questionnaires missing one section or more than 2 items in any scale were excluded.
Data entry was undertaken for 299 completed questionnaires. The response rate was
91.6 per cent.

87
Sample demographics and family characteristics

All respondents were aged between 13-18 years (mean = 15.05; SD = 1.64). The age
distribution of the pilot sample is presented in Figure 3.3. Most students were 13, 15
and 17 years of age (31.1 per cent, n = 93), 15 (29.4 per cent, n = 88), and 17 (33.1
per cent, n = 99). Very few respondents reported their age was 14, 16 and 18 years
because the students recruited for the pilot study belonged to grades 7, 9 and 11
which were equivalent to the age of 13, 15, and 17 respectively.

This sample consisted of 51.8 per cent females and 48.2 per cent males. Almost all
participants belong to the Kinh ethnic majority group (98.7 per cent, n = 295). Most
respondents were living with both their natural parents (88.3 per cent, n = 264).
Small groups of participants were living together with their natural mother or natural
father alone or none of their natural parents (4.3 per cent, n = 13; 2.0 per cent, n = 6;
2.7 per cent, n = 8 respectively). Very few were living with their natural mother and
step father (1.3 per cent, n = 4). Only one respondent (0.3 per cent) was living with
their natural father and step mother. Regarding participants’ parental status, 91.6 per
cent (n = 274) of parents were living together, 3.7 per cent (n = 11) were divorced,
2.0 per cent (n = 6) were separated and 2.3 per cent (n = 7) of parents had died (one
or both). Very few participants (n = 7) said that their parent(s) ever had problems
with drugs or alcohol. Most participants never witnessed a fight between their
parents (82.6 per cent, n = 247). Thirty nine respondents (13 per cent) said that they
were rarely exposed to their parents’ fighting. A few participants (2.7 per cent, n = 8)
were exposed sometimes and only two people (0.7 per cent) witnessed a fight often.

18 years
1.0% 13 years
17 years
31.1%
33.1%

14 years
16 years
3.3%
2.0% 15 years
29.4%

Figure 3.3: Age distribution of pilot sample

88
Quality of the scales

Internal consistency

Scale reliability in terms of internal consistency (Cronbach’s Alpha: α) of 8 scales

was calculated and the results are summarized in Table 3.1. The CES-D (20 items)
has been used in many studies of different samples including clinical samples,
general adult samples, adolescent samples in different nations including Asian
countries such as China and Japan, which show good internal consistency with α
range from .81 to 0.89 (Chen, Dunne et al., 2004; Greenberger, Chen, Dmitrieva, &
Farruggia, 2003; Iwata, Saito, & Reberts, 1994; Radloff, 1977). In this study, the
CES-D also shows good internal consistency (α = .87). Psychometric evaluations of
the RSES have shown it to have adequate internal reliability. For this adolescent
sample a reasonable α value was also obtained (α = .78). Reliability in terms of
internal consistency of other scales used in this study was also quite good with alpha
values generally well above .70 and .80 (Pallant, 2001). The only notable exception
was the physical maltreatment scale which had an alpha of .40 (this scale includes 4
items).

The physical maltreatment scale used in this study had two items including several
acts in one item which should be separated into different items such as “locking,
tying up and chaining”, “spanking, kicking, hitting and beating up”. For the main
survey these two items were split into four items resulting in six items in total in this
scale. The improvement of the internal consistency of this scale will be reported in
the chapter on the main survey results.

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 Table 3.1: Pilot study: Internal consistency of the scales

No Scales Number of items Cronbach’s Alpha

1 Emotional abuse scale 7 .76
2 Neglect scale 7 .74
3 Sexual abuse scale 8 .79
4 Physical abuse scale 4 .40
5 Physical health scale 8 .77
6 Anxiety scale 13 .82
7 Depression scale (CES-D) 20 .87
8 Self-esteem scale (RSES) 10 .78

Exploratory factor analysis of anxiety scale

An exploratory factor analysis was conducted on the anxiety scale using principle
components analysis (PCA). Before performing PCA the suitability of data for factor
analysis was assessed. The Kaiser-Mayer-Oklin value was .82 exceeding the
recommended value of .60, and the Barlett’s Test of sphericity was statistically
significant (.0001), supporting the factorability of the correlation matrix. The number
of factors retained was identified by screeplot and the extracted factors were
subjected to an oblique rotation. The screeplot revealed a clear break of slope
between three and four factors, therefore three factors were rotated. The first three
factors had the following eigenvalues: 3.87, 1.49, 1.19. The rotated loading of
anxiety items on each three components are presented in Table 3.2.

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 Table 3.2: Pilot study: Rotated loading of the anxiety scale

Component
1 2 3
Afraid to be alone in the house .783 .052 .140
Scared if I sleep away from home .752 .006 .292
Worry about sleeping alone .718 .148 -.047
Cry easily .532 .287 .102
When I feel frightened, it is hard to breath or I .056 .683 .052
sweat a lot
Difficulty falling asleep .010 .579 .194
Nightmares about something bad happening .197 .547 .181
to myself or to my family
Frightened for no reason at all .124 .535 .066
Startle easily .384 .523 .101
Feel nervous with people I don't know well .250 .233 .727
Something bad will happen .084 .306 .669
Worry about how well I do things .074 .371 .581
Worry about being as good as other kids .055 .284 .538

Per cent of variance explained 18.07% 17.44% 13.92%

Only items loading above .50 were used to form the factors. One item (“Nervous
when I have to do some things while people are watching me”) loaded lower than 0.3
in all factors and was removed. Factor 1 (4 items) accounted for 18.07 per cent of the
variance, factor 2 (5 items) for 17.44 per cent of variance and factor 3 (4 items) for
13.92 per cent. Three factors of this anxiety scale were named fears, tension and
worries which are reliable in terms of internal consistency with Cronbach’s Alphas
are .72, .64; and .62 respectively. The results of the analysis support the use of the
anxiety scale (13 items) to screen for this mental health problem in the adolescent
sample in the major survey.

91
Confirmatory factor analysis of depression and self-esteem scales

Confirmatory factor analysis (CFA) was employed using AMOS 5.0 to test the extent
to which the CES-D and RSES data from this pilot sample conformed to the factor
models; four factors for CES-D (Radloff, 1977) and two factors for RSES
(Greenberger et al., 2003), obtained in previous studies. Radloff (Radloff, 1977)
named CES-D’s four factors as depressed affect (7 items), positive affect (4 items),
somatic and retarded activity (7 items), and interpersonal (2 items). Two factors of
RSES contain five positively worded items and five negatively worded items. The
results of CFA conducted for these two scales are presented in Table 3.3. The factors
of these two scales were specified as intercorrelated (See Appendix 9) and goodness
of fit was determined on the basis of several indices: Chi-square (χ2), comparative fit
index (CFI), goodness-of-fit index (GFI), normed fit index (NFI), and root mean
square error of approximation (RMSEA). The Chi-squared test of overall model fit is
required to be non-significant which implies that the model fits. However, as
suggested by researchers that due to its sensitivity to sample size, non-normality and
model complexity, even small differences in model fit are statistically significant. It
may therefore have been unrealistic to use χ2 test as the index of fit. However, a
range of indices, as mentioned above, associated with the χ2 test could be used to
assess the extent to which these scales fit with original models (Nguyen, Kitner-
Triolo, Evans, & Zonderman, 2004; Wells & Cartwright-Hatton, 2004).

Table 3.3: Pilot study: Summary of the fit statistics of CES-D and RSES

Scales χ2 df GFI CFI NFI RMSEA

CES-D 1371* 164 .944 .912 .901 .053
RSES 281* 34 .978 .948 .941 .053

* p< 0.05

The GFI compares the postulated model with no model and its value range from 0 to
1 (with values closer to 1 representing a good fit). The NFI quantifies the amount of

92
variation and covariation accounted for a particular model by comparing the relative
fit of the given model with the fit of a baseline model (NFI ranges from 0 to 1).
Higher values indicate greater covariation accounted for; values above .90
determines an excellent model (Bentler, 1992). CFI, measuring the quality of model
fit with a value more than .90 indicating a good fit of the data, is independent of
sample size, and takes the complexity of the model into account and compares the
baseline model with the independent model. RMSEA takes into account the error of
approximation in the population. Values less than .05 present a good fit, 0.06-0.08
indicate reasonable fit. Recently, RMSEA has been recognised as one of the most
informative criteria in covariance structure modelling (Byrne, 1998; Nguyen et al.,
2004).

CFA results from our pilot study demonstrated that the same four-factor model of
CES-D and two factor model of RSES could be replicated in our adolescent sample.
This supports the use of these scales to measure depression and self-esteem in the
major survey.

Maltreatment experiences

Table 3.4 and table 3.5 depict frequencies of different items included in the scales
measuring emotional, physical, sexual maltreatment and neglect. Participants’
responses to almost all items and generally frequencies reduced according to the
level of severity. Only one item in the sexual abuse scale had no response “made you
see sexual scenes in reality”. Therefore this item was removed in the final
questionnaire.

Missing values of each item are quite low (from 0 to 1.3 per cent). It is clear from
this result that participants in this study were willing to respond to questions
regarding a sensitive topic. Non-response rate to child sexual abuse events (0.3 to 1.0
per cent) is the same as other forms of maltreatment (0.3 to 1.3 per cent).

93
After asking sexual acts experienced, participants were asked a question “How old
were you the first time any of these things happened?”. Age at the first time any of
the sexual acts happened ranges from 5 to 17 years with the highest rate at 12 years
of age (19.5 per cent, n = 8/41), then at 15 years of age (14.6 per cent, n = 6/41), and
at 10 years of age (12.2 per cent, n= 5). However, the feedback of research assistants
that participants had difficulties when answering this question as those who
experienced several acts reported they could not determine which act they should
provide information about the age when these adverse sexual acts happened. In the
final questionnaire we therefore collected separate information concerning age at
first sexual abuse experience for attempted rape and rape events only.

Table 3.4: Pilot study:

Frequency of emotional, physical maltreatment acts and neglect

Maltreatment acts Never Rarely Sometimes Often Always No

(%) (%) (%) (%) (%) answer
(%)
Emotional
maltreatment acts
Yell at you 6.0 31.8 55.9 6.4 0.0 0.0
Insult you 77.9 14.0 6.0 1.3 0.0 0.7
Try to make you feel 24.4 30.1 38.5 5.4 0.7 1.0
guilty
Embarrass you in front 83.3 12.4 3.7 0.3 0.0 0.3
of others
Make you feel like you 77.6 14.4 6.4 0.7 0.3 0.3
are a bad person
Wish you were never 90.0 7.0 2.3 0.7 0.0 0.0
born
Threaten to hurt or kill 88.0 7.4 2.3 1.7 0.0 0.7
you

Physical
maltreatment act
Pushing, grabbing, 66.6 25.8 6.0 1.7 0.0 0.0
shoving you or
throwing something at
you
Locking you up, tying 97.0 2.0 0.0 0.0 0.0 1.0
or chaining you

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Table 3.4: continued
Maltreatment acts Never Rarely Sometimes Often Always No
(%) (%) (%) (%) (%) answer
(%)
Spanking, kicking, 53.2 34.1 10.7 1.0 0.7 0.3
bitting, beating or
hitting you with fist or
other object
Choking, burning, 97.3 1.3 0.0 0.0 0.0 1.3
scalding, using a knife
on you

Neglect
Not enough food to eat 96.7 1.3 1.7 0.0 0.3 0.0
Had to wear dirty 99.3 0.7 0.0 0.0 0.0 0.0
clothes
Not taken care of when 92.6 5.4 1.0 0.0 0.3 0.7
you were sick

Didn’t make you feel 61.9 18.7 14.4 3.3 0.3 1.3
important

Didn’t look out for you 72.2 17.4 8.4 1.3 0.3 0.3
Were not close to you 66.6 15.1 13.7 3.3 1.0 0.3

Were not a source of 75.6 12.0 7.4 3.3 1.0 0.7

strength for you

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 Table 3.5: Pilot study: Frequency of sexual abuse acts

Abuse acts Never Once More than No

(%) (%) once (%) answer
(%)
Spoken to you in a sexual way 88.3 5.0 6.4 0.3

Exposed their private parts to you 97.7 1.3 0.7 0.3

Made you see sexual scenes on 98.3 0.7 0.7 0.3

video, porn magazines, photos
Made you see sexual scenes in 99.3 0.0 0.0 0.7
reality
Touched or fondled your private 89.3 5.0 4.7 1.0
parts
Made you touch or fondle their 97.0 1.3 0.7 1.0
private parts
Tried to have sexual intercourse 98.0 0.7 0.7 0.7
with you but was unsuccessful
Had sexual intercourse with you 98.0 0.7 0.7 0.7

Table 3.6: Pilot study: Prevalence of different forms of child maltreatment

Region
Chilinh Dongda Both regions
M F T M F T M F T
(%) (%) (%) (%) (%) (%) (%) (%) (%)
Emotional maltreatment
No 55.7 54.7 55.2 55.4 46.4 50.7 55.6 51.0 53.0
Minor 35.4 34.9 35.2 41.5 46.4 44.0 38.2 40.0 39.1
Severe 8.9 10.5 9.7 3.1 7.2 5.2 6.3 9.0 7.7
Prevalence* 44.3 45.4 44.9 44.6 53.6 49.2 44.5 49.0 46.8
Physical maltreatment
No 36.7 39.5 38.2 36.9 52.2 44.8 36.8 45.2 41.1
Minor 57.0 54.7 55.8 58.5 46.4 52.2 57.6 51.0 54.2
Severe 6.3 5.8 6.0 4.6 1.4 2.9 5.6 3.9 4.7
Prevalence* 63.3 60.6 61.8 64.1 47.8 55.2 63.2 54.9 58.9
Sexual abuse
No 83.5 87.2 85.5 75.4 82.6 79.1 79.9 85.2 82.6
Minor 11.4 9.3 10.3 21.5 13.0 17.1 16.0 11.0 13.4

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Table 3.6: continued
Region
Chilinh Dongda Both regions
M F T M F T M F T
(%) (%) (%) (%) (%) (%) (%) (%) (%)
Severe 5.1 3.5 4.2 3.1 4.3 3.7 4.2 3.9 4.0
Prevalence* 16.5 12.8 14.5 24.6 17.3 20.8 20.2 14.9 17.5
Neglect
No 55.7 61.6 58.8 63.1 55.1 59.0 59.0 58.7 58.9
Minor 35.4 29.1 32.2 30.8 33.3 32.1 33.3 31.0 32.1
Severe 8.9 9.3 9.0 6.2 11.6 9.0 7.6 10.3 9.0
Prevalence* 44.3 38.4 41.2 37.0 44.9 41.1 40.9 41.3 41.1

* Prevalence = minor maltreatment + more severe maltreatment

M: Male; F: Female; T: Total

Prevalence of particular types of child maltreatment was calculated as described in

the previous section entitled Derivation of variables (page 81-82) and presented in
Table 3.6 according to gender and region. It is clear that child maltreatment in this
population is not uncommon. The most common form is physical abuse (58.9 per
cent), while emotional abuse and neglect is self-reported by approximately 40 per
cent to 50 per cent of the participants. Prevalence of sexual abuse is approximately
18 per cent for this sample. Surprisingly, the rate of sexual abuse among males was
higher than females in both urban (male: 24.6 per cent; female: 17.3 per cent) and
rural (male: 16.5 per cent; female: 12.8 per cent) areas.

Table 3.7: Pilot study: Prevalence of multiple forms of maltreatment

Region
Chilinh Dongda
Male Female Total Male Female Total
(%) (%) (%) (%) (%) (%)
No maltreatment 19.0 26.5 22.4 18.5 26.1 22.4

One form of maltreatment 29.1 22.1 25.5 26.2 20.3 23.1

Two forms of maltreatment 21.5 29.1 25.5 29.2 23.2 26.1

Three forms of maltreatment 25.3 16.3 20.6 20.0 24.6 22.4

Four forms of maltreatment 5.1 7.0 6.1 6.2 5.8 6.0

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The prevalence estimates of multiple forms of abuse are presented in Table 3.7. It
can be seen that in total approximately 80 per cent of the respondents experienced at
least one form of maltreatment although it is acknowledged that this would include
rare or occasional and possibly mild adverse experiences. Approximately 30 per cent
of participants reported three and four forms of maltreatment experiences.

Correlates of maltreatment with health outcomes: Bivariate

analysis

Statistically significant associations were detected between different forms of

maltreatment and various health outcomes. The correlation coefficients are presented
in Table 3.8 below.

Table 3.8: Pilot study:

Correlation between abuse and physical and mental health outcomes

Physical health Depression Anxiety Self-esteem

Emotional abuse .300** .361** .351** -.246**
Physical abuse .311** .254** .301** -.057
Sexual abuse .158** .143** .088 -.112
Neglect .200** .292** .194* -.244**

** Correlation is significant at the 0.01 level (2-tailed)

Differences between maltreatment experience groups and mental

health outcomes

A one-way between-groups analysis of variance was conducted to examine the

associations between abuse experiences and mental health symptoms (depression,
anxiety and self-esteem). Across types of maltreatment respondents were divided
into three groups (group 1: no maltreatment, group 2: minor maltreatment, and group
3: more severe maltreatment; see Table 3.6). Post-hoc comparison using the Tukey
test indicated that there were statistically significant differences in most of the

98
comparisons except physical abuse and sexual abuse and self-esteem, and sexual
abuse and anxiety (see Table 3.9)

Table 3.9: Pilot study: Differences between abuse experiences groups and
mental health outcomes
Depression Anxiety Self-esteem
Emotional abuse F (2, 296) = 21.8 F (2, 296) = 13.9 F (2, 296) = 8.2
p = .0005 p = .0005 p = .0005
Physical abuse F (2, 296) = 7.1 F (2, 296) = 13.1 Not significant
p = .001 p = .0005
Sexual abuse F (2, 296) = 3.6 Not significant Not significant
p = .029
Neglect F (2, 296) = 15.0 F (2, 296) = 8.8 F (2, 296) = 6.6
p= .0005 p = .0005 p = .002

Calculating design effect for cluster sampling

Based on the data collected from the pilot study with the estimated prevalence of
each type of child maltreatment, total depression, anxiety, self-esteem, and physical
health problem scores as the outcome variables, the design effect for each variable
were calculated using statistical package (SUDAAN 7.5.2a). The result shows that
design effects were approximately 1.0. It means that it is no need to take into account
an inflation factor for clustering in our sample calculation and analysis in the main
survey.

Calculating sample size

To determine sample size for the main survey the formula estimating the difference
between two population proportions with specified absolute precision was employed
(Lwanga & Lemeshow, 1991).

99
• Power of 90%
• Significance of 5%

Sample size per group = Z2 1-α/2 [P1 (1 - P1) + P2 (1 – P2)]/d2

where P1 is the proportion expected in group 1 (boys) and P2 is the proportion
expected in group 2 (girls); d is the minimum detectable difference = 0.07 (for this
study)

From the pilot data a possible sample size for each type of maltreatment to detect the
difference in proportion between boys and girls who experienced that type of
maltreatment was calculated. Results show that biggest sample size (1,150 for each
group) was required in order to detect the difference of physical maltreatment
experienced by boys and girls (with P1 = 63.2 per cent, and P2 = 54.9 per cent). From
the pilot survey it was known that the rate of non response was about 10%. Hence,
1265 students in each group would be required, resulting in a total of about 2,500
participants.

3.13 Implications of the pilot study

Data collection procedure

Results of the pilot study confirmed that the procedure for data collection proposed
was appropriate. However, reports from research assistants after conducting the data
collection revealed that some teachers assumed they had the responsibility to collect
data in the class even though we sent them study information and requirements in
advance. To overcome this in the main survey, apart from making sure that teachers
did receive study instruction information, we required research assistants to
personally meet with teachers just before conducting data collection sessions in their
classes to ensure this procedure was followed.

Timing for conducting data collection was also very important. Feedback from the
pilot study revealed that optimal times for data collection were not those days close

100
to the time of regular exams, the beginning of the week or the beginning of a day’s
study session.

Findings

Preliminary findings drawn from the results of the pilot study which informed the
refinement of the main survey instrument and data collection procedure included:

• The instrument developed and selected appears to be validated for use in this
adolescent sample. However, results of the pilot study did show that changes
needed to be made to improve the quality of the questionnaire. Details of these
changes will be presented in the following section.
• Child maltreatment in this adolescent sample is not uncommon and the
prevalence of various forms of maltreatment is comparable with previous studies
in other countries.
• The rate of respondents who reported multiple forms of maltreatment experiences
were not uncommon.
• It is clear that participants were willing to participate in the research related to a
sensitive topic and disclose their unpleasant experiences. Missing data was low
and non response rate of sexual abuse questions was similar to that of other types
of child maltreatment questions

3.14 Changes to the questionnaire

Apart from changes that had been made after the qualitative study already described,
a number of changes were made to the questionnaire following the pilot study. These
included:

• Removal of some questions which were unrelated to major research questions.

• Removal of one item in the sexual abuse scale because no respondent reported
this experience in the pilot study and one item in the anxiety scale based on the
result of exploratory factor analysis.

101
• Adding a question as a proxy to measure economic status (number and type of
vehicles belonging to family members)
• Sessions asking respondents about their experiences of four forms of
maltreatment in part D “Your experiences” was moved to the end of this part
after sessions on physical and mental health and health risk behaviours.
• Physical maltreatment scale was revised (from four items to six items and
removal of some sub-question in this scale.
• Change of question asking about age the first time sexual abuse event occurred.

The final questionnaire consisted of four parts: demographics, family characteristics,

school information, and childhood experiences including self-reported physical
health, mental health and health risk behaviours, emotional maltreatment, neglect,
physical maltreatment, and sexual abuse. The full final questionnaire can be found in
Appendix 7.

102
 Chapter 4:
Prevalence and Characteristics of
Different Forms of Abuse

The following chapters present the results from the major study. As indicated in
Chapter 3, the study was designed to maximise the quality of data collection,
especially disclosure of maltreatment experiences based on ensuring the data
collection procedures and validating the questionnaire.

The main survey was conducted between December 2004 and May 2005. All eight
randomly selected schools were contacted and agreed to participate in the study
resulting in a school response rate of 100%. In total 2,737 students from 61 classes
were invited to participate in the study. Sixty-five students were absent from classes
on the days the data collection took place and 81 returned incomplete questionnaires.
Therefore the response rate of students was 94.7%. The final analysis was based on
data from 2,591 students, after questionnaire with incomplete data were excluded.

The key research questions addressed in this chapter are:

• What is the prevalence of sexual abuse, physical maltreatment, emotional

maltreatment and neglect in the school adolescent sample?
• Is the prevalence of child maltreatment of various forms among adolescents in
school setting significantly different between urban (Dongda district) and rural
(Chilinh district) area.
• Is the prevalence of four forms of child maltreatment significantly different
between these school boys and girls?
• What are the correlations between each form of child maltreatment and various
demographic variables, family characteristics and environment?

103
4.1 Sample characteristics

Demographic characteristics

Table 4.1 displays the demographic characteristics of the sample. The sample
consisted of 1,335 (51.5%) students from the urban area and 1,256 (48.5%) students
from the rural area. Females represent 52.1 % (n = 1,350) and males 47.9 % (n =
1.241). The age range was between 12 and 18 (mean = 14.99, SD = 1.47) in which
98.7% were between 13 to 17 years old. Almost all respondents belonged to the Kinh
majority group of people (99.1%, n = 2,568). About ninety per cent (n = 2,351) of
participants reported that they did not belong to any religion.

Table 4.1: Demographic characteristics of the sample

Number of Percent of
respondents sample
Region ( n = 2,591)
Urban 1,335 51.5
Rural 1,256 48.5
Sex ( n = 2,591)
Male 1,241 47.9
Female 1,350 52.1
Age in years ( n = 2,591)
Range:12-18, Mean (SD): 14.99 (1.47)
12 22 0.8
13 535 20.6
14 515 19.9
15 428 16.5
16 566 21.8
17 513 19.8
18 12 0.5
Ethnic group ( n = 2,591)
Kinh 2,568 99.1
Others 22 0.8
Religion ( n = 2,591)
No 2,351 90.7
Yes 240 9.3
Family economic status (n = 2,585)
High 188 7.3
Medium 2,003 78.6
Low 364 14.1

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Less than one in ten participants (7.3%, n = 188) come from high economic status
families and 14.1 % (n = 364) come from low economic status families. The rest
(78.6%, n = 2,003) have a medium family economic background.

Family characteristics

Characteristics of respondents’ families are presented in Table 4.2. Most of the

respondents have their parents living together (90.6%, n = 2,347). A small proportion
of 4.4% participants’ parents are divorced (n = 115) and the rate of separated couples
was just over one per cent (n = 29). Nearly a hundred of participants’ parents (3.7%)
were deceased (one or both).

Respondents’ parent education is divided into six groups. Twenty five percent (n =
656) of participants’ mother and about thirty one per cent (n = 809) of respondents’
fathers hold a university or a college degree. Nearly twenty per cent (18.1%, n = 469)
of mothers and 15.7 % (n = 407) of fathers had completed technical and vocational
education. Completion rates for upper secondary schools were about the same
(32.9%, n= 852 and 32.5 %, n = 843 respectively) for mothers and fathers.
Completion of secondary school rates were 20.9% (n = 542) and 18.7% (n = 484) for
mothers and fathers. A small number of parents attended only primary schools
(mothers: 2.6%, n = 67 and fathers: 1.9%, n = 48). Five mothers (0.2%) had never
gone to school.

Table 4.2: Family characteristics

Number of Percent of
respondents sample
Parent marital status (n = 2,588)
Living together 2,347 90.6
Divorced 115 4.4
Separated 29 1.2
Death (one or both) 97 3.7
Parents education ( n = 2,591)

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Table 4.2: continued
Number of Percent of
respondents sample
Mother
University and college degree 656 25.3
Completed technical and vocational 469 18.1
education
Completed high school 852 32.9
Completed secondary school 542 20.9
Primary school 67 2.6
No education 5 0.2
Father
University and college degree 809 31.2
Completed technical and vocational 407 15.7
education
Completed upper secondary school 843 32.5
Completed secondary school 484 18.7
Primary school and no education 48 1.9
Parent occupation ( n = 2,591)
Mother
Government staff 877 33.8
Self-employed 535 20.6
Farmer 506 19.5
Unemployment 16 0.6
Home maker 571 22.0
Others 86 3.3
Father
Government staff 1,132 43.7
Self-employed 663 25.5
Farmer 446 17.2
Unemployment 49 1.9
Home maker 100 3.9
Others 201 7.8
Parent drug and/or alcohol problems ( n = 2,582)
No 2,501 96.8
Yes 81 3.2
Whom children currently living with ( n = 2,582)
Live with both natural parents 2,239 86.6
Live with only natural mother 156 6.1
Live with only natural father 47 1.8
Live with natural mother and a 20 0.8
stepfather
Live with natural father and a stepmother 21 0.8
Live with none of natural parents 99 3.9
Number of sibling (n = 2,579)
Alone 296 11.5
Two 1,812 70.1
More than two 471 18.4

106
A significant proportion of respondents’ parents were working for the government
(33.8% mothers and 43.7% fathers). The proportion of parents who were self-
employed is 20.6% (n = 535) for mothers and 25.5% (n = 663) for fathers. The rate
of mothers and fathers who were farmers accounted for 19.5% (n = 506) and 17.2%
(n = 446) respectively. A significant proportion of mothers (n = 571, 22.0%) were
homemakers whereas only 3.9% (n = 100) respondents reported their fathers as
homemakers. A small number of respondents identified their parents were
unemployed (0.6% mother and 1.9% father). Eighty one respondents (3.2%) reported
that their parents had problems with drugs and/or alcohol.

Most respondents (86.6%, n = 2,239) were living with both their natural parents.
Small proportions of children were living with only their natural mother (6.1%, n =
156), their natural father (1.8%, n = 47), natural mother and stepfather (0.8%, n =
20), natural father and stepmother (0.8%, n = 21), and 3.9% (n = 99) respondents
were not living with their natural parents. Only 11.4% (n = 296) respondents reported
that they were the only child in their family. Most respondents (70.1%, n = 1,812)
had one brother or sister and 18.4% (n = 471) participants come from families with
three or more children.

Participants of this study were also asked questions regarding their family
environment including parent quarrelling and fighting; their source of emotional
support (Who do you most often talk to when you need help e.g. sharing feelings,
asking for advice?), and their perceived parental relationship. Their responses are
presented in Table 4.3 below.

About one third of the respondents (29.7%, n = 767) had experienced no parent
quarrels at all in their lifetime. A significant proportion of participants (42.4%, n =
1,093) rarely observed verbal conflict between their parents. And nearly one in three
respondents reported that their parents quarrelled more frequently (sometimes:
24.8% and often: 3.1%). Most respondents (75.1%, n = 1,936) said they had never
witnessed parental fighting. One in four participants reported that their parents
fighting was observed rarely (17.4%), sometimes (6.7%) or often (0.8%).

107
Most respondents perceived their families were very happy (26.7%, n = 690) or
happy (52.4%, 1,353), while a small number of participants considered their parental
relationship was unhappy (3.7%, n = 93) or very unhappy (1.0%, n = 26). However,
there were a significant proportion of participants (16.2%, n = 418) who could not
comment on the quality of their parents’ relationship.

Table 4.3: Family environment

Number of Percent of
respondents sample
Parent quarrelling ( n = 2,579)
Never 767 29.7
Rarely 1,093 42.4
Sometimes 641 24.8
Often 78 3.1
Parent fighting ( n = 2,572)
Never 1,936 75.1
Rarely 446 17.4
Sometimes 171 6.7
Often 19 0.8
Perceived parental relationship ( n = 2,580)
Very happy 690 26.7
Happy 1,353 52.4
Not sure 418 16.2
Unhappy 93 3.7
Very unhappy 26 1.0
Who do you talk to when you need help? ( n = 2,591)
Father 114 4.4
Mother 447 17.3
Brother/sister 378 14.6
Relatives 53 2.0
Friends 1,044 40,3
No one 496 19.1
Others 59 2.3

As far as emotional support was concerned, we asked participants: “who do you talk
to when you need help?”, friends were the main source for about 40% (n = 1,044) of
respondents. Participants’ mothers and brothers/sisters accounted for 17.3% (n =
447) and 14.6% (n = 378) respectively. A small number of participants were mainly
seeking help from fathers and relatives (4.4%, n = 114 and 2.0%, n = 53). There were

108
nearly a quarter of participants (19.1%, n = 496) who had no one to support them
emotionally.

4.2 Adverse experiences and prevalence of four

forms of child maltreatment

In this section adverse experiences reported by respondents are presented first

according to every act included in four scales to measure emotional maltreatment,
physical maltreatment and neglect with rating ranging from never to always, and
sexual abuse with rating ranging from never, once to more than once. Then the
prevalence of the four forms of abuse was calculated according to the method
described in Chapter 3.

Reliability, in terms of internal consistency (Cronbach’s alpha), of the scales

measuring emotional, physical maltreatment, sexual abuse and neglect calculated
based on data from the main survey and results are follows:

• Emotional abuse scale (Mean = 11.87, SD = 3.74): α = 0.81

• Physical abuse scale (Mean = 7.85, SD = 1.95): α = 0.63
• Sexual abuse scale (Mean = 9.26, SD = 2.75): α = 0.75
• Neglect scale (Mean = 9.15, SD = 3.71): α = 0.78

Adverse experiences

Frequencies of series of adverse acts ever experienced by respondents are reported in

Table 4.4, Table 4.5, Table 4.6, and Table 4.7.

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 Table 4.4: Frequency of unwanted emotional acts
(per cent of sample, n = 2,591)

Unwanted acts Never Rarely Someti- Often Always

mes
Yell at you 9.6 33.5 47.5 7.8 1.6
Insult you 69.4 17.7 10.2 2.1 0.6
Try to make you feel guilty 25.2 30.6 36.6 5.7 1.8
Embarrass you in front of
75.7 14.4 8.3 1.2 0.3
others
Make you feel like you are a
68.9 6.8 11.4 2.1 1.6
bad person
Wish you were never born 82.8 8.8 5.5 1.7 1.2
Threaten to hurt or kill you 86.6 9.1 3.3 0.8 0.2

Table 4.5: Frequency of neglect events (per cent of sample, n = 2,591)

Unwanted events Never Rarely Someti- Often Always

mes
Not enough food to eat 93.7 3.9 1.5 0.4 0.5
Had to wear dirty clothes 92.7 2.2 0.4 0.1 0.1
Not taken care of when you
92.2 4.8 1.8 0.5 0.7
sick
Didn’t make you feel
65.6 18.0 12.1 3.0 1.4
important
Didn’t look out for you 73.6 15.6 8.8 1.4 0.5

Were not close to you 71.6 14.6 9.0 3.2 1.6

Were not source of strength
77.4 9.9 6.9 3.4 2.4
to you

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Table 4.6: Frequency of unwanted physical acts (per cent of sample, n = 2,583)

Unwanted acts Never Rarely Someti- Often Always

mes
Pushing, grabbing, shoving
or throwing something at 69.3 21.4 8.6 0.6 0.1
you
Locking you up 93.8 5.2 0.8 0.1 0.0

Tying you up or chaining

94.9 4.4 0.7 0.0 0.0
you

Spanking you 33.8 38.2 25.0 2.7 0.4

Kicking, beating or hitting

81.3 13.0 4.8 0.7 0.2
you with fist or other objects
Choking or burning or
94.2 4.8 0.9 0.1 0.0
scalding you

Table 4.7: Frequency of unwanted sexual events (per cent of sample, n = 2,591)

Unwanted events Never Once More than

once
Spoken to you in sexual way 88.1 6.3 5.6
Exposed their private parts to you 96.7 2.0 1.3
Made you see sexual scenes on video, porn
96.6 2.1 1.4
magazines, photos
Touched or fondled your private parts 92.5 3.9 3.6
Made you touch or fondle their private
97.3 1.1 1.6
parts
Tried to have sexual intercourse with you
96.8 1.3 1.9
but was unsuccessful
Has sexual intercourse with you 97.3 1.9 0.8

Did other things to you in sexual ways 97.8 1.2 1.0

111
The proportions of respondents who experienced at least one adverse event of each
scale were approximately 90%, 70%, 50% and 25% for emotional, physical, neglect
and sexual scales respectively.

Just above three per cent (3.2%) participants had ever experienced attempted rape
once or more than once. And 2.7% respondents reported that they were raped once or
more than once.

Prevalence of child maltreatment

As discussed in chapter 3 about defining the prevalence of different forms of child

maltreatment, for the purpose of this study mean was used as cut-off point for
calculating prevalence: adolescent respondents scored above the mean and scored
above the mean +1.0 standard deviation on the subscales measuring child emotional
maltreatment, physical maltreatment, sexual abuse, and neglect were classified
having minor maltreatment/unpleasant experience or more severe experiences of that
type of maltreatment. It is therefore very important to note that with this approach it
did not mean that respondents who were considered to be not maltreated of any
maltreatment form did not experience any adverse event of this maltreatment scale.

The prevalence of child maltreatment is displayed for the whole sample and for
females and males in two regions separately according to the level of severity (minor
maltreatment and more severe maltreatment) in Table 4.8.

About forty per cent of respondents experienced emotional maltreatment. Prevalence

of emotional abuse is similar between urban and rural areas (39.6% and 39.1%
respectively). However, as we can see in the table female in both regions were
experienced this type of maltreatment more than males.

Nearly half of the sample reported physical maltreatment experiences (47.5%) with
higher proportion among male than female in both regions.

112
Approximately one-fifth (19.7%) of the respondents met the criteria for sexual abuse.
Interestingly, prevalence of sexual abuse was higher in the rural area (22.0%) than in
the urban area (17.6%). And, the proportion of males (26.0%) in the rural region
reported sexual abuse experiences significantly higher than their female counterparts
(18.3%). In contrast, female participants in the urban area reported slightly higher
sexual abuse experiences (18.5%) than male participants (16.4%).

Table 4.8: Prevalence of different forms of child maltreatment

Regions
Forms of Chilinh (rural) Dongda (urban)
maltreatment Male Female Total Male Female Total
(%) (%) (%) (%) (%) (%)

No 63.8 57.5 60.5 63.7 57.4 60.4

Minor 25.5 29.6 27.2 23.1 25.8 24.5
Emotional More 10.7 12.9 11.9 13.2 16.8 15.1
maltreatment severe
Prevalence* 36.2 42.5 39.1 36.3 42.6 39.6
Prevalence of the whole sample: 39.5 (Male: 36.3, Female: 42.5)

No 43.6 59.0 51.6 48.4 57.9 53.3

Minor 45.1 34.2 39.4 40.1 35.5 37.7
Physical More 11.4 6.8 9.0 11.5 6.6 9.0
Maltreatment severe
Prevalence* 56.5 41.0 48.4 51.6 42.1 46.7
Prevalence of the whole sample: 47.5 (Male: 54.0, Female: 41.6)

No 74.0 81.6 78.0 83.5 81.4 82.5

Minor 18.6 15.9 17.2 11.6 16.5 14.2
More 7.4 2.4 4.8 4.8 2.0 3.4
Sexual abuse
severe
Prevalence* 26.0 18.3 22.0 16.4 18.5 17.6
Prevalence of the whole sample: 19.7 (Male: 21.0, Female: 18.5)

No 76.4 69.5 72.8 73.9 63.8 68.7

Minor 13.4 15.8 14.6 14.9 18.2 16.6
More 10.2 14.7 12.6 11.2 17.9 14.7
Neglect
severe
Prevalence* 23.6 30.5 27.2 26.1 36.1 31.3
Prevalence of the whole sample: 29.3 (Male: 24.9, Female: 33.4)

* Prevalence = minor maltreatment + more severe maltreatment

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Just under one-third of participants of the whole sample experienced neglect
(29.3%). The neglect rates were significantly higher among female (urban: 36.1%,
rural: 30.5%) than male (urban: 26.1%, rural: 23.6%) in the two areas. (Appendix 10
summarises proportions and confidence interval for each form of child maltreatment
for Chilinh, Dongda sub-samples and for the whole sample).

Co-occurring maltreatment prevalence is summarized in Table 4.9 for the whole

sample and for females and males in two areas separately. The prevalence of co-
occurrence of child maltreatment was calculated as follows: the number of types of
child maltreatment to which a respondent reported experiencing was summed up.
This summary measure, the co-occurrence maltreatment score, range from 0
(experienced no maltreatment) to 4 (experienced 4 forms of maltreatment).

About two-thirds (67.5%) of the respondents experienced at least one form of

maltreatment. Just one in four and one in five participants suffered one form of
maltreatment (25.9%) and two forms (20.7%) of maltreatment respectively. Nearly
fifteen per cent of respondents reported three forms of maltreatment experience and
about six per cent participants met criteria for all forms of child maltreatment.

Table 4.9: Prevalence of multiple forms of child maltreatment

Regions
Whole
Chilinh (rural) Dongda (urban) sample
Male Female Total Male Female Total (%)
(%) (%) (%) (%) (%) (%)
No
28.5 34.0 31.4 34.3 32.9 33.6 32.5
maltreatment
One form of
28.8 24.5 26.5 26.2 24.8 25.5 25.9
maltreatment
Two forms of
22.1 22.8 22.5 19.8 18.4 19.1 20.7
maltreatment
Three forms of
13.2 12.5 12.8 13.9 18.1 16.1 14.5
maltreatment
Four forms of
7.4 6.2 6.8 5.8 5.8 5.8 6.3
maltreatment

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Significantly higher proportions of co-occurrence of the three forms of abuse were
reported by respondents in urban area (16.1%) than their counterparts in rural area
(12.8%). Females in urban area experienced a co-occurrence of the three forms of
abuse (18.1%) significantly higher than that of males (13.9%).

4.3 Characteristics of child maltreatment

Emotional maltreatment

Perpetrator detail was asked for the most severe adverse event. Respondents were
asked: “When you grew up, did any adults in your family threaten to hurt or kill you?
And if this ever happened who often did this?”. Approximately three hundred and
fifty (13.3%, n = 347)) respondents reported that they experienced this event. Three
hundred and nineteen respondents answered the question about the identity of the
perpetrator (8.1% missing data, n = 28). The most commonly perpetrators reported
were father (30.5%, n = 106), mother (26.5%, n = 92), siblings (16.7%, n = 58), and
relatives (7.7%, n = 27).

Physical maltreatment

Generally speaking, perpetrators of unwanted physical events were father, mother,

siblings, relatives, and neighbour in this order except for pushing, grabbing and
throwing events. Detailed results of perpetrators are summarized in Table 4.10.

115
 Table 4.10: Perpetrators of unwanted physical events

Unwanted acts Fa Mo Si Re Ne St
n (%) n (%) n (%) n (%) n (%) n (%)
Pushing, grabbing, shoving or 112 84 69 35 76 356
throwing something at youa (21.1) (15.7) (11.0) (6.5) (14.2) (66.5)
44 40 24 15 16 41
Locking you upb
(33.8) (30.7) (18.5) (11.5) (12.3) (31.4)
Tying you up or chaining 58 27 22 14 12 28
youc (47.9) (22.3) (18.2) (11.6) (9.9) (23.2)
d 926 919 153 73 33 44
Spanking you
(56.1) (55.6) (9.2) (4.3) (2.0) (2.7)
Kicking, beating or hitting 186 77 89 27 41 81
you with fist or other objectse (43.9) (18.2) (21.0) (6.4) (9.6) (19.2)
Choking or burning or 47 21 22 23 17 34
scalding youf (37.6) (16.8) (17.6) (18.4) (13.6) (27.2)

Fa: Father; Mo: Mother; Si: Siblings; Re: relatives: Ne: Neighbours; St: Strangers
a
796 (30.7%) respondents experienced these events but only 536 respondents
reported perpetrators.
b
160 (6.1%) respondents experienced these events but only 130 respondents reported
perpetrators
c
134 (5.1%) respondents experienced these events but only 121 respondents reported
perpetrators
d
1,716 (66.2%) respondents experienced these events but only 1,650 respondents
reported perpetrators
e
487 (18.7%) respondents experienced these events but only 423 respondents
reported perpetrators
f
153 (5.8%) respondents experienced these events but only 125 respondents reported
perpetrators

Consequences of experiencing any adverse physical event were also reported. Of

1,750 participants responded to the question “how often these incidents give you
bruises or scratches, broken bone or loss teeth”, about one in five (21.3%) reported
that it happened rarely, 7.4% sometimes, 1.7% often and 0.3% always.

Approximately one in ten (11.0%) respondents had rarely needed medical treatment
due to experiencing unwanted physical events. Just above three per cent (3.4%) of
participants who experienced unwanted physical incidents sometimes required
medical intervention. Less than one per cent reported often (0.43%) or always
(0.12%) needed medical treatment after experiencing adverse physical acts.

116
Sexual abuse

The majority of the perpetrators of attempted rape (3.2%, n = 82) and rape (2.7%, n =
71) were male and female strangers, neighbours, fathers, male cousins, mothers, and
brothers and sisters (see Table 4.11)

Table 4.11: Perpetrators of attempted rape and rape

Attempted rape Rape

Perpetrators Number of Per cent of Number of Per cent of
responses responses responses responses
Male stranger 48 20.0 33 29.5
Female stranger 35 14.5 25 22.3
Neighbour 32 13.3 16 14.3
Father 21 8.7 6 5.3
Male cousin 20 8.3 2 1.8
Female cousin 6 2.5 1 0.9
Mother 16 6.7 3 2.7
Uncle 11 4.9 3 2.7
Aunt 11 4.9 3 2.7
Brother 13 5.4 8 7.2
Sister 9 3.7 3 2.7
Other relatives 3 1.3 3 2.7
Others 15 6.2 6 5.3

The mean age of the first time of attempted rape described was 12.3 years (SD 2.54)
ranging from 5 to 17 years old. Similarly, the mean age of the first time rape reported
was 12.2 years (SD 3.35) ranging from 1 to 17 year olds.

4.4 Correlates of child maltreatment

A series of univariate logistic regression analysis and χ2 test for categorical data were
performed to examine the association between each form of maltreatment, divided
into two groups: maltreated and not maltreated, and demographic characteristics,
parent characteristics, child characteristics, and family environment variables.

117
Demographic correlates of child maltreatment

Tests of statistical significance, odds ratios, and 95% confidence intervals for
potential demographic correlates of four types of child maltreatment are displayed in
Table 4.12, Table 4.13, Table 4.14, and Table 4.15.

For emotional maltreatment, gender and age emerged as significant correlates. Girls
were more likely to report history of emotional abuse than boys (OR = 1.30). The
risk of emotional abuse significantly increased when adolescents grew up (OR = 1.40
for group aged 14-15, and OR = 1.62 for group aged >15) (see Table 4.12)

Table 4.12: Demographic correlates of child emotional maltreatment

Number of Number Per Odds ratio P

respondents of abused cent (95 % CI) value
Region
Chilinh 1,256 496 39.5 1.00
Dongda 1,335 528 39.6 1.01 (.86-1.17) NS
Gender
Female 1,350 574 42.5 1.00
Male 1,241 450 36.3 .77 (.66-.90) .001
Age in three
groups
12-13 557 178 32.0 1.00
14-15 943 374 43.3 1.40 (1.12-1.31) .003
>15 (16, 17, 18) 1,091 472 39.5 1.62 (1.31-2.01) .0005
Ethnic group
Kinh 2,568 1,016 39.6 1.00
Others 22 7 31.8 .71 (.029-1.75) NS
Religion
No 2,351 916 39.0 1.00
Yes 240 108 45.0 1.28 (.98-1.68) NS
Family economic
status
Low 364 144 39.6 1.00
Medium 2033 797 39.2 .99 (.78-1.24) NS
High 188 80 42.6 1.13 (.79-1.62) NS

Note: CI = Confidence interval

NS: Not significant

118
Gender is the only demographic variable found to have a statistically significant
association with child physical maltreatment. Males were more likely to report
physical abuse experiences (OR = 1.65) (see Table 4.13)

Table 4.13: Demographic correlates of child physical maltreatment

Number of Number Per Odds ratio P

respondents of abuse cent (95 % CI) value
Region
Chilinh 1,255 607 48.4 1.00
Dongda 1,328 620 46.7 .94 (.80-1.09) NS
Gender
Female 1,345 559 41.6 1.00
Male 1,238 668 54.0 1.65 (1.41-1.93) .0005
Age in three
groups
12-13 555 254 45.8 1.00
14-15 940 453 48.2 1.10 (.89-1.36) NS
>15 (16, 17, 18) 1.088 520 47.8 1.09 (.88-1.33) NS
Ethnic group
Kinh 2,560 1,215 47.5 1.00
Others 22 11 50.0 1.11 (.48-2.56) NS
Religion
No 2,344 1,101 47.0 1.00
Yes 239 126 52.7 1.26 (.96-1.64) NS
Family economic
status
Low 364 176 48.4 1.00
Medium 2026 956 47.2 .95 (.76-1.19) NS
High 187 93 49.7 1.06 (.74-1.50) NS

Note: CI = Confidence interval

NS: Not significant

Child sexual abuse was significantly correlated with region and child family
economic status. Adolescents in Chilinh (rural area) were more likely to report a
history of sexual abuse than adolescents in Dongda (urban area) (OR = 1.32).
Children who came from medium family economic background (OR = .74) were less
at risk of sexual abuse than children from low family economic background (see
Table 4.14).

119
 Table 4.14: Demographic correlates of child sexual abuse

Number of Number Per Odds ratio P

respondents of abused cent (95 % CI) value
Region
Dongda 1,334 234 17.5 1.00
Chilinh 1,256 276 22.0 1.32 (1.09-1.61) .005
Gender
Female 1,349 249 18.5 1.00
Male 1,241 261 21.0 1.18 (.97-1.43) NS
Age in three
groups
12-13 557 102 18.3 1.00
14-15 943 191 20.3 1.13 (.88-1.48) NS
>15 (16, 17, 18) 1,090 217 19.9 1.11 (.85-1.44) NS
Ethnic group
Kinh 2,567 503 19.6 1.00
Others 22 6 27.3 1.54 (0.56-3.95) NS
Religion
No 2,350 456 19.4 1.00
Yes 240 54 22.5 1.21 (.87-1.66) NS
Family economic
status
Low 364 86 23.3 1.00
Medium 2,032 377 18.6 .74 (.56-.96) .024
High 188 47 25.0 1.08 (.72-1.62) .721

Note: CI = Confidence interval

NS: Not significant

Child neglect was associated with region, gender and age. Unlike sexual abuse,
children in urban areas were more likely to experience neglect (OR = 1.23), and for
the total sample females are more at risk than males regarding child neglect (OR =
1.51). The more adolescents grew up the more they reported neglect experience (OR
= 1.5 for age group 14-15, and OR = 1.94 for age group 16 to 19). Interestingly,
family economic status was not significantly related to neglect (see Table 4.15).

120
 Table 4.15: Demographic correlates of neglect

Number of Number of Per Odds ratio P

respondents neglected cent (95 % CI) value
Region
Chilinh 1,256 342 27.2 1
Dongda 1,335 418 31.3 1.23 (1.03-1.44) .023
Gender
Male 1,241 309 24.9 1.00
Female 1,350 451 33.4 1.51 (1.28-1.77) .0005
Age in three
groups
12-13 557 117 21.0 1.00
14-15 943 272 28.8 1.52 (1.19-1.95) .001
>15 (16, 17, 18) 1,091 371 34.0 1.94 (1.53-2.46) .0005
Ethnic group
Kinh 2,568 756 29.4 1.00
Others 22 3 13.6 .38 (.11-1.28) NS
Religion
No 2,351 679 28.9 1.00
Yes 240 81 33.8 1.2540 (.95-1.66) NS
Family economic
status
Low 364 105 28.8 1.00
Medium 2,033 587 28.9 1.01 (.78-1.28) NS
High 188 66 35.1 1.33 (.92-1.94) NS

Note: CI = Confidence interval

NS: Not significant

Family characteristic correlates of child maltreatment

Due to the small number of mothers who classified their education as never went to
school/no formal education (n = 5) and completed primary school (n = 67) these
number were combined to explore the associations between this variable and
experiences of child maltreatment.

Table 4.16 summarizes the odds ratio and confidence intervals of correlates between
each form of maltreatment and family characteristic variables. For emotional
maltreatment, adolescents from divorced families (OR = 1.76) or whose parents had
died (one or both) (OR = 158) were more at risk. Adolescents whose mothers had

121
completed high school (OR = 1.35) and fathers completed technical and vocational
education (OR = 1.34) were more likely to report a history of emotional
maltreatment. Regarding parent occupation, only adolescents with self-employed
mothers were significantly more likely to report emotional maltreatment experiences
(OR = 1.29). Respondents reported their parents’ drugs and/or alcohol problems were
more likely to lead to risk of emotional maltreatment (OR = 2.54). Child emotional
maltreatment is also significantly associated with whom respondents were living
with. Children who were living with only their natural mother (OR = 1.76), natural
mother and stepfather (OR = 3.03), and natural father and stepmother (OR = 2.65)
were more likely to report emotional abuse experiences.

Table 4.16: Family characteristic correlates of emotional, physical

maltreatment, sexual abuse, and neglect

Emotional Physical Sexual abuse Neglect

maltreatment maltreatment
Odds ratio Odds ratio Odds ratio Odds ratio
(95 % CI) (95 % CI) (95 % CI) (95 % CI)
Parent marital status
Living together 1.00 1.00 1.00 1.00
Divorced 1.76** 1.61* 1.85** 2.04***
(1.21-2.56) (1.10-2.35) (1.23-2.79) (1.39-2.98)
Separated 1.99 1.63 1.61 1.80
(.95-4.14) (.78-3.43) (.71-3.67) (.86-3.79)
Death (one or both) 1.58* 1.39 .97 1.58*
(1.05-2.37) (.92-2.09) (.57-163) (1.04-2.39)
Mother education
University and 1.00 1.00 1.00 1.00
college degree
Completed technical 1.19 1.22 1.01 1.17
and vocational (.89-1.61) (.91-1.63) (.69-1.48) (.86-1.61)
education
Completed high 1.35* 1.26 .99 1.31
school (1.04-1.75) (.97-1.64) (.70-1.40) (.99-1.73)
Completed 1.35 2.02** 1.83* .96
secondary school (.86-2.10) (1.29-3.17) (1.09-3.05) (.59-1.56)
Completed primary 1.25 2.49 1.53 1.03
school and no formal (.47-3.33) (.91-6.83) (.49-4.79) (.36-2.96)
education

122
Table 4.16: continued
Emotional Physical Sexual abuse Neglect
maltreatment maltreatment
Odds ratio Odds ratio Odds ratio Odds ratio
(95 % CI) (95 % CI) (95 % CI) (95 % CI)
Father education
University and 1.00 1.00 1.00 1.00
college degree
Completed technical 1.34* 1.35* 1.11 1.08
and vocational (1.05-1.71) (1.06-1.72) (.82-1.51) (.83-1.39)
education
Completed high 1.21 1.22* 1.24 1.05
school (.99-1.48) (1.01-1.48) (.97-1.58) (.85-1.29)
Completed 1.21 1.08 1.33* .84
secondary school (.96-1.53) (.86-1.35) (1.01-1.76) (.66-1.09)
Completed primary 1.38 .75 .80 .99
school (.77-2.49) (.41-1.37) (.35-1.82) (.52-1.87)
Mother occupation
Government staff 1.00 1.00 1.00 1.00
Self-employed 1.29* 1.14 1.38* 1.27*
(1.04-1.61) (.92-1.42) (1.05-1.81) (1.01-1.59)
Farmer 1.09 1.28* 1.42* .88
(.87-1.37) (1.03-1.59) (1.08-1.86) (.69-1.13)
Unemployed 1.73 3.64* 2.93* .34
(.64-4.64) (1.17-11.37) (1.05-8.18) (.08-1.52)
Home maker 1.12 1.02 1.09 .86
(.90-1.39) (.82-1.26) (.85-1.45) (.68-1.08)
Others 1.81** 1.21 1.29 1.22
(1.16-2.82) (.78-1.89) (.75-2.24) (.76-1.95)
Father occupation
Government staff 1.00 1 1.00 1.00
Self-employed 1.09 1.04 1.18 1.15
(.89-1.33) (.86-1.26) (.93-1.51) (.93-1.41)
Farmer 1.09 1.25* 1.32* 1.04
(.87-1.36) (1.01-1.56) (1.01-1.73) (.82-1.33)
Unemployed 1.32 1.23 1.34 1.77
(.74-2.35) (.69-2.18) (.67-2.67) (.98-3.17)
Home maker .91 .97 1.46 .68
(.59-1.39) (.64-1.46) (.90-2.37) (.41-1.12)
Others 1.26 1.23 1.15 1.28
(.93-1.71) (.91-1.66) (.79-1.68) (.93-1.76)
Parent drug and/or alcohol problems
No 1.00 1.00 1.00 1.00
Yes 2.54*** 1.26 2.09** 1.78*
(1.61-4.01) (.81-1.96) (1.31-3.36) (1.14-2.79)

123
Table 4.16: continued
Emotional Physical Sexual abuse Neglect
maltreatment maltreatment
Odds ratio Odds ratio Odds ratio Odds ratio
(95 % CI) (95 % CI) (95 % CI) (95 % CI)
Whom children currently living with
Both of natural 1.00 1.00 1.00 1.00
parents
Only natural mother 1.76** 1.45* 1.05 1.55*
(1.27-2.44) (1.04-2.01) (.70-1.58) (1.10-2.17)
Only natural father 1.11 .85 1.62 1.35
(.61-1.99) (.47-1.52) (.85-3.09) (.73-2.48)
Natural mother and 3.03* 2.13 .48 2.14
stepfather (1.20-7.62) (.85-5.36) (.11-2.04) (.88-5.18)
Natural father and 2.65* 1.26 3.18** 4.24**
stepmother (1.09-6.42) (.53-2.98) (1.33-7.59) (1.75-10.29)
None of natural 1.25 1.22 1.43 1.69*
parents (.83-1.88) (.82-1.82) (.90-2.28) (1.12-2.57)
Number of sibling
Alone 1.00 1.00 1.00 1.00
Two 1.11 .92 .75 1.02
(.86-1.43) (.72-1.18) (.56-1.01) (.78-1.34)
More than two 1.28 .97 .99 1.12
(.95-1.72) (.73-1.29) (.71-1.41) (.81-1.53)

*p<.05; **P<.01; ***p<.001

For physical maltreatment, as displayed in Table 4.16 parent marital status, mother’s
education, father’s education, parent occupation, and living arrangements were
significantly associated with child physical maltreatment. Children from divorced
families (OR = 1.61), children whose mothers completed secondary school (OR =
2.02) and fathers completed technical college (OR = 1.35) or high school (OR =
1.22), mother unemployed (OR = 3.64) and parents working as farmer (OR = 1.28
for mother as a farmer, and OR = 1.25 for father as a farmer) as well as living with
only their natural mother (OR = 1.45) were more likely to report a history of physical
maltreatment.

Parental divorce significantly increased the risk of child sexual abuse (OR = 1.85).
Fathers who had completed secondary school (OR = 1.33), or fathers worked as a
farmer (OR = 1.32), mother completed secondary school (OR = 1.83) and mothers
worked as self-employed (OR = 1.38), or farmer (OR = 1.42), and unemployed (OR

124
= 2.93), parent alcohol and/or drug problems (OR = 2.09) as well as children living
with natural mother and stepfather (OR = 3.18) were emerged as significant
correlates with child sexual abuse.

Similar to child emotional maltreatment, adolescents from divorced families (OR =

2.04) or their parents had died (OR = 1.58), self-employed mother (OR = 1.27) or
parent with drugs and/or alcohol problems (OR = 1.78) were significantly more
likely to report history of neglect. Children living with only natural mother (OR =
1.55), natural father and stepmother (OR = 4.24) or none of natural parents (OR =
1.69) were significantly more likely to have experienced neglect.

Family environment correlates of child maltreatment

In general, all variables regarding family environment measured in this study

including parent quarrelling, parent fighting, perceived parental relationship, and
source of emotional support were found to be significantly associated with four
forms of child maltreatment. The results are displayed in Table 14.17. Children
looking for emotional support from their friends, other sources or from nobody were
significantly more likely to experience maltreatment, except for sexual abuse
whereby only respondents seeking for emotional advice and help from friends (OR
=1.56) were significantly likely to report sexual abuse.

Table 4.17: Family environment correlates of child emotional, physical

maltreatment, sexual abuse, and neglect

Emotional Physical Sexual abuse Neglect

maltreatment maltreatment
Odds ratio Odds ratio Odds ratio Odds ratio
(95 % CI) (95 % CI) (95 % CI) (95 % CI)
Parent quarrelling
Never 1.00 1.00 1.00 1.00
Rarely 1.89*** 1.42*** 1.14 1.86***
(1.55-2.32) (1.17-1.71) (.89-1.46) (1.48-2.34)
Sometimes 3.27*** 2.54*** 1.46** 3.21***
(2.61-4.09) (2.05-3.15) (1.12-1.90) (2.52-4.09)

125
Table 4.17: continued

Emotional Physical Sexual abuse Neglect

maltreatment maltreatment
Odds ratio Odds ratio Odds ratio Odds ratio
(95 % CI) (95 % CI) (95 % CI) (95 % CI)
Often 8.51*** 2.61*** 2.62*** 6.67***
(4.99-14.50) (1.62-4.23) (1.58-4.33) (4.09-10.86)
Parent fighting
Never 1.00 1.00 1.00 1.00
Rarely 1.97*** 2.04*** 1.95*** 1.97***
(1.59-2.42) (1.66-2.52) (1.54-2.48) (1.58-2.44)
Sometimes 3.42*** 2.71*** 1.66** 2.31***
(2.47-4.75) (1.95-3.77) (1.16-2.39) (1.68-3.18)
Often 2.11 5.08*** 4.46** 6.41***
(.85-5.22) (1.68-15.35) (1.79-11.06) (2.42-16.96)
Perceived parental relationship
Very happy 1.00 1.00 1.00 1.00
Happy 2.22*** 1.66*** 1.25 2.23***
(1.79-2.74) (1.37-1.99) (.97-1.59) (1.75-2.84)
Not sure 5.84*** 2.42*** 1.79*** 5.61***
(4.47-7.62) (1.89-3.10) (1.32-2.42) (4.22-7.47)
Unhappy 5.56*** 3.21*** 1.85* 10.12***
(3.53-8.75) (2.04-5.05) (1.12-3.08) (6.313-
16.22)
Very unhappy 19.30*** 3.34** 6.22*** 11.02***
(6.55-56.87) (1.47-7.59) (2.80-13.81) (4.78-25.39)
Emotional support
Mother 1.00 1.00 1.00 1.00
Father 1.09 1.06 .91 .98
(.69-1.72) (.69-1.62) (.51-1.62) (.59-1.61)
Brother/Sisters 1.19 1.10 1.06 .89
(.89-1.62) (.84-1.46) (.73-1.54) (.63-1.25)
Relatives 2.48** 1.77 1.52 1.88*
(1.39-4.42) (.99-3.16) (.76-3.04) ( 1.02-3.47)
Friends 1.95*** 1.47** 1.56** 1.75***
(1.54-2.48) (1.17-1.84) (1.16-2.08) (1.35-2.27)
Others 2.33** 3.20*** 1.47 2.51**
(1.34-4.04) (1.79-5.70) (.76-2.86) (1.42-4.42)
No one 2.44*** 1.77*** 1.19 2.19***
(1.86-3.19) (1.36-2.29) (.85-1.67) (1.64-2.93)

*p<.05; **P<.01; ***p<.001

126
Multivariate analysis of predictors of child maltreatment

After exploring bivariate correlations between a series of variables of demographics,

family characteristics, family environment and four types of child maltreatment, all
the variables that were significant in the univariate models were entered into the
multivariate logistic regression model simultaneously. The final multivariate logistic
regression models included all variables retaining significance after adjusting for
each other. Statistical test of the regression estimates or odds ratios were based on
Wald statistics. Results of multivariate logistic regression are summarized in Table
4.18, Table 4.19, Table 4.20 and Table 4.21 (only statistically significant variables
included) for emotional, physical, sexual abuse and neglect respectively.

As can be seen in Table 4.18, after controlling for the effects of other correlates
examined, females, older adolescents, children coming from divorced families,
parent with drug or/and alcohol problems, violence between parents, children living
only with natural mother or with natural father and step mother, and children mainly
seeking emotional support from other sources than mother and brother/sisters were
more likely to experience emotional maltreatment.

Table 4.18: Summary of risk factors for emotional maltreatment

Odds Confidence Wald χ2 P value

ratio interval

Female gender 1.26 1.05-1.50 6.24 .012

Age in three groups
12-13 1.00
14-15 1.19 .94-1.53 2.12 NS
>15 1.45 1.13-1.86 8.79 .003
Parent marital status
Living together 1.00
Divorced .49 .25-.99 3.99 .046
Separated .46 .18-1.19 2.58 NS
Death (one or both) .75 .38-1.47 .71 NS

127
Table 4.18: continued
Odds Confidence Wald χ2 P value
ratio interval

Whom children currently living with

Both of natural parents 1.00
Only natural mother 2.04 1.12-3.71 5.38 .020
Only natural father .84 .40-1.76 .21 NS
Natural mother and stepfather 2.62 .83-8.26 2.72 NS
Natural father and stepmother 3.57 1.15-11.06 4.87 .027
None of natural parents .99 .59-1.66 .00 NS
Parent drug and/or alcohol problems
No 1.00
Yes 1.72 1.01-2.89 4.05 .044
Parent quarrelling
Never 1.00
Rarely 1.48 1.18-1.86 11.70 .001
Sometimes 1.90 1.44-2.50 21.09 .0005
Often 3.78 1.91-7.49 14.47 .0005
Perceived parental relationship
Very happy 1.00
Happy 1.77 1.41-2.23 24.67 .0005
Not sure 3.29 2.41-4.52 55.47 .0005
Unhappy 2.98 1.69-5.27 14.17 .0005
Very unhappy 12.05 3.46-41.92 15.30 .0005
Emotional support
Mother 1.00
Father 1.71 1.05-2.77 4.68 .030
Brother/Sisters 1.32 .95-1.81 2.78 NS
Relatives 2.32 1.23-4.36 6.80 .009
Friends 1.86 1.43-2.41 21.71 .0005
Others 2.07 1.13-3.80 5.57 .018
No one 2.36 1.75-3.19 31.91 .0005

NS: not significant

Only gender, violent family environment (parent quarrel and fighting), perceived
parental relationship, and source of emotional support remain as risk factors of
physical maltreatment after adjusting for the effect of other variables (Table 4.19).

128
 Table 4.19: Summary of risk factors for physical maltreatment

Odds Confidence Wald χ2 P value

ratio interval

Male gender 1.79 1.52-2.13 45.30 .0005

Parent quarrelling
Never 1.00
Rarely 1.22 .99-1.51 3.55 NS
Sometimes 1.94 1.49-2.52 24.77 .0005
Often 1.26 .69-2.32 .57 NS
Parent fighting
Never 1.00
Rarely 1.64 1.29-2.08 16.64 .0005
Sometimes 1.93 1.29-2.88 10.19 .001
Often 3.38 1.05-13.97 4.15 .042
Perceived parental relationship
Very happy 1.00
Happy 1.39 1.13-1.71 9.59 .002
Not sure 1.47 1.08-1.98 6.17 .013
Unhappy 1.92 1.10-3.37 5.27 .022
Very unhappy 1.39 .52-3.74 .45 NS
Emotional support
Mother 1.00
Father 1.04 .66-1.63 .03 NS
Brother/Sisters 1.02 .76-1.37 .02 NS
Relatives 1.54 .83-2.85 1.89 NS
Friends 1.36 1.07-1.73 6.35 .012
Others 3.09 1.68-5.72 13.06 .0005
No one 1.45 1.09-1.92 6.69 .010

NS: not significant

For sexual abuse, when effects of other significant correlates were controlled,
respondents from rural areas, with unemployed mother, witnessing parent fighting,
reporting very unhappy parental relationship and having friends as a main source of
emotional support more likely to report unwanted sexual experiences (Table 4.20).

129
 Table 4.20: Summary of risk factors for sexual abuse

Odds Confidence Wald χ2 P value

ratio interval

Region
Urban 1.00
Rural 1.31 1.02-1.69 4.31 .038
Mother occupation
Government staff 1.00
Self-employed 1.22 .88-1.69 1.42 NS
Farmer 1.17 .76-1.80 .52 NS
Unemployed 3.42 1.12-10.47 4.62 .032
Home maker 1.07 .78-1.47 .15 NS
Others .99 .52-1.89 .002 NS
Parent fighting
Never 1.00
Rarely 1.61 1.23-2.11 11.82 .001
Sometimes 1.12 .71-1.77 .25 NS
Often 2.08 .69-6.28 1.68 NS
Perceived parental relationship
Very happy 1.00
Happy 1.18 .90-1.54 1.44 NS
Not sure 1.41 .98-2.04 3.36 NS
Unhappy 1.11 .59-2.09 .09 NS
Very unhappy 3.52 1.34-9.28 6.50 .011
Emotional support
Mother 1.00
Father 1.03 .57-1.86 .01 NS
Brother/Sisters 1.07 .73-1.57 .11 NS
Relatives 1.47 .69-3.09 1.03 NS
Friends 1.54 1.13-2.08 7.61 .006
Others 1.27 .63-2.57 .45 NS
No one 1.22 .85-1.74 1.15 NS

NS: not significant

Similar to the correlates of emotional maltreatment, female, older adolescents,

children living with natural father and step mother, witnessing violence between
parents, and children mainly seeking emotional support from other sources rather
than mother, father, and brother/sister were significantly associated with neglect after
controlling for the effects of other correlates (see Table 4.21).

130
 Table 4.21: Summary of risk factors for neglect

Odds Confidence Wald χ2 P value

ratio interval

Female gender 1.47 1.21-1.78 15.28 .0005

Age in three groups
12-13 1.00
14-15 1.29 .98-1.69 3.33 NS
>15 1.69 1.29-2.23 14.67 .003
Whom children currently
living with
Both of natural parents 1.00
Only natural mother 1.29 .70-2.41 .69 NS
Only natural father .95 .44-2.05 .02 NS
Natural mother and stepfather 2.17 .70-6.71 1.80 NS
Natural father and stepmother 3.73 1.17-11.87 4.97 .026
None of natural parents 1.60 .95-2.71 3.14 NS
Parent quarrelling
Never 1.00
Rarely 1.37 1.07-1.76 5.98 .014
Sometimes 1.82 1.35-2.45 15.42 .0005
Often 1.98 1.06-3.68 4.63 .031
Parent fighting
Never 1.00
Rarely 1.32 1.02-1.69 4.55 .033
Sometimes .88 .58-1.32 .41 NS
Often 2.02 .63-6.51 1.39 NS
Perceived parental relationship
Very happy 1.00
Happy 1.86 1.44-2.41 22.15 .0005
Not sure 3.71 2.66-5.18 59.09 .0005
Unhappy 6.94 3.87-12.45 42.24 .0005
Very unhappy 7.12 2.61-19.46 14.65 .0005
Emotional support
Mother 1.00
Father 1.53 .89-2.63 2.40 NS
Brother/Sisters .91 .64-1.31 .24 NS
Relatives 2.03 1.05-3.95 4.37 .037
Friends 1.51 1.14-2.01 8.34 .004
Others 2.10 1.13-3.93 5.46 .019
No one 2.04 1.48-2.80 19.01 .0005

NS: not significant

131
4.5 Summary

This chapter has presented a wide range of information including characteristics of

the major survey sample, percentage of adverse childhood events, prevalence of four
forms of child maltreatment as well as prevalence of multiple forms of child
maltreatment. Correlates of demographic characteristics, family characteristics and
family environment with child emotional, physical, and sexual maltreatment and
neglect have also been reviewed thoroughly by both univarite and multivariate
logistic regression. After controlling for effects of other examined variables the
results show that:

• The prevalence of child maltreatment of various forms among adolescents in

school settings was not significantly different between urban (Dongda district)
and rural (Chilinh district) areas except for sexual abuse. Children from the rural
were more likely to report unwanted sexual experiences than their counterparts in
the urban areas.
• Girls were more likely to report emotional maltreatment and neglect than boys,
while boys were more likely to experience physical maltreatment. And for sexual
abuse, there were no significant gender differences.
• Gender (except for sexual abuse) and family environment variables including
parental quarrelling, fighting, perceived quality of parental relationship, and
emotional support, appeared to be the most consistent factors significantly to
predict each form of child maltreatment.

132
Chapter 5: Associations between Child
Maltreatment and Health Risk
Behaviours

This chapter addresses the following research questions:

• What are the differences in health risk behaviour prevalence between female and
male adolescents and among adolescents attending urban and rural secondary
schools and across age groups?
• What are the associations between self-reported history of emotional
maltreatment, physical maltreatment, sexual abuse and neglect and risky
behaviours?
• To what extent does the co-occurrence of childhood maltreatment experiences
correlate with health risk behaviours?

The literature review indicated the potential for child maltreatment victims to engage
in taking health risk behaviours such as smoking, drinking, eating disorders, carrying
weapons, fighting and suicidal plans or actions. The study questionnaire included
eleven items about recent and life time risky behaviours.

5.1 Prevalence and correlations of health risk

behaviours

Overall, 17.6% of the sample reported that in the past 12 months, they had felt so sad
or hopeless almost every day for two weeks or more that they stopped doing some
usual activities. For intentional injury, approximately 9% of respondents had
seriously considered attempting suicide and 6% had made a specific suicide plan, and
nearly 10% of students had been involved in a physical fight in the past 12 months.

133
More than 4% of participants ever smoked cigarettes, about 9% had drunk alcohol in
the past 30 days, and 9% had ever been drunk during their lifetime. A small
proportion of participants (2.8%) reported having been injured while drunk. The rate
of participants attempting to lose weight in the past 30 days also was quite low
(3.6%). The prevalence of carrying weapons during the past 30 days was 3.2%. In a
school setting, 6.4% of the sample reported being threatened or injured in the past 12
months.

Chi-squared (χ2) tests were performed to examine gender and regional differences in
the prevalence of various health risk behaviours. As shown in Table 5.1, there were
statistically significant associations between gender and all eleven items of health
risk behaviours. A greater proportion of female students had the experience of
feeling sad or hopeless, considered attempting suicide or had made a suicide plan,
but male students were more likely to carry a weapon, to be threatened in school
setting and to be involved in physical fights. A much higher proportion of boys
smoked, consumed alcohol, had ever been drunk or injured while drunk. However,
girls were more likely to consider themselves overweight, and to be trying to lose
weight by not eating for 24 hours or so in the past 30 days.

The relationships between rural and urban areas and health risk behaviours were
examined and are presented in Table 5.2. Generally, rates of health risk behaviours
were similar in these two regions, although urban adolescents were more likely to
report attempted suicide, smoking cigarettes, and drinking alcohol.

Univariate logistic regression models were conducted to examine the correlations

between age and health risk behaviours, with a group of 12-13 year olds as the
reference group. Results are presented in Table 5.3.

134
 Table 5.1: Prevalence of health risk behaviours among adolescents by gender

Male Female Overall

(n =1,241) (n = 1,350) sample
Health risk behaviours
(%)
(%) (%)
Felt sad and hopeless almost every days
15.4 19.7** 17.6
for two weeks in the past 12 months
Ever attempted suicide in the past 12
7.0 11.2*** 9.2
months
Ever made suicide plan in the past 12
4.9 7.1* 6.1
months
Ever smoked cigarettes in the past 30 days 7.1 1.5*** 4.2

Drank alcohol in the past 30 days 12.7 5.0*** 8.7

Ever drunk during lifetime 12.7 5.3*** 8.9

Ever injured while drunk 4.5 1.2*** 2.8

No eating for 24 hours for losing weight
2.3 4.8** 3.6
in the past 30 days
Carried weapon in the past 30 days 5.4 1.3*** 3.2
Being threatened in school in the past 12
9.3 3.8*** 6.4
months
Involved in fighting in the past 12 months 14.4 5.8*** 9.9

Probability values indicate the results of Yates’ Correction for Continuity (χ2 test) comparing
prevalence of health risk behaviours among male and female.
*p < .05; **p < .01; ***p< .001

135
 Table 5.2: Prevalence of health risk behaviours among adolescents by region

Chilinh Dongda Overall

(rural) (urban) sample
Health risk behaviours
(%)
(%) (%)
Felt sad and hopeless almost every days
18.9 16.4 17.6
for two weeks in the past 12 months
Ever attempted suicide in the past 12
7.9 10.4* 9.2
months
Ever made suicide plan in the past 12
5.5 6.6 6.1
months
Ever smoked cigarettes in the past 30 days 3.3 4.9* 4.2

Drank alcohol in the past 30 days 5.7 11.5*** 8.7

Ever drunk during lifetime 8.1 9.6 8.9

Ever injured while drunk 3.1 2.5 2.8

No eating for 24 hours for losing weight
3.6 3.7 3.6
in the past 30 days
Carried weapon in the past 30 days 3.3 3.2 3.2
Being threatened in school in the past 12
7.3 5.6 6.4
months
Involved in fighting in the past 12 months 9.7 10.1 9.9

Probability values indicate the results of Yates’ Correction for Continuity (χ2 test) comparing
prevalence of health risk behaviours among urban and rural areas.
*p < .05; ***p< .001

Older students were significantly more likely to feel sad or hopeless. Even though
suicidality prevalence, rates of students carrying weapons and being threatened in
school were highest among students at the age of 14-15 years, there was no
statistically significant difference among the 3 age groups.

Prevalence of smoking, drinking and ever being drunk during lifetime markedly
increased with age. But students aged 16-18 years were significantly less likely to be
injured while drunk or to be involved in physical fights.

136
 Table 5.3: Prevalence of health risk behaviours among adolescents by age

12-13 14-15 16-18

Health risk behaviours years years years
(%) (%) (%)
Felt sad and hopeless almost every days for 14.2 18.1* 19.0*
two weeks in the past 12 months
Ever attempted suicide in the past 12 7.0 9.9 9.7
months
Ever made suicide plan in the past 12 5.4 6.7 5.9
months
Ever smoked cigarettes in the past 30 days 2.7 4.1 4.9*

Drank alcohol in the past 30 days 4.3 7.6* 11.8***

Ever drunk during lifetime 4.8 8.1* 11.6***

Ever injured while drunk 3.2 3.9 1.6*

No eating for 24 hours for losing weight in 3.4 3.7 3.7

the past 30 days
Carried weapon in the past 30 days 2.5 4.1 2.8

Being threatened in school in the past 12 7.0 8.1 4.8

months
Involved in fighting in the past 12 months 9.2 14.4** 6.4*

*p < .05; **p < .01; ***p< .001

5.2 Associations between maltreatment types,

multiple forms of maltreatment and health risk
behaviours

To estimate the effect of each type of maltreatment as well as the impact of co-
occurrence of child maltreatment on health risk behaviours, it is essential to control
for variables known to potentially influence risky behaviours such as demographic
variables, family characteristics, parent and child characteristics.

137
A series of logistic regression analyses were conducted to examine the potential
impact of child maltreatment on each health risk behaviour according to gender.
Initially, all potential risk factors were explored in bivariate logistic regression
models. All the variables that were significant in the bivariate analysis were then
entered into the multivariate logistic regression models sequentially. All significant
demographic, family, parent and child variables were entered in first step. Then four
types of child maltreatment (categorized in three groups: no maltreatment, minor
maltreatment and more severe maltreatment) were entered in the second step.
Similarly, this approach was also used in examining the correlations between co-
occurrence of child maltreatment and each of the health risk behaviours. A multiple
maltreatment variable was created whereby each individual was categorized in one of
five groups (no maltreatment, one to four types of maltreatment). This was entered in
the second step in each multivariate logistic regression model. Statistical tests of the
regression estimates or odds ratios were based on Wald statistics.

The analyses were stratified by gender. As there were small numbers of female
students exposed to smoking (n =20), ever injured while drunk (n = 16), and carrying
weapons (n = 17), the association between child maltreatment and those behaviours
was not examined. Similarly, less than 30 male students reported not eating for 24
hours or so to lose weight, so this behaviour was omitted in the analysis. As a result,
the correlations between child maltreatment and 8 health risk behaviours for females
and 10 health risk behaviours for males were examined in this study.

Due to relatively small numbers of respondents in several subgroups of some

questions, combinations of subgroups was undertaken to ensure that no two-way
table had more than 20% of the cells with frequencies less than 5, nor any expected
frequencies less than 1. In this case no restriction applied to evaluating the model
goodness-of-fit criteria for logistic regression models (Tabachnick & Fidell, 2001).
The following eleven variables had their subgroups combined compared with the
original questions:

138
• Respondents’ age was divided into three groups (12-13 years, 14-15 years, or 16-
18 years).
• Parent’s marital status was measured in two categories (parents living together or
parents not living together including divorced, separated or died).
• Family arrangement was categorized in three groups (living with both natural
parents, living with one natural parent, or living with no natural parent).
• Mother and father’s education was divided into four groups (university/college
degree, completed technical/vocational education, completed high school, or
completed secondary school and lower).
• Mother and father’s occupation was categorized into five groups (government
staff, self-employed, farmer, homemaker, or unemployed/others).
• Parent physical fighting was collapsed into 3 groups (never, rarely, or
sometimes/often).
• Perceived quality of parental relationship was measured in a four point scale
(very happy, happy, not sure, or unhappy/very unhappy).
• Child academic achievement was truncated to 3 levels (excellent, good, or
fair/poor).
• School punishment was scaled in 3 levels (never, rarely, or sometimes/more).
• Self-perception of health status was reduced to 4 categories (very good, good,
fair, or poor/very poor).
• Source of emotional support was divided into 5 groups (mother/father,
brother/sister, friends, relatives/others, or none).

In total, 8 multivariate logistic regression models for females and 10 models for
males were fitted to explore the relationship between each type of child maltreatment
and health risk behaviours. The same numbers of logistic regression models were
performed to examine the impact of co-occurrence of child maltreatment and each of
the health risk behaviours.

Omnibus Tests of Model Coefficients, and Hosmer and Lemeshow Tests were used
to test the goodness-of-fit of each model. Omnibus Test of Model Coefficients
indicates how well the model performed compared with none of the predictors

139
entered in to the model and this test needs to be statistically significant (p<.05)
(Pallant, 2004). To support the goodness-of-fit of the model, the Hosmer and
Lemeshow Test should be non-significant (p>.05) (Tabachnick & Fidell, 2001). All
the multivariate logistic regression models satisfied these two goodness-of-fit tests.

The results of multivariate logistic regression analyses showing the relationships

between four forms of child maltreatment: emotional maltreatment (female, n =
1,350; male n = 1,241), physical maltreatment (female, n = 1,350; male n = 1,241),
sexual abuse (female, n = 1,349; male n = 1,241), neglect (female, n = 1,350; male n
= 1,241), and co-occurrence of child maltreatment (female, n = 1,344; male n =
1,238) and each of the health risk behaviours by gender are presented below.

Felt sad and hopeless

Fourteen confounding variables including parent marital status, family arrangement,

number of siblings, mother and father’s education, father’s occupation, parental
quarrelling and fighting, perceived parental relationship, emotional support,
academic achievement, diagnosed chronic disease, self-perception of health status
and body satisfaction were first entered and then 4 forms of child maltreatment or
multiple forms of child maltreatment were entered in the second step in each model
to explore the correlation between each type of child maltreatment and co-occurrence
of maltreatment and feeling sad or hopeless in the female sample. Similar procedures
were applied for the male sample, however the controlled variables were region,
parent occupation, parental quarrelling and fighting, emotional support, academic
achievement, school punishment, and self-perception of health status. Table 5.4
shows the adjusted relationships between individual types of child maltreatment, co-
occurrence of child maltreatment and feeling sad for female and male students. More
severe emotional maltreatment and neglect significantly predicted sad and hopeless
feelings for both female (CEA: OR = 1.81; CN: OR = 2.43) and male (CEA: OR =
3.28; CN: OR = 1.74) respondents. Minor emotional maltreatment and neglect also
significantly increased the risk of feeling sad for male participants (CEA: OR = 2.08,
CN: OR = 1.61). Being exposed to physical and sexual maltreatment was also

140
associated with sad feelings of both females and males. Statistical significance was
only detected with minor physical maltreatment of female participants (CPA: OR =
1.56).

For multiple forms of child maltreatment, Figure 5.1 clearly shows that the more
respondents were exposed to co-occurrence of maltreatment, the more they felt sad
and hopeless. These findings are statistically significant at all levels for females and
males, except for females who experienced only one form of maltreatment (see Table
5.4).

50
45
40
35
Percentage

30
25 Fem ale
20 Male

15
10
5
0
no abuse 1 form 2 form s 3 form s 4 form s

Figure 5.1: Percentage of adolescent felt sad and hopeless by occurrence of

multiple types of maltreatment

Table 5.4: Multivariate models of child maltreatment associated with feeling sad
and hopeless
Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 12.5 1.00 8.8 1.00
Minor maltreatment 23.6 1.41 (.93-2.14) 22.6 2.08 (1.37-3.15)**
More severe 40.3 1.81 (1.06-3.08)* 35.6 3.28 (1.84-5.83)***
maltreatment

141
Table 5.4: continued
Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)

Physical maltreatment
No maltreatment 14.0 1.00 9.8 1.00
Minor maltreatment 25.8 1.56 (1.07-2.26)* 18.3 1.14 (.76-1.70)
More severe 38.9 1.55 (.81-2.94) 26.8 1.09 (.61-1.98)
maltreatment

Sexual maltreatment
No maltreatment 16.6 1.00 12.7 1.00
Minor maltreatment 30.6 1.21 (.79-1.85) 24.7 1.41 (.90-2.21)
More severe 53.3 1.76 (.72-4.33) 28.0 1.44 (.76-2.71)
maltreatment

Neglect
No neglect 14.1 1.00 11.5 1.00
Minor neglect 19.6 1.22 (.77-1.95) 22.7 1.61 (1.02-2.54)*
More severe 42.5 2.43 (1.48-3.71)*** 33.1 1.74 (1.01-3.02)*
neglect

Model 2

Multiple maltreatment
No maltreatment 9.6 1.00 5.4 1.00
One form 13.9 1.54 (.93-2.56) 11.5 1.94 (1.09-3.43)*
Two forms 25.0 2.61 (1.58-4.30)*** 19.7 3.31 (1.89-5.80)***
Three forms 33.5 3.75 (2.22-6.32)*** 30.4 5.95 (3.31-10.69)***
Four forms 48.1 7.01 (3.67-13.38)*** 34.6 6.06 (2.99-12.27)***

*p < .05; **p < .01; ***p< .001

For females, models also control for parent marital status, family arrangement, number of siblings,
mother and father’s education, father’s occupation, parental quarrelling and fighting, perceived
parental relationship, emotional support, academic achievement, diagnosed chronic disease, self-
perception of health status and body satisfaction.
For males, models also control for region, parent occupation, parental quarrelling and fighting,
emotional support, academic achievement, school punishment, and self-perception of health status.

Considered attempting suicide

Ten confounding variables including region, age, parental quarrelling and fighting,
emotional support, perceived parental relationship, school punishment, diagnosed
chronic disease and self-perception of health status, and body satisfaction were

142
entered in the model of the female sample. In the model for the male sample, eight
variables (religion, family economic status, parental quarrelling and fighting, parent
relationship, chronic disease, self-evaluation of health status and body satisfaction)
were controlled.

Suicidal thoughts of both males and females correlated with emotional maltreatment
(male: minor: OR = 1.20, more severe: OR = 2.11, female: minor: OR = 1.19, more
severe: OR = 2.78) and neglect (male: minor: OR = 1.11, more severe: OR = 2.98,
female: minor: OR = 1.83, more severe: OR = 2.93). However, statistical
significance was found only for neglect and more severe emotional maltreatment in
females and more severe neglect in males. Male respondents who experienced minor
physical maltreatment were significantly more likely to consider attempting suicide.

35

30

25
Percentage

20
Fem ale
15 Male

10

0
no abuse 1 form 2 form s 3 form s 4 form s

Figure 5.2: Percentage of adolescent thought about attempting suicide by

occurrence of multiple types of maltreatment

143
 Table 5.5: Multivariate models of child maltreatment associated with thought
about attempting suicide

Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 5.4 1.00 3.9 1.00
Minor maltreatment 11.5 1.19 (.68-2.12) 8.3 1.20 (.61-2.37)
More severe 32.8 2.78 (1.49-5.20)** 20.8 2.11 (.91-4.88)
maltreatment

Physical maltreatment
No maltreatment 7.6 1.00 3.5 1.00
Minor maltreatment 14.1 .81 (.49-1.33) 7.8 1.95 (1.01-3.79)*
More severe 26.7 1.28 (.62-2.65) 18.3 2.05 (.86-4.88)
maltreatment

Sexual maltreatment
No maltreatment 9.1 1.00 6.1 1.00
Minor maltreatment 19.6 1.47 (.89-2.42) 8.1 .67 (.31-1.45)
More severe 26.7 1.00 (.35-2.85) 16.0 1.47 (.64-3.39)
maltreatment

Neglect
No neglect 6.1 1.00 4.7 1.00
Minor Neglect 14.3 1.83 (1.03-3.25)* 8.0 1.11 (.52-2.37)
More severe 28.5 2.93 (1.66-5.16)*** 21.8 2.98 (1.39-6.38)***
neglect

Model 2

Multiple maltreatment
No maltreatment 3.1 1.00 2.1 1.00
One form 7.3 2.02 (.97-4.22) 4.7 2.34 (.92-5.96)
Two forms 15.9 4.57 (2.27-9.21)*** 9.7 3.54 (1.41-8.89)**
Three forms 19.4 3.45 (1.64-7.25)*** 14.9 7.97 (3.14-20.22)***
Four forms 34.6 9.94 (4.40-22.46)*** 16.0 4.96 (1.61-15.24)**

*p < .05; **p < .01; ***p< .001

For females, models also control for region, age, parental quarrelling and fighting, emotional
support, perceived parental relationship, school punishment, diagnosed chronic disease and self-
perception of health status, and body satisfaction.
For males, models also control for religion, family economic status, parental quarrelling and fighting,
parent relationship, chronic disease, self-evaluation of health status and body satisfaction.

144
Dose-response relationship between considering attempting suicide and exposure to
multiple types of child maltreatment is shown in Figure 5.2. Female and male
participants exposed to two forms to four forms of maltreatment were significantly
more likely to have suicidal thoughts than non-exposed counterparts (see Table 5.5).

Made a suicide plan

After controlling for other variables that were significantly correlated with making a
suicide plan (in the bivariate analysis including religion, number of siblings, mother
and father occupation, parental quarrelling and fighting, quality of parent
relationship, chronic disease, health status, body satisfaction and school punishment
for the female models, and religion, family economic status, parental quarrelling and
fighting, quality of parent relationship, health status and school punishment for male
models) only child emotional maltreatment significantly predicted suicide plan
behaviour for both female and male participants (see Table 5.6).

Regarding multiple forms of child maltreatment, similar to suicidal thoughts, Figure

5.3 clearly shows that the more respondents were exposed to co-occurrence of
maltreatment, the more they reported making suicide plan. Participants exposed to
four forms of child maltreatment were more than nine times for females, and eight
times for males more likely than non maltreatment counterparts to make a specific
suicide plan.
25

20
Percentage

15
Fem ale
10 Male

0
no abuse 1 form 2 form s 3 form s 4 form s

Figure 5.3: Percentage of adolescent making suicide plan by

multiple-type maltreatment

145
Table 5.6: Multivariate models of child maltreatment associated with making a
suicide plan

Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 3.1 1.00 1.9 1.00
Minor maltreatment 7.0 1.54 (.75-3.18) 8.0 4.27 (2.00-9.12)***
More severe 22.9 4.01 (1.86-8.66)*** 14.8 5.63 (2.20-14.39)***
maltreatment

Physical maltreatment
No maltreatment 4.3 1.00 3.0 1.00
Minor maltreatment 8.7 1.01 (.55-1.87) 5.3 1.09 (.55-2.19)
More severe 22.2 1.53 (.65-3.61) 11.3 1.01 (.39-2.57)
maltreatment

Sexual maltreatment
No maltreatment 6.1 1.00 4.2 1.00
Minor maltreatment 10.5 1.14 (.62-2.09) 5.9 .80 (.37-1.73)
More severe 20.0 .99 (.29-3.38) 12.0 1.70 (.69-4.23)
maltreatment

Neglect
No neglect 4.3 1.00 3.3 1.00
Minor Neglect 7.4 1.25 (.59-2.59) 4.5 .82 (.34-1.95)
More severe 18.1 1.79 (.91-3.53) 16.5 2.16 (.99-4.69)
neglect

Model 2
Multiple maltreatment
No maltreatment 2.7 1.00 1.3 1.00
One form 3.0 1.03 (.40-2.63) 3.5 2.85 (.98-8.32)
Two forms 10.9 3.95 (1.76-8.86)** 5.4 4.42 (1.51-12.96)**
Three forms 12.1 2.56 (1.08-6.07)* 11.9 10.18 (3.47-29.91)***
Four forms 22.2 9.45 (3.69-24.19)*** 12.3 8.46 (2.48-28.98)**

*p < .05; **p < .01; ***p< .001

For females, models also control for religion, number of siblings, mother and father occupation,
parental quarrelling and fighting, quality of parent relationship, chronic disease, health status, body
satisfaction and school punishment.
For males, models also control for religion, family economic status, parental quarrelling and fighting,
quality of parent relationship, health status and school punishment

146
Smoked in the past 30 days

As mentioned earlier, due to the small number (n = 20) of female respondents who
reported that they had smoked during the past 30 days, multivariate logistic
regression therefore was performed only for males. Results, controlling for age,
family economic status, parental quarrelling and physical fighting, parental
relationship, source of emotional support, perception of health status, school
punishment experience, and academic achievement, are presented in Table 5.7. Male
smoking behaviour was significantly predicted by emotional maltreatment (minor:
OR = 2.18, more severe: OR = 2.33) and more severe sexual abuse (OR = 3.29). Co-
occurrence of child maltreatment was a statistically significant correlate of smoking
cigarettes.

Table 5.7: Multivariate models of child maltreatment associated with male

cigarette smoking
Male
% exposed Odds ratio
(95 % CI)
Model 1
Emotional maltreatment
No maltreatment 3.5 1.00
Minor maltreatment 11.6 2.18 (1.19-3.99)*
More severe maltreatment 16.8 2.33 (1.07-5.07)*

Physical maltreatment
No maltreatment 4.0 1.00
Minor maltreatment 7.8 1.09 (.59-1.99)
More severe maltreatment 16.9 1.39 (.61-3.17)

Sexual maltreatment
No maltreatment 5.2 1.00
Minor maltreatment 11.8 1.40 (.75-2.63)
More severe maltreatment 20.0 3.29 (1.53-7.12)**

Neglect
No neglect 5.4 1.00
Minor Neglect 10.2 1.11 (.58-2.13)
More severe neglect 15.0 .88 (.41-1.90)

147
Table 5.7: continued
Male
% exposed Odds ratio
(95 % CI)
Model 2
Multiple maltreatment
No maltreatment 2.3 1.00
One form 4.1 1.19 (.48-2.97)
Two forms 9.7 2.57 (1.12-5.91)*
Three forms 14.3 4.27 (1.81-10.05)**
Four forms 19.8 3.92 (1.45-10.62)**

*p < .05; **p < .01;

Models also control for age, family economic status, parental quarrelling and physical fighting,
parental relationship, source of emotional support, perception of health status, school punishment
experience, and academic achievement.

Drank alcohol during past 30 days

Drinking alcohol among females was significantly predicted by minor emotional

maltreatment (OR = 1.94), minor physical maltreatment (OR = 1.91) and more
severe sexual abuse (OR = 4.28) when adjusted for the effect of region, age, religion,
family economic status, mother and father’s education and occupation, parental
quarrelling and fighting, emotional support, body satisfaction, and school
punishment. More severe emotional maltreatment (OR = 2.09), minor (OR = 1.77)
and more severe (OR = 3.02) sexual abuse significantly predicted male drinking
behaviour when controlling for age, region, family economic status, mother and
father education and occupation, body satisfaction, self-perception of health status,
and school punishment.

Experiencing co-occurrence of child maltreatment was significantly associated with

drinking alcohol among both females and males. However, the correlations were
stronger among females (see Table 5.8).

148
 Table 5.8: Multivariate models of child maltreatment associated with alcohol
drinking

Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 3.0 1.00 9.6 1.00
Minor maltreatment 8.3 1.94 (1.01-3.75)* 15.6 1.28 (.81-2.03)
More severe 6.5 .78 (.30-2.00) 23.5 2.09 (1.12-3.89)*
maltreatment

Physical maltreatment
No maltreatment 3.3 1.00 8.9 1.00
Minor maltreatment 6.8 1.91 (1.03-3.53)* 15.0 1.41 (.92-2.15)
More severe 8.9 1.89 (.66-5.39) 19.7 1.28 (.67-2.47)
maltreatment

Sexual maltreatment
No maltreatment 4.4 1.00 10.6 1.00
Minor maltreatment 6.4 1.11 (.55-2.23) 17.7 1.77 (1.07-2.91)*
More severe 16.7 4.28 (1.24-14.75)* 28.0 3.02 (1.58-5.74)***
maltreatment

Neglect
No neglect 3.6 1.00 11.2 1.00
Minor Neglect 7.8 1.41 (.69-2.83) 14.2 .95 (.56-1.63)
More severe 7.7 1.09 (.50-2.38) 21.8 .94 (.51-1.74)
neglect

Model 2

Multiple maltreatment
No maltreatment 1.1 1.00 7.4 1.00
One form 4.5 4.02 (1.38-11.73)* 10.6 1.38 (.80-2.37)
Two forms 8.3 7.96 (2.77-22.87)*** 15.8 2.19 (1.27-3.79)**
Three forms 8.3 5.51 (1.87-16.26)** 17.3 2.66 (1.45-4.78)**
Four forms 7.4 5.30 (1.41-19.89)* 28.4 4.41 (2.22-8.78)***

*p < .05; **p<.01; ***p< .001

For females, models also control for region, age, religion, family economic status, mother and
father’s education and occupation, parental quarrelling and fighting, emotional support, body
satisfaction, and school punishment.
For males, models also control for age, region, family economic status, mother and father education
and occupation, body satisfaction, self-perception of health status, and school punishment.

149
Had ever been drunk

Being exposed to more severe emotional maltreatment (OR = 2.1), sexual abuse
(minor: OR = 1.69, more severe: OR = 3.04) and multiple forms of child
maltreatment was significantly associated with higher risk of having ever been drunk
among male respondents when the effect of various confounding variables including
age, parental fighting and quarrelling, parental relationship, emotional help, chronic
disease, self-evaluation of health status, body satisfaction, and school punishment,
were controlled.

For female participants, however, after adjusting for age, family economic status,
mother and father’s education, father’s occupation, source of emotional support,
school punishment and repeated class only more severe sexual abuse (OR = 4.06)
and experience of four forms (OR = 3.44) of maltreatment significantly increase the
risk of ever being drunk (see Table 5.9)

Table 5.9: Multivariate models of child maltreatment

associated with ever been drunk

Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 4.0 1.00 8.8 1.00
Minor maltreatment 5.9 1.06 (.55-2.04) 15.6 1.09 (.66-1.80)
More severe 9.5 1.07 (.45-2.51) 27.5 2.11 (1.09-4.08)*
maltreatment

Physical maltreatment
No maltreatment 4.3 1.00 7.7 1.00
Minor maltreatment 6.0 .99 (.55-1.80) 14.8 1.61 (1.00-2.06)
More severe 11.1 1.65 (.64-4.27) 25.4 1.79 (.90-3.55)
maltreatment

150
Table 5.9: continued
Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Sexual maltreatment
No maltreatment 4.5 1.00 10.0 1.00
Minor maltreatment 6.8 1.17 (.61-2.25) 18.8 1.69 (1.01-2.85)*
More severe 23.3 4.06 (1.37-12.08)* 33.3 3.04 (1.59-5.81)**
maltreatment
Neglect
No neglect 3.9 1.00 10.4 1.00
Minor Neglect 6.5 1.43 (.72-2.86) 15.9 1.18 (.68-2.06)
More severe 10.0 1.43 (.68-2.99) 24.8 1.18 (.61-2.26)
neglect

Model 2

Multiple maltreatment
No maltreatment 2.7 1.00 5.9 1.00
One form 5.1 1.99 (.89-4.45) 9.7 1.51 (.81-2.81)
Two forms 6.2 2.03 (.89-4.66) 15.1 2.01 (1.07-3.79)*
Three forms 7.8 2.29 (.99-5.28) 23.8 4.56 (2.39-8.68)***
Four forms 11.1 3.44 (1.27-9.35)* 28.4 5.06 (2.30-11.09)***

*p < .05; **p< .01; ***p<.001

For females, models also control for age, family economic status, mother and father’s education,
father’s occupation, source of emotional support, school punishment and repeated class.
For males, models also control for age, parental fighting and quarrelling, parental relationship,
emotional help, chronic disease, self-evaluation of health status, body satisfaction, and school
punishment.

Injured while drunk

Very few females reported ever being injured while drunk. Sufficient male
respondents (n = 56) reported that they were injured while drunk to perform
multivariate logistic regression analysis. Age, religion, father’s education and
occupation, parental quarrelling and physically fighting, school punishment, and self-
perception of health status were entered first to the sequential logistic regression
models to explore the extent to which child maltreatment impacted on exposure to
injury while drunk among the male sample.

Table 5.10 summarizes the results of the models. No individual maltreatment types
significantly predicted injured while drunk among male participants, only those who

151
reported experiencing four forms of maltreatment were significantly more likely to
be accidentally injured while drunk (OR = 4.80).

Table 5.10: Multivariate models of child maltreatment associated with male

injury while drunk

Male
% exposed Odds ratio
(95 % CI)
Model 1
Emotional maltreatment
No maltreatment 2.8 1.00
Minor maltreatment 6.6 1.65 (.79-3.44)
More severe maltreatment 9.4 1.65 (.62-4.41)

Physical maltreatment
No maltreatment 3.2 1.00
Minor maltreatment 3.8 .99 (.49-2.05)
More severe maltreatment 12.7 2.08 (.84-5.16)

Sexual maltreatment
No maltreatment 3.6 1.00
Minor maltreatment 5.9 .97 (.44-2.15)
More severe maltreatment 13.3 2.32 (.93-5.78)

Neglect
No neglect 3.6 1.00
Minor Neglect 4.5 .90 (.38-2.15)
More severe neglect 10.5 1.64 (.66-4.05)
Model 2

Multiple maltreatment
No maltreatment 2.8 1.00
One form 3.2 .884 (.36-2.16)
Two forms 3.9 1.19 (.47-2.96)
Three forms 7.1 1.99 (.79-4.96)
Four forms 14.8 4.80 (1.78-12.93)**

*p < .05; **p< .01; ***p<.001

Models also adjust for age, religion, father’s education and occupation, parental quarrelling and
physically fighting, school punishment, and self-perception of health status

152
Did not eat in 24 hours to lose weight

This analysis was conducted for the female sample only due to the relatively small
number of male participants (n = 29) who reported this behaviour. Even though the
odds ratios increased when participants experienced each form of maltreatment or
co-occurrence of maltreatment, only the co-occurrence of child maltreatment was
significantly related to eating disorder behaviour among female students (two forms:
OR = 4.78, four forms: OR = 9.80) when adjusted for father’s occupation, perceived
parental relationship, body satisfaction, chronic disease, and academic results.

Table 5.11: Multivariate models of child maltreatment associated with female

not eating to lose weight

Female
% exposed Odds ratio
(95 % CI)
Model 1
Emotional maltreatment
No maltreatment 3.1 1.00
Minor maltreatment 4.6 1.03 (.47-2.24)
More severe maltreatment 11.9 1.39 (.57-3.54)

Physical maltreatment
No maltreatment 2.9 1.00
Minor maltreatment 6.6 1.73 (.85-3.49)
More severe maltreatment 12.2 2.08 (.75 (5.77)

Sexual maltreatment
No maltreatment 3.8 1.00
Minor maltreatment 8.7 1.79 (.90-3.56)
More severe maltreatment 13.3 2.16 (.62-7.56)

Neglect
No neglect 3.2 1.00
Minor Neglect 5.7 1.69 (.79-3.64)
More severe neglect 10.4 1.35 (.59-3.05)

153
Table 5.11: continued
Model 2

Multiple maltreatment
No maltreatment 2.0 1.00
One form 2.7 1.64 (.54-4.99)
Two forms 7.6 4.78 (1.80-12.67)**
Three forms 6.3 2.08 (.67-6.45)
Four forms 16.0 9.80 (3.37-28.45)***

*p < .05; **p< .01; ***p<.001

Models also adjust for father’s occupation, perceived parental relationship, body satisfaction, chronic
disease, and academic results.

Carried a weapon

For the behaviour of carrying a weapon, the analysis was performed only with the
male sample because of the same reason given above. After controlling for family
economic status, parental quarrelling and fighting, perceived parental relationship,
source of emotional support, self-perception of health status and school punishment,
more severe emotional maltreatment (OR = 4.07) and severe sexual abuse (OR =
4.09) were significantly associated with carrying a weapon among male participants.
Co-occurrence of child maltreatment also clearly increased the risk of taking this
behaviour.

Table 5.12: Multivariate models of child maltreatment associated with male

carrying a weapon

Male
% exposed Odds ratio
(95 % CI)
Model 1
Emotional maltreatment
No maltreatment 2.8 1.0
Minor maltreatment 7.3 1.95 (.98-3.88)
More severe maltreatment 15.4 4.07 (1.76-9.42)**

154
Table 5.12: continued
Male
% exposed Odds ratio
(95 % CI)
Physical maltreatment
No maltreatment 3.0 1.00
Minor maltreatment 5.7 1.08 (.55-2.12)
More severe maltreatment 14.1 1.32 (.54-3.21)

Sexual maltreatment
No maltreatment 3.7 1.00
Minor maltreatment 8.1 1.28 (.63-2.58)
More severe maltreatment 21.3 4.09 (1.90-8.79)***

Neglect
No neglect 4.2 1.00
Minor Neglect 8.0 1.03 (.50-2.11)
More severe neglect 10.5 .65 (.26-1.59)

Model 2

Multiple maltreatment
No maltreatment 1.8 1.00
One form 3.2 1.65 (.62-4.37)
Two forms 6.6 2.87 (1.14-7.25)*
Three forms 11.3 4.77 (1.86-12.21)**
Four forms 16.0 5.64 (1.92-16.56)**

*p < .05; **p< .01; ***p<.001

Models also adjust for family economic status, parental quarrelling and fighting, perceived parental
relationship, source of emotional support, self-perception of health status and school punishment.

Threatened or injured by somebody with weapon on school

setting

Child maltreatment appears to have more impact on being threatened or injured by

somebody with a weapon in a school setting among male than female respondents.
When controlled for family arrangement, parental quarrelling and fighting, parent
relationship, self-perception of health status, and school punishment, male
participants who experienced severe emotional maltreatment (OR = 3.01), minor
physical maltreatment (OR = 1.86), minor sexual abuse (OR = 2.43) and co-
occurrence of child maltreatment were significantly more likely to be threatened and

155
injured in school property. While for female respondents, exposure to emotional
maltreatment (minor: OR = 2.70, more severe: OR = 3.51), severe physical
maltreatment (OR = 3.06), and three forms of child maltreatment (OR = 4.09)
significantly increased the risk of being threatened and injured at school, adjusted for
age, religion, parental fighting, academic result, and school punishment.

Table 5.13: Multivariate models of child maltreatment associated with being

threatened or injured

Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 1.8 1.00 5.8 1.00
Minor maltreatment 5.1 2.70 (1.25-5.86)* 12.0 1.31 (.77-2.22)
More severe 9.0 3.51 (1.40-8.78)** 22.8 3.01 (1.54-5.88)**
maltreatment

Physical maltreatment
No maltreatment 2.2 1.00 5.1 1.00
Minor maltreatment 4.7 1.40 (.69-2.85) 11.2 1.86 (1.11-3.11)*
More severe 13.3 3.06 (1.19-7.86)* 19.0 1.92 (.94-3.92)
maltreatment

Sexual maltreatment
No maltreatment 3.5 1.00 6.8 1.00
Minor maltreatment 4.1 .71 (.32-1.58) 18.8 2.43 (1.47-4.03)**
More severe 10.0 1.59 (.39-6.35) 18.7 2.04 (.99-4.18)
maltreatment

Neglect
No neglect 3.2 1.00 7.3 1.00
Minor Neglect 4.3 .84 (.38-1.89) 11.4 1.11 (.62-1.98)
More severe 5.4 .59 (.26-1.40) 21.3 1.29 (.66-2.51)
neglect

156
Table 5.13: continued
Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 2

Multiple maltreatment
No maltreatment 1.8 1.00 3.8 1.00
One form 2.4 1.29 (.47-3.51) 6.8 1.70 (.86-3.39)
Two forms 4.7 2.27 (.89-5.79) 8.5 2.22 (1.09-4.49)*
Three forms 8.3 4.09 (1.67-10.03)** 21.4 6.88 (3.45-13.74)***
Four forms 6.2 2.49 (.75-8.23) 23.5 7.81 (3.41-17.85)***

*p< .05; **p<.01; ***p<.001

For females, models also control for age, religion, parental fighting, academic result, and school
punishment.
For males, models also control for family arrangement, parental quarrelling and fighting, parent
relationship, self-perception of health status, and school punishment.

Involved in physical fights

Male participants who reported experiencing emotional maltreatment (minor: OR =

1.69, more severe: OR = 2.04), minor physical maltreatment (OR = 1.54), and minor
sexual abuse (OR = 1.76) were significantly more likely to be involved in fighting
when age, religion, family economics, family arrangement, parent quarrel and
fighting, parent relationship, body satisfaction, academic results, and school
punishment were controlled. In contrast, a history of neglect (minor: OR = 2.19,
more severe: OR =2.56) as well as minor sexual abuse (OR = 2.19) significantly
increased the risk of being involved in physical fights among the female sample after
taking into account the effect of various variables (religion, family economic status,
mothers and fathers occupation, parental quarrelling, fighting and drug problems,
emotional support, health status, and school punishment experience).

The dose-response rate of concomitance of child maltreatment is presented in Figure

5.4. Multiple forms of child maltreatment were significantly associated with being
involved in physical fights for both female and male participants. The impact,
however, was much stronger among female (four forms: OR = 9.88) than among
male respondents (four forms: OR = 4.67).

157
 35

30

25
Percentage

20
Fem ale
15 Male

10

0
no abuse 1 form 2 form s 3 form s 4 form s

Figure 5.4: Percentage of adolescent involved in physical fights by occurrence of

multiple types of maltreatment

Table 5.14: Multivariate models of child maltreatment associated with

involvement in physical fight

Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Model 1
Emotional maltreatment
No maltreatment 3.1 1.00 9.7 1.00
Minor 6.7 1.34 (.67-2.67) 20.3 1.69 (1.10-2.59)*
maltreatment
More severe 14.4 1.83 (.81-4.12) 27.5 2.40 (1.32-4.38)**
maltreatment

Physical maltreatment
No maltreatment 3.7 1.00 9.1 1.00
Minor 7.7 1.29 (.69-2.37) 16.7 1.54 (1.02-2.33)*
maltreatment
More severe 13.5 .99 (.39-2.55) 27.5 1.80 (.99-3.27)
maltreatment

158
Table 5.14: continued
Female Male
% Odds ratio % Odds ratio
exposed (95 % CI) exposed (95 % CI)
Sexual maltreatment
No maltreatment 4.5 1.00 11.6 1.00
Minor 10.5 2.19 (1.18-4.07)* 24.7 1.76 (1.14-2.75)*
maltreatment
More severe 16.7 2.43 (.75-7.86) 25.3 1.63 (.87-3.07)
maltreatment

Neglect
No neglect 3.4 1.00 12.8 1.00
Minor Neglect 7.8 2.19 (1.07-4.51)* 16.5 .88 (.53-1.47)
More severe 13.1 2.56 (1.25-5.26)* 23.3 .80 (.44-1.48)
neglect

Model 2

Multiple maltreatment
No maltreatment 2.2 1.00 7.9 1.00
One form 3.3 1.20 (.46-3.13) 10.3 1.29 (.76-2.19)
Two forms 6.9 2.96 (1.23-7.12)* 17.8 2.36 (1.39-3.97)**
Three forms 10.7 4.15 (1.71-10.06)** 24.4 3.15 (1.79-5.55)***
Four forms 18.5 9.88 (3.64-26.84)*** 32.1 4.67 (2.36-9.26)***

*p< .05; **p<.01; ***p<.001

For females, models also control for religion, family economic status, mothers and fathers
occupation, parental quarrelling, fighting and drug problems, emotional support, health status, and
school punishment experience.
For males, models also control for age, religion, family economics, family arrangement, parent
quarrel and fighting, parent relationship, body satisfaction, academic results, and school punishment.

5.3 Summary

There were statistically significant gender differences in all health risk behaviours
examined. The rates of taking most health risk behaviours in this examined list
among urban and rural adolescents were not statistically different, except that
adolescents in urban area were more likely to consider attempting suicide, to smoke
cigarettes, and to drink alcohol. Regarding age groups, older students were
significantly more likely to report feeling sad and hopeless, smoking, drinking, and
being drunk during their lifetime.

159
Many significant correlates between each type of maltreatment, each level of
maltreatment co-occurrence and each health risk behaviour, were found after
controlling for a wide range of potential confounding variables (see summary Table
5.15). In general, the relationship pattern between child maltreatment and health risk
behaviours was similar for the female and male samples. Emotional maltreatment
significantly correlated to most of the behaviours examined. Physical maltreatment
seems to be more likely associated with being involved in physical fights and being
threatened. Sexual abuse was significantly related to smoking, drinking, being drunk,
and involvement in fighting. Statistically significant associations between neglect
and intentional injuries (involved in fighting, felt sad and hopeless, suicide attempts
and plans) were found.

Clearly, co-occurrence of child maltreatment was significantly associated with

almost all examined health risk behaviours. And dose response trend was observed in
most of the cases.

160
 Table 5.15: Summary significant correlations between child maltreatment and health risk behaviours
(adjusted for background factors and other types of child maltreatment)

Significant associations
Behaviour Female Male
CEA CPA CSA CN MTM CEA CPA CSA CN MTM
a b a b a b a b 1 2 3 4 a b a b a b a b 1 2 3 4
Felt sad √ √ √ √ √ √ √ √ √ √ √ √ √ √
Suicide attempt √ √ √ √ √ √ √ √ √ √ √
Suicide plan √ √ √ √ √ √ √ √ √
Smoke √ √ √ √ √ √
Drink √ √ √ √ √ √ √ √ √ √ √ √ √
Drunk √ √ √ √ √ √ √ √
Injured while √
drunk
No eating to lose √ √
weight
Carry weapon √ √ √ √ √
Being threatened √ √ √ √ √ √ √ √ √ √
Involve in √ √ √ √ √ √ √ √ √ √ √
fighting

CEA: child emotional abuse; CPA: child physical abuse; CSA: child sexual abuse; CN: child neglect.
MTM: Multiple-type maltreatment.
a: minor maltreatment; b: more severe maltreatment; 1: one form; 2: two forms; 3: three forms; 4: four forms.
√ : Association is statistically significant at p<.05.
Blank: Association is not statistically significant or not applicable.

161
Chapter 6: Associations between Child
Maltreatment and Mental and
Physical Health

Chapter 5 explored the possible impact of each type of child maltreatment and co-
occurrence of child maltreatment on a wide range of health risk behaviours,
controlling for a number of confounding variables among female and male
participants. The findings indicate that maltreatment victims appear to be
significantly more likely to take health risks. This is may be one of the pathways
leading to the impact of child maltreatment on physical and mental health of
maltreatment survivors. The main questions to be addressed in Chapter 6 are:

• What do background factors predict mental and physical health of the

adolescents?
• Do the effects of self-reported history of child maltreatment on mental and
physical health vary by the type of maltreatment, including emotional
maltreatment, physical maltreatment, sexual abuse and neglect?
• To what extent is the co-occurrence of childhood maltreatment experiences
associated with mental and physical health?

Before conducting the analyses in this chapter, evaluation of assumptions was

performed. The results led to transformation of several variables to reduce skewness,
the number of outliers, and improve the normality and linearity of the following
scales: four scales measuring child maltreatment (emotional, physical maltreatment,
sexual abuse, and neglect), two scales measuring mental health (depression and
anxiety). Logarithmic transformations were used on all these scales.

162
6.1 Descriptive analyses

Mental and physical health was measured using four scales assessing depression
(CES-D), anxiety, self-esteem (RSES), and physical health. For the depression and
anxiety scales, a higher score means more severe symptoms of these mental health
problems. With the self-esteem scale, a higher score indicates higher self-esteem. For
the physical health scale a higher physical health score means poorer general
physical health. These scales were tested and validated in the pilot study presented in
Chapter 3.

The reliability in terms of internal consistency of these scales in the main survey was
somewhat the same as the results in the pilot study, with Cronbach’s Alpha
coefficients ranging from .73 to .85. Cronbach’s Alpha values of these scales
together with means and standard deviation are presented in Table 6.1 below:

Table 6.1: Mean, standard deviation and reliability statistics of mental and
physical health scales

Scale (n = 2,591) Mean SD Cronbach’s Alpha

Physical health 13.15 2.57 .76
Self-esteem 17.55 3.95 .73
Depression 14.84 8.72 .85
Anxiety 20.05 4.09 .79

Preliminary examination of the levels of depression, anxiety, self-esteem, and

physical health, including comparisons by gender, region and age groups using
independent-sample t-tests were performed. The results are summarized in Table 6.2.

Independent t-tests revealed that there were significant differences in mean scores of
all four variables between males and females. This means that females were more

163
likely to be physically weaker than males, had lower self-esteem and more
depression and anxiety. However, as we can see from Table 6.2, the effects were
small, except for anxiety (eta squared = .10).

Table 6.2: Mental and physical health scores by gender

Scale Male Female t-test eta

(n = 1,241) (n = 1,350) square
Mean SD Mean SD
Physical health 12.75 2.57 13.52 2.52 7.69*** .02
Self-esteem 17.76 3.95 17.36 3.94 -2.62** .002
Depression 13.77 8.08 15.83 9.17 6.08*** .01
Anxiety 18.69 3.73 21.31 4.00 17.21*** .10

**p<.01; ***p<.001

Table 6.3 summarizes the means and standard deviations of physical health, self-
esteem, depression and anxiety scales reported by adolescent participants according
to rural (Chilinh) and urban (Dongda) areas. Urban adolescents had significantly
higher self-esteem, less depression and anxiety than their rural counterparts.
However, the differences in the means were very small (eta squared = .01)

Table 6.3: Mental and physical health scores by region

Scale Chilinh Dongda t-test eta

(n = 1,256) (n = 1,335) square
Mean SD Mean SD
Physical health 13.19 2.61 13.11 2.53 .86 .00
Self-esteem 17.11 3.83 17.97 4.01 -5.56*** .01
Depression 15.72 8.51 14.02 8.85 4.99*** .01
Anxiety 20.43 4.18 19.69 3.97 4.58*** .01

***p<.001

164
T-tests were also performed to compare the means of the four scales according to age
groups. For ease of description and in accordance with adolescent age groups
attending secondary and high schools, participants’ age was divided into two groups,
including 12-15 years equivalent to students studying at lower secondary school and
16-18 years equivalent to students studying at upper secondary school.

Older adolescents reported being significantly less physically healthy, and having
less self-esteem, and more anxiety than younger adolescents. Again, the effect sizes,
however, were small (eta squared = .002-.01) (see Table 6.4)

Table 6.4: Mental and physical health scores by age groups

Scale 12-15 years 16-18 years t-test eta

(n = 1,500) (n = 1,091) square
Mean SD Mean SD
Physical health 12.89 2.57 13.49 2.53 -5.90*** .01
Self-esteem 17.69 4.00 17.36 3.87 2.07* .002
Depression 14.65 8.50 15.11 9.02 -1.33 .00
Anxiety 19.75 4.11 20.46 4.02 -4.38*** .006

*p<.05; ***p<.001

6.2 Bivariate correlations of child maltreatment with

mental and physical health

The analyses were stratified into female and male. Correlation matrices of four
variables measuring emotional maltreatment, physical maltreatment, sexual abuse
and neglect and the four measures of physical health, depression, anxiety, and self-
esteem for females and males are presented in Table 6.5 and Table 6.6 respectively.

Emotional abuse was associated strongly with physical maltreatment and neglect in
both females (physical maltreatment: r = .51, neglect: r = .59) and males (physical

165
maltreatment: r = .52, neglect: r = .56). These results indicate the fact that each type
of child maltreatment was significantly related to each of the other maltreatment
domains. This finding is consistent with other studies examining multiple forms of
childhood maltreatment experiences (Higgins & McCabe, 2001a; Ney, Fung, &
Wickett, 1994; Turner et al., 2006). As can be seen from Tables 6.5 and 6.6, all four
health measures were also correlated with each other as expected; for example,
depression symptoms were positively associated with anxiety and poor physical
health and negatively with self-esteem. These results provide additional evidence on
the quality of maltreatment scales and health outcome measures used in this study.

The results of bivariate correlations clearly show that all four forms of child
maltreatment were significantly related to depression, anxiety, self-esteem, and
physical health, at the level of p<.001, among female and male adolescents alike. For
female participants, however, emotional maltreatment correlated strongest with all
four variables measuring health outcomes compared with physical maltreatment,
sexual abuse and neglect. A similar pattern was also observed among male
respondents.

166
Table 6.5: Bivariate inter-correlations of child maltreatment variables, physical
health and mental health variables (females)

1 2 3 4 5 6 7 8
1. Emotional _
maltreatment
2. Physical .51* _
maltreatment
3. Sexual .28** .29** _
maltreatment
4. Neglect .59** .40** .26* _

5. Physical .29** .23** .13** .23** _

health
6. Depression .39** .24** .17** .35** .25** _

7. Anxiety .33** .24** .14** .27** .35** .46** _

8. Self-esteem -.34** -.16** -.09** -.25** -.11** -.54** -.36** _

** Correlation is significant at the 0.01 level (2-tailed).

Table 6.6: Bivariate inter-correlation of child maltreatment scales, physical

health and mental health scales (males)

1 2 3 4 5 6 7 8
1. Emotional _
maltreatment
2. Physical .52* _
maltreatment
3. Sexual .21** .32** _
maltreatment
4. Neglect .56** .40** .25* _

5. Physical .31** .23** .10** .22** _

health
6. Depression .38** .28** .18** .33** .23** _

7. Anxiety .34** .27** .15** .27** .34** .43** _

8. Self-esteem -.36** -.25** -.10** -.26** -.15** -.52** -.28** _

** Correlation is significant at the 0.01 level (2-tailed).

167
6.3 Impact of co-occurrence exposure to child
maltreatment

Two-way between groups analyses of variance were conducted to explore the impact
of co-occurrence of various forms of child maltreatment and age on physical and
mental health and to examine whether age moderated the relationship between
multiple forms of child maltreatment and health for female and male respondents.
Respondents were divided into 5 groups by level of exposure to child maltreatment
(coding ranges from 0 to 4 with 0 equal to no maltreatment; 1: one type of
maltreatment; 2: two types of maltreatment; 3: three types of maltreatment; and 4:
four forms of maltreatment), and two groups according to their age (12-15 years and
16-18 years).

The main effects of multiple maltreatment and age and the interaction effects on
depression, anxiety, self-esteem and physical health of female and male are
summarized in Table 6.7.

There were statistically significant main effects of co-occurrence of child

maltreatment on all four health outcome measures (depression, anxiety, self-esteem
and physical health) for both females and males at the level of p< .001. The effect
size of multiple maltreatment on depression for both female and male samples was
high (eta squared = .17 for female and .19 for male). Moderate effect sizes were
observed with anxiety (eta squared = .10 for female and male alike), self-esteem (eta
squared = .08 for female and .09 for male), and physical health (eta squared = .08 for
female and .06 for male).

The main effects of age and interaction effects on health outcomes did not reach
statistical significance or, if significant (effect of age on self-esteem for males and
physical health for males and females as well as effect of interaction on self-esteem
for females), the effect sizes were very small, from nearly zero to only .01.

168
Figures 6.1; 6.2; 6.3 and 6.4 illustrate the effect of exposure to concomitance of
various types of child maltreatment on four measures of health outcomes. Mean
scores of depression, anxiety, self-esteem and physical health are compared across
groups of participants with different levels of maltreatment exposure (non-
maltreatment to exposure to four types of maltreatment) by gender and two age
groups.

Table 6.7: Cumulative impacts of co-occurrence of child maltreatment and age

on health outcomes

Female (n = 1,344) Male (n = 1,238)

df F eta df F eta
squared squared
Depression
Multiple maltreatment 4 68.99*** .17 4 72.19*** .19
Age 1 .57 .00 1 .85 .00
Interaction of age and 4 1.79 .01 4 .71 .00
multiple maltreatment

Anxiety

Multiple maltreatment 4 38.90*** .10 4 35.39*** .10

Age 1 1.59 .00 1 .21 .00
Interaction of age and 4 1.41 .00 4 1.58 .01
multiple maltreatment

Self-esteem

Multiple maltreatment 4 28.46*** .08 4 31.50*** .09

Age 1 1.70 .00 1 5.30* .00
Interaction of age and 4 2.43* .01 4 1.18 .00
multiple maltreatment

Physical health

Multiple maltreatment 4 27.87*** .08 4 20.00*** .06

Age 1 9.69** .01 1 4.52* .00
Interaction of age and 4 1.19 .00 4 1.36 .00
multiple maltreatment

*p<.05; **p<.01; ***p<.001

169
 30

Females
25
Mean score

20
12-15 years
16-18 years
15

10

5
No 1 form 2 forms 3 forms 4 forms

25

Males
20
Mean score

12-15 years
15
16-18 years

10

5
No 1 form 2 forms 3 forms 4 forms

Figure 6.1: Mean depression scores by number of forms of child maltreatment

170
 25
Females

23
Mean score

21
12-15 years
16-18 years
19

17

15
No 1 form 2 forms 3 forms 4 forms

25
Males 12-15 years
16-18 years
23
Mean score

21

19

17

15
No 1 form 2 forms 3 forms 4 forms

Figure 6.2: Mean anxiety scores by number of forms of child maltreatment

171
 24
Females
22

20
Mean score

18 12-15 years
16-18 years
16

14

12

10
No 1 form 2 forms 3 forms 4 forms

24

Males
22

20
Mean score

18 12-15 years
16-18 years
16

14

12

10
No 1 form 2 forms 3 forms 4 forms

Figure 6.3: Mean self-esteem scores by number of forms of child maltreatment

172
 19
Females
17

15
Mean score

13 12-15 years
16-18 years
11

5
No 1 form 2 forms 3 forms 4 forms

19
Males
17

15
Mean score

13 12-15 years
16-18 years
11

5
No 1 form 2 forms 3 forms 4 forms

Figure 6.4: Mean physical health scores by number of forms of child

maltreatment

173
It is clear in each graph from Figures 6.1; 6.2; 6.3; and 6.4 that there were strong
associations between number of maltreatment forms experienced and the increase in
symptoms of depression, anxiety, poor physical health and the decrease of self-
esteem for both females and males and in the two age groups. Detailed figures of
mean scores of four health outcome measures by levels of maltreatment experience,
gender and age groups are summarized in Appendix 11.

Post-hoc comparison of mean levels of depression, anxiety, self-esteem, and physical

health across groups with various levels of maltreatment exposure for female and
male participants according to two age groups using the Tukey HSD test was
performed. The significant matrix across maltreatment levels for four health outcome
measures is presented in Table 6.8. With a few exceptions, comparisons across
number of child maltreatment forms showed statistically significant mean differences
(p<.05) in all health outcome measures.

174
 Table 6.8: P values of post-hoc comparisons of means across maltreatment
levels for four measures of health status

Female Male
No 1 2 3 No 1 2 3
Depression
No maltreatment - -
1 form .001 - .071 -
2 forms .000 .000 - .000 .000 -
3 forms .000 .000 .102 .000 .000 .000
4 forms .000 .000 .000 .014 .000 .000 .000 .001

Anxiety No 1 2 3 No 1 2 3
No maltreatment - -
1 form .018 - .039 -
2 forms .000 .000 - .000 .000 -
3 forms .000 .000 .187 .000 .000 .324
4 forms .000 .000 .000 .107 .000 .000 .003 .263

Self-esteem No 1 2 3 No 1 2 3
No maltreatment - -
1 form .091 - .038 -
2 forms .000 .000 - .000 .000 -
3 forms .000 .000 .999 .000 .000 .043
4 forms .000 .000 .561 .716 .000 .000 .005 .728

Physical health No 1 2 3 No 1 2 3
No maltreatment - -
1 form .005 - .137 -
2 forms .000 .005 - .000 .003 -
3 forms .000 .000 .497 .000 .000 .245
4 forms .000 .000 .011 .273 .000 .000 .038 .769

No: No child maltreatment; 1: one form; 2: two forms; 3: three forms.

6.4 Relative influence of each type of child

maltreatment

To examine the relative influence of child emotional maltreatment, child physical

maltreatment, child sexual abuse, and neglect on each of four health outcome
measures including depression, anxiety, self-esteem, and physical health of
adolescent students, eight sequential multiple regression models were performed for

175
both female and male samples. For the first step of each equation, background
variables including demographic variables, family characteristics, child
characteristics (see Table 6.9) were entered in a block. Four child maltreatment
variables were entered as a block on step 2. Results of eight multiple regression
models are displayed in Table 6.9, including the unstandardized regression
coefficients (B), the standardized regression coefficients (β), t-test, R2 change, F
change, and adjusted R2 after entry of all independent variables.

For predicting the impacts on depression, the presence of four types of child
maltreatment significantly increases the amount of explained variance by 7% for
females and 8.8% for males. Emotional maltreatment and neglect were significantly
predictors for both female and male adolescents (p<.001). Region, emotional
support, self-perception of health status and academic achievement for males and
region, father’s occupation, body satisfaction, emotional support, and academic
achievement for females among the back ground variables, significantly survived as
predictors of depression in female and male respondents. The overall models were
significant, explaining 28% [F(26, 995) = 14.62, p <.001] for males and 26 % [F(26,
1,069) = 15.44, p <.001] for females.

Regarding the influence of child maltreatment on anxiety, child maltreatment

significantly explained about 6% of anxiety variance in females and males. Again,
emotional maltreatment and neglect significantly predicted anxiety for males.
However, for females, significant child maltreatment predictors were physical and
emotional maltreatment. Among the back ground variables, region, self-perception of
health status, chronic disease, body satisfaction, and parental quarrelling were
significantly associated with male anxiety, whereas region, age, father’s occupation,
self-perception of health status, chronic disease, and body satisfaction significantly
correlated with female anxiety. The final models significantly explained 22% [F(26,
995) = 11.84, p <.001] of anxiety in males and 21% [F(26, 1,069) = 11.85, p <.001]
in females.

176
 Table 6.9: Complete results of sequential multiple regression analyses of the impact of various forms of child maltreatment
on mental and physical health

Variable Male Female

B β t R2 F change B β t R2 F change
change change
Depression
Step 1
Region -.08*** -.13 -4.03 .206 11.79*** -.07** -.11 -3.37 .185 11.10***
Age .00 .01 .20 .00 .00 -.11
Religion .04 .04 1.52 -.03 -.03 -1.10
Family economic status -.01 -.02 -.66 -.02 -.03 -1.15
Number of sibling .00 .00 -.02 -.01 -.02 -.62
Family arrangement .03 .05 1.23 .01 .02 .51
Parental status -.05 -.05 -1.24 -.02 -.02 -.53
Mother education .01 .03 .84 .00 .01 .26
Father education .00 -.01 -.18 .01 .03 .72
Mother occupation -.01 -.03 -1.01 .00 -.01 -.38
Father occupation .01 .02 .58 .02* .07 2.16
Parent drug problem .05 .03 .96 .00 .00 -.10
Parent quarrel .02 .04 1.26 -.01 -.04 -1.15
Parent fighting .02 .05 1.43 .02 .04 1.27
Perceived parental
.02 .04 1.26 .02 .06 1.68
relationship
Emotional support .02** .08 2.71 .01 .05 1.90
Child chronic diseases .02 .04 1.29 .02 .03 .94

177
Table 6.9: continued
Variable Male Female
2
B β t R F change B β t R2 F change
change change
Self-perception of health
.07*** .17 5.60 .07*** .14 5.15
status
Body satisfaction .01 .03 .86 .07*** .15 5.31
Academic achievement .04*** .11 3.57 .04** .09 3.21
School punishment .01 .03 1.08 .01 .01 .49
Repeated class .10* .06 2.19 -.04 -.02 -.56
Step 2
Sexual abuse .17 .04 1.44 .07 24.19*** .22 .04 1.28 .088 32.19***
Physical maltreatment .09 .03 .97 .06 .02 .58
Neglect .32*** .14 4.02 .31*** .14 3.98
Emotional maltreatment .40*** .18 4.63 .52*** .22 6.03

Total adjusted R2 = .28, F(26, 995) = 14.62, p <.001 Total adjusted R2 = .26, F(26, 1,069) = 15.44, p <.001

Anxiety
Step 1
Region -.01*** -.09 -2.62 .175 9.60*** -.02** -.10 -2.95 .165 9.65***
Age .00 -.02 -.49 .01* .06 2.03
Religion .01 .02 .75 .01 .04 1.27
Family economic status -.05 -.03 -.87 -.01 -.04 -1.28
Number of sibling .00 -.02 -.59 .00 -.01 -.24
Family arrangement .00 .01 .28 .00 .00 .05
Parental status .00 -.01 -.19 .00 .00 .03
Mother education .00 .02 .39 .00 -.03 -.79

178
Table 6.9: continued
Variable Male Female
2
B β t R F change B β t R2 F change
change change
Father education .00 .02 .52 .00 .02 .55
Mother occupation .00 .03 .76 .00 .03 .94
Father occupation .00 .00 .04 .01* .07 2.04
Parent drug problem .02 .04 1.21 .02 .05 1.63
Parent quarrel .01*** .12 3.52 .00 .03 .88
Parent fighting .00 .00 .09 .00 .02 .64
Perceived parental
.00 -.04 -1.07 .00 .01 .39
relationship
Emotional support .00 -.01 -.39 .00 -.02 -.79
Child chronic diseases .02*** .13 4.31 .02** .09 3.32
Self-perception of health
.02*** .18 5.94 .02*** .17 6.08
status
Body satisfaction .01* .07 2.12 .02*** .13 4.48
Academic achievement -.01 -.04 -1.36 -.01 -.05 -1.76
School punishment .00 -.04 -1.22 -.01 -.05 -1.65
Repeated class .02 .04 1.22 -.02 -.02 -.69
Step 2
Sexual abuse .03 .03 .85 .062 20.11*** .03 .02 .57 .059 20.16***
Physical maltreatment .05 .06 1.73 .08* .08 2.48
Neglect .06** .10 2.71 .04 .07 1.84
Emotional maltreatment .12*** .18 4.62 .12*** .18 4.68

Total adjusted R2 = .22, F(26, 995) = 11.84, p <.001 Total adjusted R2 = .21, F(26, 1,069) = 11.85, p <.001

179
Table 6.9: continued
Variable Male Female
2
B β t R F change B β t R2 F change
change change
Self-esteem
Step 1
Region .58* .07 2.20 .208 11.91*** 1.05*** .13 4.04 .220 13.77***
Age -.10 -.04 -1.27 -.05 -.02 -.58
Religion .06 .00 .15 .04 .00 .10
Family economic status .30 .04 1.19 -.04 .00 -.15
Number of sibling -.39 -.05 -1.78 .19 .03 .92
Family arrangement -.13 -.01 -.38 -.34 -.04 -1.16
Parental status .67 .05 1.22 .82 .07 1.74
Mother education -.36* -.10 -2.51 .00 .00 -.02
Father education .06 .02 .42 -.23 -.07 -1.65
Mother occupation .18 .06 1.78 .00 .00 .01
Father occupation .04 .01 .37 -.17 -.05 -1.71
Parent drug problem -.16 -.01 -.24 -.42 -.02 -.71
Parent quarrel -.12 -.03 -.72 .10 .02 .65
Parent fighting .05 .01 .21 .22 .04 1.07
Perceived parental
-.45* -.09 -2.38 -.38* -.08 -2.25
relationship
Emotional support -.25** -.09 -3.19 -.09 -.03 -1.05
Child chronic diseases .08 .01 .33 .01 .00 .05
Self-perception of health
-.68*** -.11 -3.73 -.67*** -.11 -3.88
status
Body satisfaction -.91*** -.17 -5.45 -1.60*** -.27 -9.59
Academic achievement -.41* -.07 -2.39 -.66*** -.11 -3.86

180
Table 6.9: continued
Variable Male Female
2
B β t R F change B β t R2 F change
change change
School punishment -.41* -.08 -2.54 -.44* -.06 -2.26
Repeated class -1.01 -.05 -1.66 .29 .01 .28
Step 2
Sexual abuse .15 .00 .09 .044 14.68*** 1.23 .02 .52 .050 18.18***
Physical maltreatment -1.62 -.04 -1.19 1.43 .03 1.01
Neglect -2.03 -.06 -1.79 -1.11 -.04 -1.08
Emotional maltreatment -5.71*** -.18 -4.70 -7.98*** -.25 -6.79

Total adjusted R2 = .23, F(26, 995) = 12.89, p <.001 Total adjusted R2 = .28, F(26, 1,069) = 15.19, p <.001

Physical health
Step 1
Region -.78*** -.15 -4.41 .164 8.88*** .07 .01 .36 .111 6.12***
Age .02 .01 .43 .06 .03 1.09
Religion .68** .08 2.68 .69** .08 2.71
Family economic status -.08 -.01 -.46 -.29 -.05 -1.79
Number of sibling .03 .01 .23 -.17 -.04 -1.27
Family arrangement .09 .02 .43 -.10 -.02 -.49
Parental status -.25 -.03 -.68 .33 .04 1.02
Mother education -.12 -.05 -1.27 .02 .01 .22
Father education -.01 .00 -.06 .06 .03 .65
Mother occupation -.06 -.03 -.86 .06 .03 .94
Father occupation -.13 -.06 -1.89 .05 .02 .67
Parent drug problem -.16 -.01 -.36 .58 .04 1.44

181
Table 6.9: continued
Variable Male Female
2
B β t R F change B β t R2 F change
change change
Parent quarrel .36** .11 3.12 .16 .05 1.48
Parent fighting -.04 -.01 -.27 .06 .01 .41
Perceived parental
-.18 -.05 -1.45 -.15 -.05 -1.27
relationship
Emotional support .02 .01 .34 .00 .00 .01
Child chronic diseases .91*** .17 5.62 .37* .07 2.38
Self-perception of health
.60*** .16 4.96 .59*** .15 4.94
status
Body satisfaction .18 .05 1.63 .16 .04 1.4
Academic achievement -.07 -.02 -.59 -.36 -.09 -3.09
School punishment .18 .05 1.63 .08 .02 .59
Repeated class -.35 -.03 -.85 .75 .03 1.05
Step 2
Sexual abuse .04 .00 .03 .043 13.55*** 1.14 .02 .71 .049 15.74***
Physical maltreatment 1.01 .04 1.11 2.53** .09 2.60
Neglect 1.22 .06 1.62 .83 .04 1.17
Emotional maltreatment 3.73*** .18 4.59 3.28*** .16 4.08

Total adjusted R2 = .19, F(26, 995) = 9.98, p <.001 Total adjusted R2 = .28, F(26, 1,069) = 7.88, p <.001

*p<.05; **p<.01; ***p<.001

182
The presence of four types of child maltreatment in the equations predicting self-
esteem also significantly contributed to explaining variance of self-esteem among
females (5%) and males (4.4%). Emotional maltreatment again was a significant
predictor for both females and males. Many background variables were significant
predictors of self-esteem for females, including region, perceived parental
relationship, body satisfaction, self-perception of health status, academic
achievement, and school punishment. For males, apart from predictors listed for
females, mother’s education and emotional support also significantly explained the
variance of self-esteem. In total, the models explained 23% [F(26, 995) = 12.89, p
<.001] of self-esteem variance for males and 28% [F(26, 1,069) = 15.19, p <.001] of
variance for females.

Finally, the variance of the physical health measure was also significant explained by
the multiple regression models. For males it explained 19% [F(26, 995) = 9.98, p
<.001] of the variance and 28% [F(26, 1,069) = 7.88, p <.001] of the variance for
females. However, four types of child maltreatment only contributed to significantly
explaining less than 5% of the variance in each model. Emotional maltreatment
significantly influenced male physical health whereas emotional and physical
maltreatment significantly predicted physical health of female adolescents.
Background variables that significantly predicted male physical health were region,
religion, parental quarrelling, chronic disease, and self-perception of health status.
For female physical health, the variables were religion, chronic disease, and self-
perception of health status.

6.5 Summary

This chapter has examined the impact of child maltreatment including each
individual type and multiple types on health outcome measures including depression,
anxiety, self-esteem and general physical health. In bivariate correlation analyses,
each type of child maltreatment was significantly associated with each health
outcome measure. However, correlations between emotional maltreatment and health
were higher than for the other three forms of maltreatment. All types of child

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maltreatment appeared to correlate more highly with depression than the other health
outcomes.

Regarding co-occurrence of maltreatment, the results presented in this chapter

suggest that cumulative exposure to multiple forms of child maltreatment represents
a substantial risk for adolescent health, especially mental health (depression and
anxiety).

In multiple regression analyses, after controlling for a wide range of background

variables, the presence of four types of child maltreatment significantly explained the
variance (between 5% to 9%) of adolescent health status. Emotional maltreatment
and neglect appeared to be the strongest influences on mental and physical health of
adolescents.

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 Chapter 7: Discussion

This study reports on the prevalence and co-occurrence of four forms of child
maltreatment and examines associations with demographic factors, family
characteristics and family environment in a school-based Vietnamese adolescent
sample. Furthermore, the possible effects of child maltreatment on a wide range of
health risk behaviours and physical and mental health were examined. To the best of
our knowledge this study is the most comprehensive of this kind to be conducted in
Vietnam and is one of the first such studies in Asia.

Unlike most previous studies conducted in different parts of the world, this study
simultaneously focused on all main forms of child maltreatment. As a result, it was
able to estimate not only the prevalence of each form of child maltreatment but also
the prevalence of co-occurring types of maltreatment including those forms that have
seldom been studied in earlier research (i.e. emotional maltreatment and neglect).
Moreover, we adjusted for the effects of a wide range of possible confounding
factors including demographic characteristics, family structure and environment
variables when examining the correlations between child maltreatment and health
outcomes. This study has generated a number of valuable findings, both for
improving knowledge of child maltreatment in Vietnam, and for broader research
into the consequences of maltreatment.

7.1 The prevalence of child maltreatment and

correlates with background variables

An important limitation of existing research worldwide is that many studies use

measures and survey methods that are not directly comparable (Fergusson & Mullen,
1999). Consequently, it is difficult to make an accurate comparison of child
maltreatment prevalence between studies. However, there is sufficient international
data available to establish the probable ranges of prevalence of different forms of
child maltreatment. Findings from this study are broadly consistent with previous

185
studies in that child maltreatment is found to be a widespread phenomenon wherever
it is measured (Fergusson & Mullen, 1999).

The prevalence of child physical maltreatment in Vietnam appears to be lower

compared with several other studies in developing countries. Nearly fifty per cent
(47.5%) of respondents in this study reported lifetime physical maltreatment
experiences and boys (54.1%) were more likely to be maltreated than girls (41.0%).
Kim and colleagues (2000) reported higher physical prevalence in the Chinese and
Korean school student sample. During the last 12 months 70.6% of children in China
and 68.9% of children in Korea experienced physical violence in the family.
Additionally, severe physical maltreatment was more predominant in China (22.6%)
and especially in Korea (51.2%) compared to Vietnam (9.0%). Egyptian study
(Youssef et al., 1998a, , 1998b) also revealed a higher prevalence of physical
maltreatment than that of present study in Vietnam. During the school year, 72.8% of
Egyptian adolescents reported physical maltreatment by teachers and 37.5% by
parents.

Furthermore, the proportion of adolescents who required medical consultations as a

result of injuries incurred by physical maltreatment was also higher in Egypt (21.9%
and 22.8% due to physical maltreatment by teachers and parents respectively)
compared to our study (14.9% due to physically maltreated by any adult). It is also
very important to note that our study retrospectively asked about life time physical
maltreatment by any adult while the study in Egypt asked about physical
maltreatment during one scholastic year and only abuse by parents and teachers. It
therefore may be assumed that the lifetime prevalence of physical maltreatment
among adolescents in Egypt would be much higher than the annual incidence rates
estimated in that study.

However, the rate of adolescents who experienced physical maltreatment and the
proportion of adolescents injured from physical maltreatment in our study was higher
than that of recent studies conducted among Hong Kong adolescents. Authors (Lau et
al., 2003; Lau et al., 2005) found more than four per cent adolescents physically

186
maltreated during the last 6 months and 10.4% ever injured and 2.9% injured in the
past 6 months from beating occurring without provocation by family members).
Again, differences in definition of perpetrators and time frame which were broader in
the current study than in Hong Kong studies might explain some of the differences in
physical maltreatment prevalence and the proportion of adolescents injured due to
this violence.

The prevalence of physical maltreatment in Vietnam in comparison with several

other studies conducted in European and Western countries appeared to be higher.
However, those studies all used narrower definitions of child physical maltreatment
(May-Chahal & Cawson, 2005; Meston et al., 1999; Moran et al., 2004; Sebre et al.,
2004). Nevertheless, regarding the prevalence of physical maltreatment among boys
and girls, our finding was consistent with most previous studies that find males are
more likely to report having physically maltreatment experiences than females
regardless of the discrepancies in definitions.

Little research into child maltreatment has been done in Vietnam and most child
maltreatment research has focused mainly on physical punishment. Most local
information is derived from studies by NGOs, and do not have clear description of
study methodology and definition of maltreatment. Therefore it is impossible to
make an accurate comparison of our findings with previous Vietnamese data.
Nevertheless, just recently there have been two reports issued by UNICEF
(Michaelson, 2004) and Save the Children Sweden in Vietnam (PFCSI & SCS,
2005). These reports revealed preliminary information regarding some forms of child
maltreatment, which is similar to that of the present study. The estimated physical
maltreatment prevalence from these reports ranging from nearly forty to just above
fifty per cent of adolescents reported that they had been physically punished with an
implement in their life time and boys were significantly more likely than girls to
report this adverse experience. Similar to the survey conducted by the Vietnam
Population, Family and Children Scientific Institute and Save the Children Sweden
(PFCSI & SCS, 2005) our study also revealed that the father was the most common
perpetrator of physical maltreatment.

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Internationally, there have been quite a few community and school-based surveys
aimed at determining the life time prevalence of childhood sexual abuse. As
indicated in the Appendix 1 child sexual abuse prevalence among adolescents and
early adulthood varies considerably from nearly two per cent in the US (Smith et al.,
2005) up to over fifty per cent in South Africa (Madu & Peltzer, 2000) depending on
the definition of study, the number and wording of the questions used to estimate
prevalence, and also of course on the cultural differences of the study context. In
Vietnam, estimated prevalence of any type of sexual abuse of 19.7% in the whole
sample falls in the middle of the range of international findings. It is comparable to
the recent study conducted with a representative sample of young people in the
United Kingdom used a similar broad definition including non-contact and contact
sexually adverse events (16.0%) (May-Chahal & Cawson, 2005).

Also using broad definition of child sexual abuse, findings from Vietnam’s
neighbouring country, China were slightly lower; 13.6% of Chinese school
adolescents reported any unwanted sexual experiences before age of 16 (Chen,
Dunne et al., 2004), than our estimated prevalence (19.7%). It is important to note
that child sexual abuse case defined by our study was somewhat different from the
definition used in the study in China in terms of timeframe and the number of
adverse sexual events experienced by the respondents. It is therefore difficult to
assess whether the findings reflect the true difference or whether there was a
discrepancy in defining abuse cases.

The proportion of participants in our study who reported experience of attempted

rape and rape were 3.2% and 2.7% respectively, which also falls in the lower range
of internationally estimated rates (see Appendix 1) from about two per cent to more
than eight per cent for attempted rape and from nearly one per cent to six per cent of
actual rape (Chen, Dunne et al., 2004; Choquet, Darves-Bornoz, Ledoux, Manfredi,
& Hassler, 1997; King et al., 2004). These findings are very similar to recent studies
among adolescents in China (Chen et al., 2006; Chen & Dunne, 2006). In the report
of UNICEF, Vietnam, the only community based information of sexual abuse in
Vietnam available so far, Michaelson (2004) estimated that 2.7% of adolescents

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reported having been raped or experiencing other forms of sexual assault as a child.
Unfortunately, the report did not provide in details what sexual assault means in this
survey. In this regard, we therefore could not make further discussion.

The results of our study indicated that sexual abuse is usually perpetrated by
someone known by the victims and predominantly by male perpetrators. These
findings replicate national (Michaelson, 2004; SIDA, 2000) and international
findings (Finkelhor, 1994).

Interestingly, unlike most studies where girls are more likely to report having adverse
sexual experiences than boys, our study found that more boys (21.8%) than girls
(18.4%) met the criteria of exposure to sexual abuse. This finding is similar to the
pattern found in other studies on sexual maltreatment in Jewish and Arab schools in
Israel (Benbenishty et al., 2002; Zeira et al., 2002) and in accordance with results of
Michaelson’s study in Vietnam (Michaelson, 2004), in which males were twice as
likely to report experience of unsafe touching of private parts while growing up or
being raped as a child, than were females.

It would be premature to conclude that the actual incidence of sexual abuse of female
children is lower in Vietnam. There is a need for more research, especially because
the pattern in Vietnam and a few other countries is strikingly different from the
majority of research in western countries. There are several possible explanations.
The lower rate of sexual abuse among girls in the first two community based studies
in Vietnam may be a reflection of the residual attitudes of shame associated with
reporting sexual abuse (SIDA, 2000). Shame feelings seems to be more predominant
among females than males because of the cultural values where the power
differences between males and females in Asia make it difficult for females to
reported “shameful” adverse experiences, especially when the perpetrator is a man
known within the family or community (Futa, Hsu, & Hansen, 2001). This
contention is supported by the apparent reluctance of adult females to report having
experienced sexual abuse when compared with higher rates reported by adult males
and female children (Michaelson, 2004). Another possibility related to cultural

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norms is that fondling the private part of young boys is considered as a common
cultural practice of adult male relatives in Vietnam. While many adults perceive that
the practice is a harmless expression of adult affection, many boys report that they
consider it as intrusive or even abusive (Michaelson, 2004).

There are similarities and differences in our findings concerning child sexual abuse
in Vietnam compared with patterns found in international studies. Overall, though,
our data clearly indicate that Vietnamese children are just as vulnerable to sexual
abuse as are children living in many other parts of the world.

Relatively little is known about the extent of child emotional maltreatment and
neglect worldwide. This study is among the first to report prevalence of emotional
maltreatment (39.5%) and neglect (29.3%) among young people in Vietnam. Again,
our results fall within the range of the findings from international studies that
estimate the prevalence of emotional maltreatment and neglect among community-
based adolescent and early adult samples (see Appendix 1). Females in our study
were more likely to report experiences of emotional maltreatment and neglect than
were males. This pattern was similar to studies conducted in the UK (May-Chahal &
Cawson, 2005), Turkey (Zoroglu et al., 2003), and Japan (Yamamoto et al., 1999)
but contrary to the findings from studies in Iran (Stephenson et al., 2006), Israel
(Benbenishty et al., 2002), and Canada (Meston et al., 1999). More comprehensive
studies are needed before we can determine whether there is a universal gender
difference in incidence of emotional maltreatment and neglect, or true variation
across cultures.

The prevalence of child emotional maltreatment in our study was somewhat

consistent to the findings from two recent studies in Vietnam where children aged
from 6 to 18 years old reported that they were shouted at (65.2%) and humiliated,
insulted (30.9%) by adults when they had made a mistake (PFCSI & SCS, 2005) and
35.7% adolescents in another study reported having experienced verbal or emotional
maltreatment (Michaelson, 2004). It is impossible to make a comparison of neglect
prevalence due to the fact that there are no figures available on neglect in Vietnam.

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Michaelson’s (2004) qualitative study in Vietnam indicated that emotional neglect
and educational neglect may be common and serious forms of neglect in Vietnam.
Most participants in Michaelson’s study appear to clearly separate the unavoidable
effects of living in poverty from the concept of child neglect. During qualitative
interviews for the pilot phase of this research, we interviewed 4 teachers, 4 parents
and 8 students (see Chapter 3 and Appendix 8). The qualitative interviews of our
research revealed that emotional neglect is an emerging problem that may be
independent of the poverty issue and needs to be addressed. This is indicated in the
accounts of two teachers below.

A common type of child maltreatment now is lack of care for children in the

broader sense that is not only lack of care for materials but now many families

in cities can earn a lot of money and give money to children and they incorrectly

think that is enough. It really creates a new social problem. (Female teacher,

Hanoi)

Child maltreatment is understood that now many families do not treat children

well, for example not supporting children studying, parents travelling for doing

business and leaving children with their relatives. In Chilinh now increasing

numbers of parents are working abroad; their children have to stay at home and

those children are at risk of maltreatment. (Female teacher, Chilinh)

It is evident that maltreatment types do not occur independently. Rather, a significant

proportion of maltreated individuals experience not just multiple events of one type
of maltreatment but they also are likely to be exposed to other maltreatment forms.
Multiple-type maltreatment refers to the co-occurrence of more than one form of
child maltreatment, commonly including sexual abuse, physical and emotional
maltreatment and neglect, some researchers also mention witnessing violence as
another type of child maltreatment (Clemmons et al., 2003; Higgins & McCabe,

191
2001b). From the literature review, it is clear that the empirical knowledge base of
the coexistence of various maltreatment types is limited. This study is among the
first in Asia to estimate the extent to which the concomitance of different types of
child maltreatment was reported by a community-based adolescent sample.

The present research extends findings from a few previous studies on poly-
victimization maltreatment in Western countries (Clemmons et al., 2003; Higgins &
McCabe, 2000a; Scher et al., 2004) to an Asian country. We found that Vietnamese
adolescents may also commonly experience multiple forms of child maltreatment. In
this study, more than forty per cent (41.5%) of participants reported being subjected
to two or more forms of child maltreatment, of which 20.7%, 14.5% and 6.3%
experienced 2 forms, 3 forms and 4 forms respectively. These results are relatively
similar to the findings from a community-based adult sample in Australia (Higgins &
McCabe, 2000a). In his study, Higgins examined the co-occurrence of five forms of
child victimization (sexual, physical, emotional maltreatment, neglect and witnessing
family violence). He found that 43.4% of respondents reported experiencing two or
more forms of maltreatment with 15.4%, 11.4%, 9.7%, and 6.9% experienced two,
three, four, or five forms respectively. However, our estimated prevalence of poly
victimization maltreatment seems to be higher than Scher’s estimate (2004) in
America with 13.5% of an adult sample exposed to two or more forms of child
maltreatment. Our findings are also much higher than that reported in the only study
available from a non-western country, Turkey, where 8.7%, 3.8%, and 1.3% of the
school adolescents reported having experienced of two, three, and four forms of
maltreatment respectively (Zoroglu et al., 2003). The differences of definition of
maltreatment cases used in these studies may be among the potential factors to
contribute to the differences in the findings.

In this study, the most common co-occurrence of two forms of maltreatment was
emotional and physical maltreatment (8.3%), and of three forms of maltreatment was
emotional, physical maltreatment and neglect (8.9%). This pattern of concomitance
of child maltreatment corroborates those of earlier research conducted among an
adult community sample in the USA that also reported emotional abuse and physical

192
abuse as the most common combination of child maltreatment types (8.3% of the
overall sample) (Scher et al., 2004).

While the multiple type maltreatment rates may be somewhat different between
studies, the conclusion from our findings supports that of earlier research, that co-
occurrence of various forms of child maltreatment is not uncommon. This finding
strongly suggests that studying individual types of child maltreatment in isolation
from other types may not capture a comprehensive picture of the problem.

The present study examined the correlates of a wide range of background variables
which consist of demographic characteristics, family characteristics and family
environment, for each of the four forms of child maltreatment. This study examined
key variables in two level of the ecological model including individual and family
levels and one variable belonging to community level (urban and rural region).
Generally speaking, findings are congruent with the ecological model (see Figure 2.1
in Chapter 2) with risk factors of child maltreatment embedded in different layers
from individual to relationships, community and society (Belsky, 1993). The
significant predictors of each form of child maltreatment varied considerably. The
key risk factors for reporting child maltreatment experience in this study were
individual factors (gender, age, parent marital status, family arrangement),
relationship factors (parental quarrelling and fighting, perceived parental
relationship, and source of support), and community factors (urban and rural areas)
when adjusted for other factors. The only factors that emerged as strongly
significantly associated with all maltreatment types examined were relationship
factors: quality of parent relationship and source of support to whom children can
turn when they need help.

The finding that witnessing verbal and physical violence between parents and poor
quality parental relationship significantly increased the risk of all four forms of
maltreatment is consistent with the results from numerous studies conducted in the
West (Black, Heyman et al., 2001a; Black, Heyman, & Smith Slep, 2001b; Black,
Smith Slep et al., 2001; Schumacher et al., 2001) and with a recent study in a

193
developing country (Stephenson et al., 2006). The present study also found that in
comparison to children who ask for support from members of the family including
mother, father, or siblings when they need help, those who did not seek help from
those family members were significantly more likely to report maltreatment
experiences. However, this factor by itself may not cause the maltreatment rather it
might reflect the poor parenting style, poor parental attachment and poor relationship
among family members, which may have a causal relationship with maltreatment.

Parental drug and alcohol problems and social demographic characteristics often are
found to be significantly associated with child maltreatment (Black, Heyman et al.,
2001a; Black, Heyman et al., 2001b; Black, Smith Slep et al., 2001; Fergusson &
Lynskey, 1997; Fergusson & Mullen, 1999; Finkelhor & Baron, 1986; Schumacher
et al., 2001; Sebre et al., 2004). Children who come from low income families, with
low parent education, unemployed mothers, and without one of the biological parents
at home were most at risk of being maltreated. However, these findings were not
replicated in our study. Family economic status did not predict any type of
maltreatment. Although parent education and occupation were marginally correlated
with maltreatment in bivariate analysis, both appeared to be insignificant after
controlling for the effects of other factors in multivariate logistic regression models,
excepting the association between mother’s unemployment and sexual abuse. These
findings do not mean that it reflects the actual fact in Vietnamese context, rather it
suggests that more studies need to be conducted to comprehensively examine the risk
factors of child maltreatment in Vietnam. Parental drug and alcohol problems also
were not significantly associated with maltreatment in multivariate analysis in this
study. However, power issue when using multivariate logistic regression could be the
main reason because we found only a small percentage [3.2% (81 respondents) for
overall sample] of participants who reported their parents had this problem. In
comparison to large-scale community-based studies in North America where parent
substance abuse was found as a significant predictor of child maltreatment when
using multivariate analysis, the prevalence of parental substance abuse was much
higher than our data (Chaffin et al., 1996; Walsh et al., 2003). In Canada, Walsh,
MacMillan, and Jamieson (2003) found that 17.2% of 8,359 respondents reported a

194
parental history of substance abuse. In a prospective community case-control study
in the US, Chaffin, Kelleher, and Hollenberg (1996) revealed that 5.7% of control
group and 15.1% of physical abuse respondents and 21.0% of neglect cases reported
parent substance abuse disorders.

7.2 Correlates of child maltreatment and health risk

behaviours

Health risk behaviours in adolescence such as smoking, drinking, drug use, self-harm
and anti-social behaviours etc. are issues of major public health concern.
Researchers, mostly in the United States and other developed countries, and recently,
in a small number of developing countries, have begun documenting the prevalence
and risk and protective factors of a number of health risk behaviours (Anteghini et
al., 2001; Blum et al., 2003; Dowdell & Santucci, 2004; Sarigiani, Ryan, & Petersen,
1999; Zweig et al., 2001). History of being maltreated has been reported to increase
rates of various health risk behaviours in studies among Western adult samples
(Dube et al., 2006; Rodgers et al., 2004; Walker et al., 1999) and adolescent samples
(Bensley, Spieker et al., 1999; Bensley, Van Eenwyk, Spieker, & Schoder, 1999;
Chen et al., 2006; Chen, Dunne et al., 2004). However the degree of risk associated
with different types of maltreatment and cumulative effects of co-occurrence of
maltreatment are not well documented. Our study is among the first in Vietnam and
Asian countries to examine the relative and additive effects of four forms of child
maltreatment on a wide range of health risk behaviours.

Focusing first on the prevalence and gender differences in various health risk
behaviours, we found that prevalence is somewhat similar to results from other large
scale surveys conducted among school adolescents in Hong Kong, China and
Malaysia (Chen, Dunne et al., 2004; Chen, Lee, Wong, & Kaur, 2005; Lee & Tsang,
2004; Liu, Tein, Zhao, & Sandler, 2005). Boys appear to report more externalizing
harmful behaviours such as involvement in physical fights, carrying a weapon,
smoking, drinking, and being injured while drunk, whereas girls report more
internalizing health risk behaviours, for example, suicidal thoughts and attempts, and

195
dangerous dieting practices. However, the proportion of children with intentional
injury, smoking, drinking, and binge drinking in our study was much lower than in
the USA (Zweig et al., 2001), where also not many gender differences in these
behaviours was observed. This could be due to the fact that risk behaviours among
adolescents may be partially determined by culture (Ebin et al., 2001; Grunbaum et
al., 2000; Kaplan et al., 2003; Viner et al., 2006). Studies conducted among
adolescents in the UK and the USA have found that rates of smoking, drinking, and
other health compromising behaviours are lower among Asian American and Asian
British adolescents than Hispanic or Caucasian young people. In traditional Asian
cultures the individual is considered as part of the family and community. The
relationship between parent and child is hierarchical whereby children are expected
to follow the family rules and maintain family traditions. This traditional practice
may play a role in explaining the effect of health risk behaviours of Asian
adolescents (Bhattacharya, 1998).

There is little information on health related behaviours among adolescents available

in Vietnam to make comparison to the present study. The rate of participants in this
study reporting that they had carried a weapon (3.2%) was comparable with the
Survey Assessment of Vietnamese Youth (SAVY) (2.3%), which was conducted
from 2003-2005 and is the largest and most comprehensive survey ever among youth
in Vietnam (MOH, GSO, WHO, & UNICEF, 2005). The proportion of male
adolescents in our study who reported smoking behaviours (7.1%) was also relatively
similar to SAVY’s result of male rates of current smoking (9.8%). However, the
proportion of youths who reported suicidal thoughts in SAVY was much lower than
the finding from our study (3.4% versus 9.2%). We could not find any explanation
for that at the moment, however as SAVY’s report (MOH et al., 2005) notes that:

Some anecdotal evidence and hospital records suggest that suicide is a more

significant cause of [Vietnamese] youth mortality and morbidity than SAVY

suggests. It is important to understand further these self-harm and self-

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 destructive behaviours and thoughts, and consider what might be the

contributing factors. (p.71)

Problem behaviours in adolescence might be influenced by a variety of factors such

as peer pressure to perform behaviours not allowed by adults, disappointment in
relationships, or academic difficulties (Bensley, Van Eenwyk et al., 1999).
Furthermore, the literature review has also shown that a history of child maltreatment
is a contributing factor for engaging in behaviours that compromise health. The
findings of this study clearly showed the significant relationship between child
maltreatment and various health risk behaviours of adolescents when statistically
controlling for differences in the family social backgrounds, and other adolescent
characteristics. These findings are consistent with results of international studies such
as those by Bensley, Spieker et al.(1999); Bensley, Van Eenwyk et al.(1999); Chen,
Dunne et al. (2004); Hibbard et al. (1990); King et al (2004); Lau et al. (2005); and
Riggs et al. (1990).

In general, in this study child emotional and physical maltreatment, sexual abuse and
neglect had independent correlations with different health risk behaviours examined
for both female and male adolescents. There was a clear dose-response relationship
with frequencies of health risk behaviours increasing according to the levels of
maltreatment severity. Multivariate analysis showed that for both females and males
emotional maltreatment were significantly correlated with more behavioural
problems examined (see Table 5.15). However, sexual abuse seems to have a
particular effect on behavioural problems among males. Controlling for background
factors and co-occurring types of maltreatment, CSA was significantly associated
with smoking, drinking, being drunk, carrying a weapon, being threatened and
involving in fighting among male participants while only drinking, being drunk and
involvement in fighting remained significant among female respondents. This pattern
of gender difference in the impact of sexual abuse on behaviours of adolescents is in
accordance with studies among adolescents in the USA (Hibbard et al., 1990) and
China (Chen, Dunne et al., 2004). A question could be raised here as to why sexually
abused males exhibit more externalizing problematic behaviours. The differences in

197
socialization patterns and in the ways of expressing of psychological and emotional
problems might be among various possibilities. Further study is needed to address
this issue.

In current study physical maltreatment and neglect appear to have less robust
associations with behavioural problems, in comparison with emotional maltreatment
and sexual abuse. The relationship between physical maltreatment and adolescent
behaviours such as suicidal behaviours, smoking and drinking in our study was less
strong than results reported in studies in Hong Kong (Lau et al., 1999; Lau et al.,
2005) and the US (Bensley, Spieker et al., 1999; Riggs et al., 1990), in terms of the
values of odds ratios and statistical significance. There are several possible
explanations for the differences. First, the potential confounding factors such as
demographic characteristics, family factors and adolescent characteristics were not
taken into account (Lau et al., 1999) or that was less comprehensive adjustment
(Bensley, Spieker et al., 1999; Lau et al., 2005) compared to this study. Second, the
literature has shown that childhood maltreatment victims are more likely to have
multiple maltreatment experiences. Given the comorbidities that exist between
different types of child maltreatment, those previous studies, when examining the
relative association of one type of child maltreatment (physical maltreatment in this
case) had failed to control for effects of other types (Lau et al., 1999; Lau et al.,
2005) or only controlled for the effects of sexual abuse (Bensley, Spieker et al.,
1999; Riggs et al., 1990) but not emotional maltreatment and neglect, unlike this
Vietnamese study. Third, in controlling for quite a few confounding variables and the
effects of three other types of maltreatment, less statistical power might make it
impossible to detect significant relationships as in the other studies when they may
actually exist in our study in several models. Larger sample sizes are recommended
for future studies of this kind.

Neglect seems to have a strong influence on internalising behaviours such as feeling

sad and hopeless and considering suicide for both males and females in our study.
Zoroglu and colleagues (2003) had reported similar results that neglect had
significant association with suicide attempt and self-mutilation among adolescents in

198
Turkey. No other research has examined the effect of neglect with other health
compromising behaviours. Individually, each type of child maltreatment examined in
the present study appears to have its own pattern of relationships with a wide range
of health risk behaviours that would lead to the suggestion that these types of child
maltreatment in isolation, may contribute to certain health problems in adolescents.

Although much prior research has focused on the effects of unique forms of child
maltreatment such as sexual abuse or physical maltreatment, as different type of
maltreatment often coexist, focusing on the effect of just one type of maltreatment
may be misleading (McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995). Recently,
several studies have identified the dose-response relationship of multiple types of
child maltreatment with various health related outcomes, mainly among adult
samples. A graded relationship between a number of adverse childhood experiences
and later risk of engagement in the number of health compromising behaviours such
as smoking, alcohol and drug use, obesity, and physical inactivity were found (Dube
et al., 2006; Felitti et al., 1998; Walker et al., 1999).

The present study revealed that nearly one third (31.5%) of all respondents reported
having experienced two or more childhood trauma types. We examined the additive
effects of multiple types of maltreatment. Consistent with previous research among
adult samples in Western countries, results of our study also strongly support the
hypothesis that an increase in the number of maltreatment types significantly
increased the risk of adolescents engaging in a wide range of health risk behaviours
when effects of various background variables were controlled. This pattern was
found for both females and males and in almost all the behaviours examined (see
Table 5.15). In particular, we found that exposure to three or four forms of child
maltreatment greatly increased the chance of suicidal thoughts and attempts,
involvement in physical fights (for both males and females) and disordered eating
behaviour (for females) with the odds ratios increasing up to nearly 10 compared
with non-maltreated participants. In studies among school adolescents in the USA,
results also revealed that much stronger associations were found between combined
abuse and molestation and alcohol/cigarette experimentation, marijuana use/regular

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drinking, suicide thoughts and plan, non injurious and injurious suicide attempts
compared with non sexual abuse or molestation alone (Bensley, Spieker et al., 1999;
Bensley, Van Eenwyk et al., 1999) or between combined physical and sexual abuse
and substance use (tobacco, alcohol, and illicit drugs) (Moran et al., 2004). There is
a paucity of information about this issue in non-Western and developing countries.
The only available study among school based adolescents examining the additive
effects of four types of child maltreatment on suicide attempt, self-mutilation, and
dissociation was conducted in Turkey by Zoroglu et al. (2003). Their findings were
consistent with prior research.

Results of this study also indicated that there seem to be few cultural differences in
terms of effect of child maltreatment on health risk behaviours of adolescents. This
study replicated main findings from studies conducted in Western and other cultures.
First, certain health risk behaviours may strongly relate to specific types of child
maltreatment. Second, and more importantly, co-occurrence of different types of
child maltreatment had a strongly graded relationship with a wide range of health
compromising behaviours. The findings of concomitant effects on health risk
behaviours of Vietnamese adolescents from our study further suggest that it is
important for researchers in all cultures to examine a broader history of child
maltreatment experiences rather than trying to relate certain forms of maltreatment to
specific outcomes (Dong et al., 2003).

What might explain these phenomena? A review of possible theoretical mechanisms

which might mediate the relationship between child maltreatment experiences and
victims’ health risk behaviours suggested possible developmental pathways to
negative outcomes including chronic problems, behavioural and emotional disorders
(Wolfe, 1999). This theory proposes that child maltreatment together with various
factors such as family disadvantage set a lifelong pattern for poor relational
representations. This may lead to dysregulation of emotions and deficits in social
awareness and peer acceptance. These processes, in turn, influence adjustment
outcomes. Maltreated children, for example, may develop negative representational
models of themselves and others, changes in self-worth, and development of

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maladaptive coping styles which further impairs their ability to regulate their
affective and behavioural responses (Bensley, Spieker et al., 1999; Wolfe, 1999).
Individuals with a history of maltreatment may be more likely to use avoidance
coping methods (Bal, Crombez, Van Oost, & De Bourdeaudhuij, 2003; Hiebert-
Murphy, 1998; Thabet, Tischler, & Vostanis, 2004) such as smoking, drinking and
drug use to deal with the abusive experiences, with expectancies that they obtain
possible relief and stress reduction.

For substance use in particular, there is an important question about whether the
association between child maltreatment and subsequent substance use reflects a
causal relationship. The answer for this question is still controversial. In a study of
substantiated cases of child maltreatment from 1967 to 1971, matched on sex, age,
race, and social class with non-maltreated children and followed prospectively into
early adulthood, Schuck and Widom (2001) suggested that childhood maltreatment
may be one of the causal factors in the development of alcohol problems in female
victims. In contrast, other studies found that child maltreatment is indirectly linked to
smoking and drinking and poly-substance use through a number of factors including
negative family support, poor social support, avoidance coping, negative mood state,
low self-esteem and avoidance belief (Hodson, 2002; Simons, 2001). Although
evidence indicating the direct causal relationship between child maltreatment and
problem behaviours of victims is controversial, a number of studies have supported
the proposed pathway mentioned above. Yet, given the complexity of child
maltreatment and its effects, there are still challenges in operationalizing and testing
the theory.

Nevertheless, the findings of the present study provide additional evidence to

indicate that there have been strong relative correlations between each form of child
maltreatment and additive associations between multiple types of child maltreatment
with a numbers of health risk behaviours among Asian population-based adolescents.
The increased risk of undertaking health compromising behaviours among maltreated
victims has been proposed as one of the best known possible pathways, namely
behaviour, social, cognitive, and emotional pathways, by which maltreatment

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victimisation might influence health (Kendall-Tackett, 2002). The following section
will discuss findings from our study on the influence of maltreatment experiences on
the health of adolescents.

7.3 Correlates of child maltreatment and physical and

mental health

Over the past decades, researchers have documented the higher frequency of many
health problems among maltreated individuals. The present study examined the
influence of childhood maltreatment experiences on self-reported general physical
health, depression, anxiety and self-esteem. Unlike most previous studies in this area,
we did not examine each type of child maltreatment in isolation; rather we
simultaneously focused on four forms of maltreatment experiences and took into
account the broader context that is likely to impact on health outcomes. Further
more, this study also examined the cumulative effects of experiencing multiple types
of child maltreatment on adolescent health. This is one of the pioneering studies in
Asian countries taking these approaches when looking at the possible health
consequences of child abuse.

As earlier studies indicated, that there was a high degree of overlap between different
forms of child maltreatment experiences. Prior to examining the influence of child
maltreatment on health outcomes, correlation between four maltreatment scales was
performed. In accordance with findings from Western countries (Bernstein et al.,
1994; Dong et al., 2004; Higgins & McCabe, 2000a; Turner et al., 2006) all
maltreatment measures were associated with each other. The strongest relationship
was found between emotional maltreatment and neglect, and physical maltreatment
for both males and females. These findings indicated that children who reported
being emotionally maltreated also are likely to be physically abused or neglected.
From the current data, it is clear that different forms of child maltreatment
experiences do not occur in isolation. Therefore our results support the argument that

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a study which looks only at the effects of one form of maltreatment in isolation with
other forms might not be appropriate.

The bivariate correlations between all four types of maltreatment and each mental
health outcome measure from our study were consistent with previous studies (Bal,
Van Oost et al., 2003; Chen, Dunne et al., 2004; Haj-Yahia & Tamish, 2001;
Lansford et al., 2002; Oates, Forrest, & Peacock, 1985; Sebre et al., 2004). We also
found significant association between child maltreatment and general physical
health.

Stratification by age and gender the study results supported the hypothesis that some
adolescent health problems (specifically, depression, anxiety, self-esteem, and poor
general physical health) increased as reported experiences of the number of different
types of child maltreatment increased. This finding corroborates a small body of
previous research conducted in this area among adults (Duran et al., 2004; Higgins &
McCabe, 2000a; Walker et al., 1999) and children (Turner et al., 2006) in developed
nations. A wide range of health outcomes were examined in previous studies such as
self-esteem, dissociation, anxiety, depression, anger/aggression, sexual problem,
various physical health symptoms etc. In these studies victimization combinations
were found to be more traumatic and associated with more health problems than
single forms of victimization. The evidence of cumulative effects of co-occurrence of
various types of child maltreatment on health outcomes supports an additive model
of trauma (Fox & Gilbert, 1994).

Furthermore, results of the present study also showed that for all health outcomes,
the mean increased in a stepwise fashion for depression, anxiety and physical health
problems, and decreased stepwise for self-esteem from no maltreatment to two,
three, and four forms of childhood maltreatment. In most cases the pair-wise
comparisons were statistically significant. This finding indicates clearly the dose-
response pattern between cumulative lifetime maltreatment types and health
consequences, when controlling for gender and age.

203
The clinical implications of these findings appear substantial. For example, the level
of depression reported by female adolescents experiencing two forms of child
maltreatment and male adolescents experiencing three types of child maltreatment
scored at about 18-19 (on the CES-D scale) which is well above the suggested cut-
off point (16) for depression (Knight, Williams, McGee, & Olaman, 1997; Radloff,
1977). It is also important to emphasize that many young people may be at risk, with
41.8% of females and 20.1% of males who reported having experienced two or more,
and three or more trauma types respectively. These young people may need mental
health care. Additionally, these findings from mainstream sample of adolescents
further emphasize the need for broadly based counselling, support and referral
services in schools.

Multivariate regression analyses allow examination of the significant contribution of

a number of background variables and the relative influence of different forms of
child maltreatment on the physical and mental health of adolescents. Gender, socio-
economic status, family characteristics, and other individual characteristics have
strong influences on the health status of every population, so it is not surprising that
these variables accounted for the largest proportion of variance in each health
outcome (both females and males). Among those background variables, region
emerged as a consistently significant factor affecting the health of adolescents.
Children growing up and living in an urban area like Hanoi, the capital of Vietnam,
are more likely to have better physical health, higher self-esteem, and less depression
and anxiety. This might reflect the fact that although there has been dramatic
development in the past two decades as a result of the “doimoi/reform” policy
introduced in 1986; however, Vietnam is still a poor developing country with more
than 75% of people living in rural areas engaged in agricultural work (O'Donnell,
Doorslaer, & Rosati, 2003). Even though the Vietnamese government has undertaken
a wide range of prioritized projects to support the economic and social development
of rural regions especially remote and mountainous areas, a substantial gap between
urban and rural areas remains and this challenges the next phase of the country’s
reform (MOH et al., 2005). This social and economic inequality between urban and
rural areas has a significant impact on the development of children.

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As expected, family characteristics such as family arrangement, parent’s marital
status, and quality of parental relationship were strong predictors for mental health,
especially for depression, independent of other demographic and family variables
such as family economic status, age, parental education and occupation. Compared to
children who usually seek help from parents and siblings, those who need to seek
help outside of their close family, have more depression and lower self-esteem. This
might reflect the poor family connectedness or the quality of relationship between
children and other members of the family. These have been documented as risk
factors of depression and low self-esteem (Cash, 2003; Dopheide, 2006; Mann,
Hosman, Schaalma, & Vries, 2004). Self-perception of health of the children
emerged as a consistently significant predictor across male and female samples and
health outcomes. Children who perceived better health (measured by one question of
self-perception of health from very good to very poor) also reported having better
general physical health (measured by adolescents’ self-report symptoms of physical
illness), higher self-esteem and less depression and anxiety. It was also no surprise
that child chronic disease and self-perception of health were the two strongest
predictors of children’s general physical health in the present study. These results
again indicated the validity of the information collected in this study. Consistent with
the literature (Mirza, Davis, & Yanovski, 2005; Pesa, Syre, & Jones, 2000; Siegel,
Yancey, Aneshensel, & Schuler, 1999) we also found that body satisfaction was a
significant predictor for all mental health measures, and especially was the strongest
predictor for self-esteem among female adolescents.

Recently, increasing anecdotes and media reports in Vietnam have been raising a
relatively new phenomenon called educational pressure that might have negative
effects on the health of young people. This has also been observed and reported in
other countries in Asia (Bossy, 2000) and reflects an Asian cultural norm that places
an enormous value on education and the role that education plays in potentially
meeting the family’s social and economic goals and ensuring a secure future for the
child. As a result, it puts intense pressure on the children to be successful at school,
especially for adolescent students who are preparing for university entrance exams.
In the first large-scale study conducted among adolescents and adults in Vietnam

205
funded by UNICEF examining perception and prevalence of child maltreatment,
Michaelson (2004) concluded that academic pressure is a major problem facing
Vietnamese youth, especially for children living in urban areas and that further
investigation on the prevalence, indicators and the effects of this problem is needed.
Another study in Vietnam by Mensch el al. (2003) also found that education is a
major concern or worry for youth. Preliminary findings of these studies as well as the
literature showed that parents and teachers put enormous pressure on children to
succeed and made academic performance the most serious concern for young people
(Bossy, 2000; Hesketh, Ding, & Tomkins, 2003; UNICEF, 2002). Aside from
maltreatment, this type of pressure has the potential for negative health outcomes.

Results from this study revealed that self-report academic achievement, as measured
by the school’s assessment of previous scholastic years, above other background
variables emerged independently as predicting depression, self-esteem and anxiety
for both female and male adolescents. Adolescents who reported getting fair or poor
results in the previous academic year were more likely to suffer depression, anxiety
and low self-esteem than their counterparts with good or excellent academic results.
This finding is in accordance with the literature that documented the correlation
between mental health and academic performance (Cash, 2003; Mann et al., 2004;
Pelkonen, Marttunen, & Aro, 2003) and to some extent contributed to providing
preliminary evidence on the relationship between pressure of education achievement
and health of Vietnamese students, which had never been documented before.
However, whether this is a causal relationship or whether this is an indirect
association remains unclear. While acknowledging that academic performance is
related to students’ mental health via a complex web of factors, socio-economic,
cultural, and cognitive, in the context of education pressure in Asian culture,
academic performance could be a major risk factor for Vietnamese students’ mental
health. There may be two possible pathways. First, growing up in a society where
having constantly good academic results is believed to be the only way for their
success in adulthood can make students put a lot of pressure on themselves. It might
directly cause mental health problems for students. Second, the relationship between
academic achievement and students’ mental health might be mediated by other

206
factors. Quantitative and qualitative evidence from several recent studies in Vietnam
revealed that parents and teachers physically or emotionally maltreated children as a
method to force them to get good study results. This is not uncommon practice
nowadays in Vietnam (UNICEF, 2002). Nearly one third of children surveyed in a
study conducted in four provinces in Vietnam reported that not performing well at
school was the reason for them to be physically or emotionally maltreated by adults
(PFCSI & SCS, 2005). Accounts from students participating in qualitative interviews
in our research also revealed this problem: “My friends often talk about corporal
punishment at home for example one of my friends often said to me that ‘I was
physically punished by my parents because I got a bad mark’” (14 year old girl,
Chilinh).

In this study, multivariate regression models allowed us to evaluate the extent to

which child maltreatment experiences influence adolescent health collectively and
independently after controlling for a wide range of other essential background
factors. The most consistent findings across gender and health outcomes were that
four types of child maltreatment collectively had significant effects on both mental
and general physical health of adolescents independent of the contextual factors that
have been proved to influence psychological adjustments and physical health. This
study supports findings from a small body of previous work that simultaneously
examined, within a broader context, the influence of several types of child
maltreatment on various measures of psychological adjustments, in normative and
special children as well as adult samples in Western countries (Higgins & McCabe,
2000b; Meyerson, Long, Miranda, & Marx, 2002; Turner et al., 2006). There is no
earlier research available examining the combined impact of various types of child
maltreatment on the self-reported general physical health measure of the victims.

The present study supports a suggestion that child maltreatment may not only be the
outcome of a negative family environment and social context, which probably
mediates the effect of victimization, but also is an independent source of trauma with
negative physical and mental health correlates.

207
Furthermore, this study is among only several studies worldwide that provides results
concerning the independent influence of different types of child maltreatment on
trauma symptomatology in normative samples, with contextual factors and other
maltreatment domains controlled. The observation that different forms of
maltreatment independently influenced depression, anxiety, self-esteem, and physical
health was relatively consistent for both females and males. In general, although all
four forms of child maltreatment have their relative contribution to variance in
adolescent health, in most cases child emotional maltreatment and neglect had the
strongest independent correlation with depression, anxiety, self-esteem, and physical
health. Emotional maltreatment had consistently significant effects on all health
outcome measures in both female and male adolescents. This result corroborates the
finding from Higgins’s study in an Australian adult sample (Higgins & McCabe,
2000b), and suggests that child emotional abuse and neglect might be more
destructive in their influences on the young victims than other types of victimization
(Crosson-Tower, 2005; Hildyard & Wolfe, 2002; O'Hagan, 1993).

Interestingly, close examination suggested that physical maltreatment had a different

effect on anxiety and general physical health for males and females. Physical
maltreatment had stronger effects on anxiety and physical health among females than
among males and emerged as significantly independent predictor of these health
outcomes for females after controlling for other maltreatment forms. This finding is
different to that reported by Meyerson et al. (2002) whereby physical abuse
significantly predicted depression and distress for males but not females in the study
of 131 USA high risk group of adolescents living at Job Corps facility, a place for
adolescents referred from the department of Human Services or Juvenile court or
discharged from inpatient care because they did not have an alternative residence.
Numerous differences in sample characteristics between these two studies regarding
the prevalence and severity of abuse as well as the social and cognitive factors which
might impact on mental health could be the main reason for the difference in the
findings.

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The total variance of depression and self-esteem measures explained by various
maltreatment types variables (R2 change) (depression: .07 for males and .088 for
females; self-esteem: .044 for males and .05 for females) and by final models
(adjusted R2) (depression: .28 for males and .26 for females; self-esteem: .23 for
males and .28 for females) in the present study are comparable with that of previous
studies conducted in community-based samples of children and adolescents (Turner
et al., 2006) (adjusted R2 of depression: .228 for 2-9 year old sample; and .20 for 10-
17 year old sample) and a community adult sample (Higgins & McCabe, 2000b)
(self-esteem: .05 for R2 change; and .33 for adjusted R2) in Western countries.
Moreover, it is noteworthy to examine the squared semi-partial correlation (sr2)
which is the unique contribution of the independent variable to R2 in a set of
independent variables (Tabachnick & Fidell, 2001). For all four child maltreatment
types, although each had its unique effect on health, with emotional maltreatment
being the strongest predictor, in most of the cases more than half of the health
outcome measures’ variances explained by child maltreatment were contributed to by
two or more types of victimization. For example, in models predicting depression,
out of 7% (among males) and 8.8% (among females) the overall depression variance
explained by four types of child maltreatment was only 2.9% and 3.7% respectively.
This is equivalent to the sums of variance independently explained by each type of
maltreatment. Therefore, it is evident that while different forms of child maltreatment
have their own direct influence on the health of the victims, the co-occurrence of
child maltreatment significantly contributes to increase the risk of mental and
physical health problems.

7.4 Strengths, weaknesses and implications for

further research

The literature review revealed gaps in previous studies in the area of child
maltreatment that focus on only one or two forms of child victimization when
estimating the impact of maltreatment experiences upon health and well-being.
Additionally, many experts have strongly emphasised the importance of taking into
account the family and social context while examining the consequences of child

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maltreatment (Boney-McCoy & Finkelhor, 1996; Fergusson & Mullen, 1999; Nash,
Neimeyer, Hulsey, & Lambert, 1998). The present study was designed to fill these
gaps by examining simultaneously four main forms of child maltreatment taking into
account the possible effects of broader background factors including various
demographic, family characteristics and child characteristics. With this approach it is
expected that the estimated effects on adolescents’ health risk behaviours and health
problems of each form of child maltreatment and the co-occurrence of the
victimization would be more accurate.

Cultural appropriateness was carefully considered in the questionnaire development

process and data collection procedure of this study. The final questionnaire used in
the study was developed based on international and local literature, qualitative study
among important stakeholders and careful translation and back-translation
procedures according to accepted guidelines for cross-cultural research (Guillemin,
Bombardier, & Beaton, 1993).

As mentioned, this study is among the first of its kind conducted in Asian countries
in general and in Vietnam in particular. The study provides valuable evidence on the
extent to which the problems of child maltreatment exist and also underlines its
harmful effects in the context of Asian culture. Although the study was designed in
an attempt to take a relatively comprehensive approach in examining the complex
child maltreatment issue, some limitations of this study must also be taken into
account in the interpretation of the findings.

First, this study is cross-sectional in nature, so it is impossible for us to determine the

direction of causation between several groups of variables, such as background
variables and child maltreatment, background variables and health outcomes, and
child maltreatment and health outcomes. Therefore, prospective, longitudinal
research in the future which tests the possible models of how a wide range of risk
and protective factors predict health and health related behaviours is necessary to
determine pathways that explain how child maltreatment can influence health in
Vietnamese adolescents.

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Another weakness in our study is related to the nature of our sample, which consisted
of representative students at secondary and high schools in two districts (Chilinh and
Dongda) in the North of Vietnam. The findings therefore might not be generalisable
to the overall population of adolescents in Vietnamese society. Additionally,
although it is estimated that a significant proportion of Vietnamese adolescents (more
than 75% aged 14-17 years old) are in schools (MOH et al., 2005), this study did not
capture the more than 20% of adolescents who never go to school or drop out. Given
that children who do not have the benefits of school may be at high risk for many
adversities, findings of this study may underestimate the maltreatment rates and the
extent to which they influence adolescent health. It is therefore recommended to
conduct future studies on this topic among nationally representative samples of
people in various age groups.

Third, as with many earlier studies in this area, all data were assessed by
retrospective self-report, this may have resulted in under-reporting of maltreatment
events due to difficulties in recall and disclosure. The problem of potential recall bias
may also influence the accuracy of research findings in the other direction, whereby
adolescents with current adjustment problems possibly are more prone to recall and
report their adverse experiences. Such recall bias might lead to over-estimation of the
relationship between maltreatment problems and health outcomes, even though little
evidence is available to support the extent or nature of this bias (Fergusson &
Mullen, 1999). However, given the fact that most children’s adverse experiences are
never officially reported, especially in Vietnamese society where a child
maltreatment report system does not exist, self-report remains a valuable source of
information.

Another important limitation is the usage of the mean score cut-off point in this study
to classify abuse groups for each type of child maltreatment. Statistically, this may
result in prevalence estimates for each form of maltreatment around 50% if the
pattern of endorsement of each maltreatment scale is nearly normal. This approach
can also be subjected to the criticism that it does not take into account the norms
regarding what is considered to be abusive by community and child protection

211
experts in Vietnam or even by international standards. In the literature review and
methodology chapters, it has already been mentioned that the operational definition
of each form of child maltreatment is a matter of much scientific debate
internationally. At present, there is no “gold standard” that researchers can use to
estimate various forms of child maltreatment prevalence which can be comparable
across cultures.

It is arguable that “simplicity is the best” and we should base comparisons on

estimates of prevalence of behaviourally specific maltreatment events. However, this
often leads to inordinately high estimates of “abuse” prevalence if we settle for
simple event/non-event classification. One negative practical impact of reporting
very high rates from surveys is that often these do not have face validity for
professionals and the general community and the research can be dismissed out of
hand. The essential problem is that maltreatment prevalence is heavily influenced by
the width of the range of questions asked (Gorey & Leslie, 1997). In the absence of a
culture-free and globally accepted instrument, we created a tool by pooling items in
four maltreatment sub-scales based on extensive literature review, as well as
incorporation of abuse events suggested by qualitative research with young people in
Vietnam. The event/non-event prevalence estimates for each item are shown in tables
4.4; 4.5; 4.6 and 4.7, and this is followed by the prevalence estimates for three levels
of abuse severity, based on the summative scale scores. Therefore, in this thesis the
item by item prevalence estimates for adverse experiences are presented so they can
be used for international comparison of basic indicators, and the summative scores
are shown to indicate the proportions of this sample of adolescents who may have
been mildly or more seriously “abused”.

Despite this endeavour, it can be argued that a preferable alternative approach is to

create a categorical classification for each type of child maltreatment. This should be
based on the norms regarding violent acts toward the child as suggested by typical
attitudes and/or professional experience of relevant stakeholders. Further research is
necessary in Vietnam and indeed in all Asian societies. A broad program of research
should include qualitative, focus-group and one to one interview inquiries into

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norms. The strategy should also include systematic analyses of experts’ opinions (eg
Delphi studies) to determine if consensus can be gained. Such research may identify
cut-off points for each maltreatment scale by using the Receiver Operating
Characteristics method which considers the assessment made by clinicians as the
“gold standard”, as has been done in several previous studies in other countries
(Fernandopulle & Fernando, 2003; Walker et al., 1999).

Fifth, to measure various forms of maltreatment experiences this study used a Likert-
type scale with ratings from never, rarely, sometimes, often to always. Such
categories may be vague and vary in interpretation from respondent to respondent
which can increase response variability (Myers & Winters, 2002). However, Hamby
and Finkehor (2000) argued that there is no empirical evidence to demonstrate which
response categories are the best for use with children and adolescents. Asking
respondents to give precise numbers of maltreated episodes can be too demanding.
Indeed, in this study the focus group interviews suggested with adolescents do not
like to estimate numbers of abusive incidents. Against this background, it was
decided that a 5-point rating from never to always is most appropriate.

Sixth, in this study when analysing correlations between maltreatment variables and
various health outcomes, Likert-type scales measuring four forms of maltreatment
were treated as interval data. A reasonable question is whether these are truly
continuous variables because there is not a constant spacing between the values. In
practice, however, the Likert-type scale may be treated as if continuous provided that
the data meet other assumptions of the analysis (Tabachnick & Fidell, 2007).
Additionally, using Likert–type scales as continuous variables to measure different
forms of maltreatment has been supported by numbers of researchers because there
are advantageous from statistical and analytical perspectives. This approach
enhances reliability and maximises statistical power (Bernstein et al., 2003; Higgins
& McCabe, 2001a).

Finally, regarding instruments used in this study to measure health outcomes, four
scales including depression, self-esteem, anxiety and physical health were employed.

213
While vigorous procedures were used to construct and validate depression, self-
esteem and anxiety scales, a similar approach could not be employed for constructing
and validating the physical health scale, due to the absence of strong, guiding
hypotheses regarding impacts on physical health, and resource limitations of the
researcher. It is therefore suggested that this scale should be tested and validated in
future research.

7.5 Conclusion

Enormous efforts on research into child maltreatment have been made over nearly
four decades. However, most studies have been conducted in English speaking and
developed countries and focused only on a single form of child maltreatment,
predominantly on childhood sexual and physical adverse experiences. The present
study extends a small body of previous research examining poly victimization in
developed nations to an Asian country, and contributes some new insights to
international knowledge on cross-cultural child maltreatment problems. We have
found considerable commonalities as well as some differences in the findings from
our study compared with earlier research.

The results revealed the relative widespread existence of various forms of child
maltreatment as in other places worldwide where they have been measured. In
general, the proportions of adolescents in our study who reported experiencing
different types of victimizations fall within the range of international findings.
Startlingly, a high rate of sexual abuse of male children – higher than among females
was found in this study. This pattern is different to those which were reported from
previous studies and needs to be explored in future research. Consistent with earlier
research, our study also indicates that co-occurrence of various forms of child
maltreatment is not uncommon. Although the significant predictors of each type of
child victimization varied, in accordance with many earlier studies quality of parental
relationship and factors related to child connectedness with other members in the
family emerged as consistently significantly associated with every form of
maltreatment.

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Another significant conclusion, in agreement with previous studies, concerns the
independent correlations between various types of child maltreatment and health,
including a wide range of health risk behaviours, depression, anxiety, self-esteem,
and general physical health, while controlling for other domains of victimization and
different background factors. While every form of child maltreatment had its own
significant associations, emotional maltreatment emerged as the strongest risk factor
for the health of victims. This finding has a significant implication in terms of the
urgent need to raise public awareness on harm not only from sexual and physical
abuse but also other forms which have received less attention.

This study provides important findings regarding the cumulative effects on different
outcomes of multiple forms of child maltreatment, which had been reported in only a
few other studies in developed nations. Co-occurrence of different types of child
maltreatment had strongly and consistently graded relationships with various health
risk behaviours, and mental and physical health of maltreated adolescents.
Furthermore, as co-occurrence of various types of child maltreatment is common and
maltreatment forms share a significant proportion of the variance in health outcomes,
it is important that the effects of any type of child maltreatment should be examined
only within the context of assessing the potential variance contributed by other
maltreatment forms.

Vietnam is still in the early stage of the battle against child maltreatment. The
findings from the present study provide valuable and timely evidence that can be
used to increase public awareness as well as develop and implement appropriate
responses to child maltreatment. To be effective, apart from learning experiences
from other countries, the public health response to child maltreatment in Vietnam
should be based on evidence relevant to local social and cultural contexts. More
studies are needed to extend the current research to national representative samples,
to examine child maltreatment effects on other outcome measures and to
comprehensively test potential risk and protective factors for different forms of child
maltreatment. When we have this vital information, we should be able to design and
implement effective prevention programs.

215
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 APPENDICES
Appendix 1: Summary table of prevalence studies of four forms of
child maltreatment with community-based samples of adolescents
and young adults ……………………………………………………... 241
Appendix 2: Summary of prior research: Adolescent and early adult
retrospective reports of child maltreatment …………………………... 269
Appendix 3: Brief demographic profile of Vietnam ………………… 291
Appendix 4: Map of Vietnam and two study sites: Dongda district,
Hanoi city and Chilinh district, Haiduong province …………………. 293
Appendix 5: Guideline for in-depth interview ………………………. 297
Appendix 6: Guideline for focus group discussion ………………….. 299
Appendix 7: Self-administered questionnaire for the major survey … 301
Appendix 8: Main themes emerging from the qualitative study …….. 319
Appendix 9: Results of confirmatory factor analysis of depression
and self-esteem scale data ……………………………………………. 327
Appendix 10: Estimated prevalence of each form of child
maltreatment (with confidence intervals) …………………………….. 331
Appendix 11: Mean scores of depression, anxiety, self-esteem, and
physical health by levels of maltreatment exposure, age groups and
gender ……………………………………………………………........ 335

239
 APPENDIX 1

Summary table of prevalence

studies of four forms of
child maltreatment with
community-based samples of
adolescents and young adults

241
 Summary table of prevalence studies of four forms of child maltreatment
with community-based samples of adolescents and young adults

Author and Country Child abuse (CA) definition Sample characteristics and Proportion (%) reporting maltreatment
date used response rate (RR) Female (F) Male (M) Both F and M
Child physical abuse
Stephenson Iran Two questions: (1) ask 1.370 school students (age 11- 28.0 at 45.0 at 38.5 at
et. al., 2006 whether the child had ever 18) home; home; home;
been physically abused at RR: 98% 22.6 at 55.7 at 43.3 at
home or at school. If yes (2) school school school.
ask about degree of PA
(scratching or bruising,
broken bones, burning,
tying…).
Self- administer
Elbedour Israel Adapted from Frinkelhor’s 217 female high school students 89.6
et. al., 2006 scale. (aged 14-18 years, mean = 16, experienced
Self- administer SD = 1.19) some type
Smith et. USA Substantiated cases from 1,000 students interviewed one 4.1
al., 2005 Child Protection Office in every 6 months (average age
happened after age 12 to 17 from first interview was 13.5
years. years and the 12th interview was
22 years.

242
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Lau et al., Hong Two indicators: (1) Corporal Secondary data of a cross- Corporal Corporal Corporal
2005 Kong punishment by family sectional survey of 95, 788 punishment punishment punishment
members in the last 6 secondary school students (aged 4.1; 4.1; 4.1;
months. (2) Injured from a mainly from 12-19 years) Beaten to Beaten to Beaten to
beating without provocation (male: 50,091; female: 11,663) injured: 2.7 injured: 3.1 injured: 2.9
by parents in the last 6 RR: 87.3%
months.
Self- administer
May-Chahal United Researcher-assessed Random probability sampling Intermediate: Intermediate: 25.0 PA by
and Kingdom definition levels (serious, of the population of 18-24 year 12.0 15.0 anyone. 21.0
Cawson, intermediate, and cause of olds after stratification. Serious: 8.0 Serious: 6.0 by parents
2005 concern) 2,869 interviewed (1.234 men and carers.
Computer Assisted Personal and 1,635 women) Serious: 7.0
Interviewing RR: 69% Intermediate:
14.0
Cause of
concern: 3.0
Rich et al., USA Conflict Tactics Scale. Convenience sample of 551 16.7
2005 Self-administer college women with 88.4 % moderate,
aged 18-19 years. 7.4 severe
RR: Not available (NA) from mother.
21.8
moderate,
6.2 severe
from father.

243
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Moran et USA Ask only 1 question: “being 2187 school students from 10.6 PA
al., 2004 beat up, hit with an object, grade 10-12 from public schools only; 6.2 SA
kicked, or some other form in rural Oregon county. 54% and PA
of physical force”. female
Self- administer RR: 98.9%
Thabet et Palestine Used Child Maltreatment 97 male adolescents (15-19 Range from
al., 2004 Interview Schedule (Briere, years) attending a vocational 36.5 to 6.2%
1992) with 7 physical training centre in Gaza Strip. (beaten,
maltreatment items: Yes/No RR: 99% injured by
answer during the previous 3 adult …to
years. tied by chain
Self-administer or rope by
parent or
brothers)
Sebre et al., Latvia Conflict Tactic scale, Child Total of 1,145 school students 17.4: Latvia;
2004 Lithuania Form R with 10 items related aged 10-14 years: 26.0: Lith;
Macedonia to physical abuse. Coded PA Latvia: 297 12.2: Mace-;
Moldova when the child marked Lithuania: 300 29.7: Mol-;
“sometimes”, “often” or Macedonia: 302
“always” for any of items or Moldova: 246
at least “rarely” for the more .
severe items.
Self-administer

244
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Perkins & USA Ask only 1 question: “Have 16,313 school adolescents (12- 12.4 7.7 20.1
Jones, 2004 you ever been physically 17 years) from 43 middle and
abused by an adult (i.e. high schools in 36 communities
where an adult caused you to of Midwestern state.
have scar, black and blue RR: NA
marks, welts, bleeding, or a
broken bone?”: Yes/No
Self- administer
Zoroglu et Turkey Physical violence against a 862 high school students from 4 12.1 14.6 13.5
al., 2003 person under 16 by someone schools in Istanbul. 14-17 years.
at least 5 years older or by RR: 100%
family member at least 2
years older than the victim.
Self- administer
Lau et al., Hong 3 questions: 489 secondary school students 3.8 corporal 5.0 corporal 4.5 corporal
2003 Kong “Whether they have received (= grade 8 in US system). punishment; punishment; punishment;
corporal punishment from RR: 41 schools invited to 9.7 beaten 11.6 beaten 10.9 beaten
your family members in the participate of which 10 agreed for no for no for no
last 6 months?”; “Whether to take part. season; season; season;
you have been beaten 9.2 beaten to 11.0 beaten 10.4 beaten
without any reason by your injury. to injury. to injury.
family members in the last 6
months?”; “Whether you
have ever beaten to injury by
your family members?”
Self- administer

245
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Csoboth et Hungary 5 questions dealt with PA National representative sample 22.9 by
al., 2003 including abused by partners, of 3,615 female (2,016 students parents or
parent, relatives; by anyone and 1,599 community sample); relatives;
in the last year; afraid of PA 15-24 years. 7.4 by
by anyone in family or RR: 94% partner;
people surrounding. 12.7 abused
Yes/No. Self- administer in the part
year;
Back et al., USA Used Trauma Assessment for Women university sample; 65 62.8:
2003 Singapore Adult-Self Report Form. Did from University of Georgia, Singapore
not describe in detail in the USA; 88 from National 38.5: USA
study. university of Singapore; 19.2 ±
Self-administer 2.44 years
RR: 100%
Benbenishty Israel 3 items related to PA such as 10,410 student in grade 7-11 in 6.7 18.7 13.0
et. al., 2002 pinching, slapping and 161 schools across Israel
pushing perpetrated by RR: school: 91%; student: 95%
school staff during the last
month: Yes/No.
Self- administer
Ackard et USA Ask only 1 question: “Have 6,728 adolescent in grade 5-12 8.2 PA only; 7.6 PA only;
al., 2001 you ever been physically from 297 public and private 4.9 both SA 2.5 both SA
abused?”: Yes/No schools in USA and PA and PA
Self- administer

246
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Hadi, 2000 Bangladesh Physical assault or beating at 4,643 adolescents aged 10-15 2.3
work (did not explained in years in 150 villages.
details in the study) RR: nearly 90%.
Interview
Perez, 2000 USA Ask: How many times they 2,468 Mexican-American (MA) 14.8 PA
had been “beaten by parent”. and non-Hispanic White only; 5.5
Self- administer (NHW) adolescents between the both SA and
ages of 12 and 18 from 3 PA
district schools and school drop-
outs in the South-western US.
RR: >92%
Diaz et al., USA NA 3,015 girls in grade 5-12 from 8 PA only;
2000 Self- administer 265 public, private and 5 SA and PA
parochial schools
RR: NA
Kim et al., South Conflict Tactic Scale (Straus, 498 (Korea) and 483 (China) China: 25.7
2000 Korea & 1979). school children in grade 4-6 (minor
China Violence in the family within (early adolescents?) violence);
the past year. RR: 96.7% (China); 99.8% 13.7 (serious
(Korea) violence);
Korea: 11.7
(minor
violence);
14.3 (serious
violence);

247
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Lau et al., Hong 3 questions: 3,355 secondary school students 4.3 corporal 5.4 corporal 4.9 corporal
1999 Kong “Whether they have received aged 13-19 years in one district punishment; punishment; punishment;
corporal punishment from of HK 2.4 beaten 1.5 beaten 2.0 beaten
your parent in the last 3 RR: 98% for no for no for no
months?”; “Whether you season; season; season;
have been beaten without any 1.1 beaten to 1.1 beaten to 1.1 beaten to
reason parent in the last 3 injury. injury. injury.
months?”; “Whether you
have ever beaten to injury by
your family members in the
part 3 months?”
Self- administer
Yamamoto Japan Asked participants had 119 adolescents age 18-21 years 28.4 20.0
et al., 1999 experienced any of (part of longitudinal punched by punched by
maltreated categories epidemiological study on either parent; either parent;
including punching with a mental health and illness in 18.9 hit by 6.7 hit by
fist; hitting with an object; adolescent with total of 1,473 either parent either parent
burning, eg. with a cigarette adolescents)
by father or mother before RR: 34% (of total 304
the age of 16 in 5-point scale. responded after contacted by
Interview mail with 1,473 adolescents at
time 1 of the study)

248
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Meston et Canada 13 items of PA; severe PA 1,052 University of British 10: non 14: non
al., 1999 defined as endorsement of Columbia undergraduate (92% Asian Asian; 34:
one or more of severe between ages of 18-25).582 women; Asian men.
physical items: “black eyes non-Asian and 470 Asian 19: Asian
from being hit”; “injured by ancestry. women;
parents to require medical RR: NA
care”. Self- administer
Youssef et Egypt Corporal punishment defined 2,170 school students (aged 61.5 by 79.9 by 72.8 by
al., 1998 a,b as slapping, beating, 10.5-20) (multistage random teachers; teachers; teachers;
- CPA at whipping, or other physical sample technique) from 14 37.6 by 37.4 by 37.5 by
schools and force used to discipline a schools (44 classes were parent parent parent
at home child whether or not this led selected) from 7 educational
to physical injuries or zones).
necessitated medical RR: NA
consultation.
Self-administer
Fergusson New Different levels (never to 1,025 adolescents at age 18 of 7.6 parent
& Lynskey, Zealand parent treated me harsh and population-based longitudinal used PP
1997 abusive way) of physical study regularly;
punishment (PP) by parent. RR: 81% of initial cohort; 3.9 used PP
92.3% of all cohort members too often or
Interview. still alive and live in New in harsh and
Zealand. abusive way.

249
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Stock et al., USA Question asked: “whether 3,128 girls in grades 8, 10 & 12 21.3
1997 respondents had ever been Data extracted from (18: among 8
physically abused or Washington State Survey of graders; 21.9
mistreated by an adult” Adolescent Health Behaviours among grade
Yes/No with sample of grades 6,8,10 & 10 and 25.1
Self-administer. 12 in 70 school districts. among grade
RR: NA 12).
Fatma et al. Egypt Physical punishment (not 798 Suez Canal University At schools:
1997 described in details) students (mean age: 21.1 ± 1.6 67.6
Self-administer years) (sometimes);
RR: NA 2.6
frequently;
At home:
59.7
(sometimes);
5.7
frequently;
Berrien et Russia Example of general question: 412 school students aged 11-16 28.9 one
al., 1995 “Who punish you especially years in one district school in episode of
hard?” and “How does this Siberian city. inflicted
person punish you?” RR: NA physical
punishment;
3.8) required
medical
attention

250
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Hibbard et USA Ask only 1 question: “Have Final total of 3,998 students in 8.8 PA only 9.2 PA only 9.0 PA only
al., 1990 you ever been physically grade 7-12 in rural Midwestern & 6.7 SA & 3.7 SA & 5.2 SA
abused?”: Yes/No community, US. and PA and PA and PA
Self- administer RR: 69% (total students
informed about the study was
5,780).
Riggs et al., USA Ask only 1 question: “Have 635 adolescents in grades 9-12 5.2 PA only
1990 you ever been physically hurt from an urban public school. & 2.7 SA
or abused by some close to and PA
you?”: Yes/No RR: NA
Self- administer
Child sexual abuse
Chen et al., China Endorsed one or more of the 351 females in a medical 21.9% at
2006 12 questions relating to secondary school aged 16-19 least one
childhood non-contact and years (mean: 17.6, SD = 1.1) type of SA
contact unwanted sexual RR: 75% enrolled students 14.0%
experiences occurring before physical
age 16. contact SA.
Alikasifoglu Turkey Unwanted sexual experience 1,955 female students (mean 11.3 touches
et al., 2006 (touching or/and intercourse) age = 16.3, SD = 1.05) from 4.9
sample of 4,153 students of the intercourse.
main study. 3.0 both
RR: 95.7% answered the types.
questions related to sexual
abuse experiences.

251
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Elbedour et Israel Adapted from Frinkelhor’s 217 female high school students 53.3
al., 2006 scale (aged 14-18 years, mean = 16, experienced
Self- administer SD = 1.19) at least one
type

Rich et al., USA Childhood sexual Convenience sample of 551 Childhood:

2005 victimization: Conflict college women with 88.4 % 6.2
Tactics Scale. aged 18-19 years. moderate,
Adolescent sexual 1.4 rape
victimization (from age 14 to Adolescent:
present): Sexual experience 26.7
survey. moderate,
Self-administer 7.6 rape.
Smith et al., USA Substantiated cases from 1,000 students interviewed one 1.6
2005 Child Protection Office in every 6 months (average age
happened after age 12 to 17 from first interview was 13.5
years. years and the 12th interview was
22 years.
May-Chahal United Used a list of sexual abuse Random probability sampling 21.0 SA 11.0 SA 16.0 SA
and Kingdom acts divided into two groups: of the population of 18-24 year 15.0 contact 6.0 contact 10.0 contact
Cawson, Contact and non-contact (SA olds after stratification. 7.0 non- 4.0 non- 6.0 non-
2005 if respondents endorsed any 2,869 interviewed (1.234 men contact contact contact
of acts) and 1,635 women)
Computer Assisted Personal RR: 69%
Interviewing

252
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Marin et al., Australia Ask only 1 question: “Have School students in South 5.4 2.0 3.6
2004 you ever been sexually Australia at year 9 (mean age
abused?”: Yes/No 14); 2,485 boys and girls; RR:
Self- administer 85-87%
Moran et USA Ask only 1 question: “when 2187 school students from 5.5 SA only;
al., 2004 someone in your family or grade 10-12 from public 6.2 SA and
another person does sexual schools in rural Oregon county. PA
things to you or make you do 54% female
sexual things to them that RR: 98.9%
you don’t want to”: 3 scale:
0: no; 1: was maltreated but
stop; 2: currently being
maltreated (1+2) = abused in
the part and present. Self-
administer
Saewyc et USA Identical question in both Minnesota student Surveys in 2 27 in 1992 6 in 1992
al., 2004 years: “Has any older or independent cohorts of school 22 in 1998 9 in 1998
stronger member of your students in grades 9-12; 1992
family ever touched you survey sample of
sexually or forced you touch Male: 15,446; Female: 13,741
them sexually?” and “Has 1998 survey sample of Male:
any adult or older person 12,843;
outside the family ever Female: 12,159.
touched you sexually against RR: school- level: 99% in 1992
your wishes or forced you to & 92 % in 1998.
touch them sexually?
Yes/No. Self-administer.

253
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
King et al., South Attempted rape and actual Stratified sampling of 2,946 13.3 2.0 8.4
2004 Africa rape. school students in grades 8-11 attempted attempted attempted
Self-administer at public high schools in Cape rape and rape and 5.0 rape and 5.8
Town, then randomly selected 5.97 actual actual rape actual rape
939 students for this study. rape
RR: NA
Kogan, USA Unwanted sexual experience: 1,987 female of 4,023 13
2004 any experiences you’ve had adolescents agreed to interview
where someone tried to make among 5367 eligible households
you do something sexual you in National Survey of
didn’t want to do, no matter Adolescents.
who did it, how long ago it RR: 75%
happened, or whether it was
reported to police.
Telephone interview.
Chen et al., China Answered positively to 1 or 3,216 students in grade 11 and 16.7 10.5 13.6
2004 more of 12 questions related 12 from 4 high schools
to unwanted sexual RR: 70.5 (returned valid
experience before age of 16 questionnaire)
years (both contact and non-
contact).
Self-administer

254
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Csoboth et Hungary Ask only 1 question: “Have National representative sample 2.0
al., 2003 you been forced to perform of 3,615 female (2,016 students
sexual intercourse by and 1,599 community sample);
someone in the past year?”: 15-24 years.
Yes/No. RR: 94%
Self- administer
Zoroglu et Turkey Involvement of a person 862 high school students from 4 13.3 6.7 10.7
al., 2003 younger than 16 old in any schools in Istanbul. 14-17 years.
kind of sexual activities RR: 100%
including non-contact and
contact activities with
someone at least 5 years
older or by family member at
least 2 years older than the
victim. Self- administer
Back et al., USA - Physically sexual contact Women university sample; 65 4.5:
2003 Singapore with someone at least 5 year from University of Georgia, Singapore
older than you before you USA; 88 from National 15.5: USA
were 13 years old. university of Singapore; 19.2 ±
- Instance of verbally 2.44 years
coerced sexual contact RR: 100%
- Instance of physically
coerced sexual contact before
the age 18.
Self- administer

255
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Chen et al., China Answered positively to 1 or 239 male high school students 23.0
2003 more of 10 questions related RR: NA 1.3
to unwanted sexual attempted
experience before age of 16 intercourse
years (both contact and non- 0.8
contact). completed
Self-administer intercourse
Zeira et al., Israel Sexual harassment (SH): 7 10,400 students in grades 7-11 Range Range 29.1
2002 items describe specific from public schools in Israel among among
events. Students asked that (two-stage stratified cluster grades 11.4- grades 21.0-
they had been victims of sample). 35.7 50.5
each one of event during the RR: NA
month before survey. SH is
positively answered at least
one item.
Ex. A student took off, or
tried to take of part of your
clothes when you didn’t
agree….. Self -administer
Tang, 2002 Hong Kong List of sexual behaviours Convenience sample of 3,218 7.4 4.2 6.2
was presented then asked Hong Kong Chinese college
wether someone older than students (18-25 years)
participants had committed RR: 72.3%
this behaviour on them
before they were 17 years
old. Self-administer

256
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Benbenishty Israel 3 items related to verbal and 10,410 student in grade 7-11 in 5.2 9.9 8.2
et al., 2002 physical sexual harassment 161 schools across Israel
(made sexual comment; tried RR: school: 91%; student: 95%
to touch in sexual manner;
made sexual advances)
committed by school staff
during the last month:
Yes/No. Self- administer
Ackard et USA Ask only 1 question: “Have 6,728 adolescent in grade 5-12 5 SA only 2 SA only
al., 2001 you ever been sexually from 297 public and private 4.9 both SA 2.5 both SA
abused?”: Yes/No schools in USA and PA and PA
Self- administer
Perez, 2001 USA Ask: How many times they 2,466 Mexican-American (MA) 24 (NHW) &
had been “raped or sexual and non-Hispanic White 10 (MA)
assaulted”. (NHW) adolescents between the
Self- administer ages of 12 and 18 from 3
district schools and school
drop-outs in the South-western
US.
RR: >92%
Anteghini et Brazil Sexual intercourse before 15 2534 school student in grades 8 9.9 35.2
al., 2001 years and 10 living in Santos, Brazil.
Self-administer Analysis restricted to age 13-17
years result total participants
was 2059.
RR: NA

257
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Madu & South Physical contact form of 414 students in grades 9 and 10 53.2 56.0 54.3
Peltzer, Africa sexual abusive before the age from 3 high schools in the
2000 of 17 years with an adult or Northern Province. Mean age:
person at least 5 years older 18.5 ± 2.18 (age range 14-30
or person in position of years)
power. RR: NA
Edgardh & Sweden “Have you ever experienced 2,583 adolescents at the age of 11.2 3.1
Ormstad, any of following contact and 17 years (students and school 17.2 for girls 4.9 for boys
2000 non-contact acts against your non attendees) living in living in
will, with an adult or a young RR: 83.3% major urban major urban
person at least 5 years your areas; 9.7 for areas; 2.7 for
senior?” other girls other boys
Self-administer
Diaz et al., USA NA 3,015 girls in grade 5-12 from 5 SA only;
2000 Self- administer 265 public, private and 5 SA and PA
parochial schools
RR: NA
Meston et Canada 6 items questions related to 1,052 University of British 40: non 11: non
al., 1999 non contact and contact Columbia undergraduate (92% Asian Asian and
sexual activities that you between ages of 18-25).582 women; Asian men.
don’t want to before age 18. non-Asian and 470 Asian 25: Asian Forced to
Abuse identified if one or ancestry. women; have sexual
more items were endorsed. RR: NA Forced to intercourse:
Self- administer have sexual 1 and 1
intercourse:
9 and 4

258
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Krahe et al., Germany Ask only 1 question: “As a 304 female adolescent, aged 17- 8.9
1999 child or young adolescent, 20 accessed in variety of setting
have you been sexually offering leisure activities to
abused?”?: Yes/No young people.
Self- administer RR: NA
Fergusson New Ask different items about Community based sample of 17.9
et al., 1997 Zealand non-contact to contact female at age 18 years of
episodes including sexual longitudinal study.
intercourse before age 16. 520 participants;
Interview RR 92.7%
Stock et al., USA Question asked: whether 3,128 girls in grades 8, 10 & 12 23
1997 respondents had ever Data extracted from (18: among
experienced sexual abuse Washington State Survey of 8 graders; 24
(defined: when someone in Adolescent Health Behaviours among grade
your family or else touches with sample of grades 6,8,10 & 10 and 28
you in a sexual way in a 12 in 70 school districts. among grade
place you did not want to or RR: NA 12).
does something to you
sexually which they
shouldn’t have done).
Self-administer.
Hibbard et USA Ask only 1 question: “Have Final total of 3,998 students in 6.2 SA only 2.3 SA only 4.3 SA only
al., 1990 you ever been sexually grade 7-12 in rural Midwestern & 6.7 SA & 3.7 SA & 5.2 SA
abused?”: Yes/No community. RR: 69% (total and PA and PA and PA
Self- administer students informed about the
study was 5,780).

259
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Riggs et al., USA Ask only 1 question: “Have 635 adolescents in grades 9-12 5.4 SA only
1990 you ever been sexually from an urban public school. & 2.7 SA
abused by some close to you and PA
and if so, at what age?”: RR: NA
Yes/No
Self- administer
Choquet et France “I have at sometime during 8,140 students in public 0.9 rape 0.6 rape 0.8 rape;
al., 1997 my life been victim of sexual secondary school in France 2.1 attempt
assault”: yes/no. It yes, (grades 8 to 12). rape;
“I was victim of attempt Mean age: 16.2 ± 2.02 years 1.9 another
rape: yes/no; rape: yes/no; RR: 87% sexual
another sexual assault: assault.
yes/no”.
Self-administer.
Pedersen Norway Involuntarily exposed to 465 adolescents of longitudinal 17.3 0.9 9.7
and sexual acts study of 607 adolescents from
Skrondal, Self-administer junior high schools in the
1996 greater (12-15 years) Oslo area
(survey after following up 6
years)
RR: 77% of original sample;
90% of those who were mailed
the survey (522)

260
Author and Country CA definition used
date
Singh et al., Malaysia Broad definition of CA:
1996 rape, sodomy, molestation,
or exhibitionism occurring
intra-family or extra-family
to a child less than 18 years
of age
Halperin et Switzerland Comprise a list of common
al., 1996 form of child sexual abuse
(contact and non contact acts
including look at porn.
materials)
Self-administer
Lodico et USA “Adult or older person
al., 1996 outside family or older or
stronger member of your
family ever touched you
sexually or had you touch
them sexually”
Self-administer
Sample characteristics and Proportion (%) reporting maltreatment
response rate (RR) Female (F) Male (M) Both F and M
616 paramedical students aged 8.3 2.1 6.8
20-24 years in Malaysia.
RR: NA
1,193 adolescents aged 13-17 33.8 10.9
years from randomly selected
68 classes in 17 schools of
public school system in Geneva.
RR: 93.5%
6,224 students sample in grade 16.5 4.1 10.1
9 and 12 (10% of random
sample of the students in grade
9 and 12 throughout Minnesota
school districts.
RR: 90% of schools
261
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Child emotional abuse (CEA) & neglect (CN)

Stephenson Iran CEA at home: 7 questions 1.370 school students (age 11- CEA: 64.7 CEA: 80.4 CEA: 74.5
et al., 2006 (discrimination between 18) at home; at home; at home;
siblings, unfavourable RR: 98% 49.8 at 66.0 at 59.9 at
comparison with friends, school. school. school.
threats to be sent out from CN: 71.1 at CN: 85.6 at CN: 80.1 at
home…) home. home. home.
CEA at school: 2 questions 51.7 at 55.9 at 54.4 at
(made to feel ashamed, school school school
experienced verbal
maltreatment)
CN at home: 4 questions
(forced to work, felt love by
parents, …)
CN at school: not feeling
emotionally supported by
staff or teachers.
Self- administer
Elbodour et Israel Adapted from Frinkelhor’s 217 female high school students CEA: 60.9
al., 2006 scale (aged 14-18 years, mean = 16, by siblings;
Self- administer SD = 1.19) 54. by
mothers;
48.9 by
fathers; 42.4
by teachers

262
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Rich et al., USA Childhood verbal abuse: Convenience sample of 551 67.3 some
2005 Conflict Tactics Scale. college women with 88.4 % form from
Self-administer aged 18-19 years. father (18.0
moderate ,
49.4 severe)
and 80.1
from mother
(26.5
moderate ,
53.6 severe).

May-Chahal United CEA: Mid point score of 7 Random probability sampling CEA : 8.0 CEA: 4.0 CEA: 6.0
and Kingdom dimensions (4 ore more) of the population of 18-24 year CN: serious CN: serious CN: serious
Cawson, CN: failure to give basic olds after stratification. absence of absence of absence of
2005 physical care and safeguard 2,869 interviewed (1.234 men care: 7.0 care: 6.0 care: 6.0;
(researcher-assessed neglect and 1,635 women) Intermediate:
levels: serious, intermediate RR: 69% 9.0; cause of
and cause of concern concern: 2.0
Computer Assisted Personal Serious lack
Interviewing of
supervision:
5.0;
Intermediate:
12.0

263
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Smith et al., USA Substantiated cases from 1,000 students interviewed one Adolescent
2005 Child Protection Office in every 6 months (average age neglect and
happened after age 12 to 17 from first interview was 13.5 emotional
years. years and the 12th interview was abuse: 3.6
22 years.

Sebre et al., Latvia Conflict Tactic Scale, Child Total of 1,145 school students CEA:
2004 Lithuania Form R with 11 items related aged 10-14 years: 28.8: Latvia;
Macedonia to emotional abuse. Coded Latvia: 297 33.3: Lith;
Moldova CEA when the child marked, Lithuania: 300 12.5: Mace-;
“often” or “always” for any Macedonia: 302 32.1: Mol-;
of items or at least Moldova: 246
“sometimes” for the more
severe emotional abuse
items.
Self-administer

Bal et al., Belgium Did not explain in the study; Girls: n=508; Boys: n=462 CN: 1.5
2003 Self- administer General Secondary School
(n=423:43%); Technical
Secondary School
(n=350:36%); Vocational
training (n=196:21%);
RR: 93%

264
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Zoroglu et Turkey CEA: use of excessive verbal 862 high school students from 4 CEA: 16.1; CEA: 15.6; CEA: 15.9;
al., 2003 threats, ridiculous and schools in Istanbul. 14-17 years. CN: 18.9 CN: 12.5 CN: 16.5
personally demeaning RR: 100%
comments, derogatory
statement and threats against
the young person to the
extent that a child’s
emotional and mental well-
being will be jeopardized.
CN: refers to acts of
omission in which the child
is not properly cared for
physically or emotionally.
Self- administer

Benbenishty Israel 2 items related to being 10,410 student in grade 7-11 in CEA: 20.7 CEA: 28.6 CEA: 24.9
et al., 2002 humiliated or cursed by 161 schools across Israel any any any
school staff during the last RR: school: 91%; student: 95% emotional emotional emotional
month; Yes/No. Self- maltreatment maltreatment maltreatment
administer

265
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Meston et Canada CEA: 9 items related to 1,052 University of British CEA CEA
al., 1999 emotional abuse; (6-point Columbia undergraduate (92% (severe): 25: (severe): 25:
scale: 0-never to 5 – very between ages of 18-25).582 non Asian non Asian;
frequently); severe non-Asian and 470 Asian women; 53: Asian
emotional abuse defined as ancestry. 39: Asian men.
and EA composite score of RR: NA women;
greater than 10); CN CN (severe):
CN: 6 items related to (severe): 9: 18: non
neglect; severe neglect as the non Asian Asian; 32:
endorsement of one or more women; Asian men.
of the severe neglect items, 18: Asian
eg. “I was looked out of the women;
house without sufficient
clothes or shoes in the
winter” and “I have had food
or water withheld from me
for more than a day”.
Self- administer

266
Author and Country CA definition used Sample characteristics and Proportion (%) reporting maltreatment
date response rate (RR) Female (F) Male (M) Both F and M
Yamamoto Japan Asked participants had 119 adolescents age 18-21 years CEA: CEA:
et al., 1999 experienced emotional abuse (part of longitudinal 12.2: once in 2.2: once in
including saying “you are not epidemiological study on the lifetime; the lifetime;
my child”; or threat not mental health and illness in 8.1: several 6.7: several
giving food and disrupting adolescent with total of 1,473 times a year; times a year;
participants’ cherished pets adolescents) 9.5: several 6.7: several
or toys” or putting a shame times a times a
like scolding cruelly and RR: 34% (of total 304 month; month;
making fun of the child in responded after contacted by 8.1: several 0.0: several
front of others by father or mail with 1,473 adolescents at time a week time a week
mother before the age of 16 time 1 of the study)
(in 5-point scale).
Interview

267
 APPENDIX 2

Summary of prior research:

Adolescent and young adult
retrospective reports of child
maltreatment

269
 Summary of prior research:
Adolescent and young adult retrospective reports of child maltreatment

Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Turner et C C C C C,9 USA 1; 2; 10; 1; 2,030 Used 2 (for M/F All;
al., 2006 17; 30; 2- 17 years continuous children 10- Outcome:
variables 17 year Depression;
olds); Anger/ Aggression
4.
Smith et D D D, 8 USA 2; 17; 45; 1; follow 1,00 Non-abused 3; M/F All;
al., 2005 46; 48; from 13 to Cohort Outcome: arrest,
49; 50. 22 years study general offending,
violence
offending, drug
use
Rich et al., C C C USA 3; 551 Non-abused F All;
2005 18-19 Outcome:
years Depression,
Trauma symptom,
Interpersonal
functioning
Wolfe et C C C C C,1 USA 3;4;5 2; 1,317 Non-abused 1; M/F None;
al., 2004 14-19 longitudinal Outcome: Dating
years violence

270
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA C Othersg variable typec and size group of data of partitioned?f
CP N included?b age included?d collectione sample
Moran et D D D USA 2; 10 2; 2,187 Non-abused 1; M/F All
al., 2004 Grade 10, Outcome:
11, 12 substance use
Thabet et D C Palestine 5; 97 Non-abused 1; M None
al., 2004 15-19 Outcome;
years emotional/
behaviour
problems
Dalenberg C C Russia 3; 301 Non-abused 1; M/F None
& Palesh, 20.55 ± Outcome:
2004 4.26 (age Dissociation,
range 15-
55 years)
Sebre et C C Latvia 2; 297; Non-abused 1; M/F None
al., 2004 Lithuania 10-14 300; Outcomes:
Macedonia years 302; Depression,
Moldova 246 Anger,
Total: Dissociation,
1,145 PTSD, anxiety,
sexual concerns,
somatic problems
Paivio & C C C C Canada 3; 470 Prevalence 1; M/F N/A
Cramer, 19 ± 3.22 study –
2004 years testing CTQ

271
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA C Othersg variable typec and size group of data of partitioned?f
CP N included?b age included?d collectione sample
Newcomb C C C C USA 6; 7 1; 904 Non-abused 1; M/F All
et al., 2003 13-24 HIV risk
years behaviours
& many
others
Bal et al., D D Belgium 1; 1,041 Non-abused 1; M/F N/A
2003 11-19 Outcomes: Stress-
years related symptoms
Blum et C C 9 2; 2; 15,695 Non-abused 1; M/F None
al., 2003 Caribbean 10-18 Outcomes:
countries years General health;
ever had sexual
intercourse;
attempted suicide.
Csoboth et D D Hungary 1&2 3,615 Non-abused 1; F None
al., 2003 15-24 (2,016 Outcomes:
years students Smoking. Alcohol,
and 1,599 drugs
communit
y sample)
Zoroglu et C C C C Turkey 19; 2; 862 Non-abused 1; M/F All
al., 2003 14-17 Outcomes: Suicide
years attempt,
Self-mutilation

272
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA C Othersg variable typec and size group of data of partitioned?f
CP N included?b age included?d collectione sample
Back et al., D D USA 20; 3; 65-USA Non-abused 1; F All
2003 Singapore 19.2 ± 2.44 88 - Outcomes:
years Singapore Psychological
symptoms
Levendos- C C C C USA 1;3 111 Non-abused 1; M/F None
ky et al., 14.86 ± .84 adolescen Outcomes:
2002) years t and Mental health;
their Violence & Ado.
mothers Peer relationship

Benbenish- D D D Israel 2; 10,410 Prevalence 1; M/F N/A

ty et al., Grade 7-11 study –
2002 abused by
educational
staff
Champion D D D USA 6; 50 Non-abused 2; F None
and Kelly 14-19 Outcome: risk
(2002) years behaviour and
psychological
distress.
Ackard et D D USA 1; 8 2; 6,728 Non-abused 1; M/F All
al., 2001 Grade 5-12 Binge-Purge
behaviours
Harrison et D D USA 2; 4 76,159 Screening 1; M/F N/A
al., 2001 instrument

273
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA C Othersg variable typec and size group of data of partitioned?f
CP N included?b age included?d collectione sample
Perez, D D USA 1;2;9; 10; 1(school 2,466 Non-abused 1; M/F All
2001 11 drop out Outcome:
students);2 adolescent
16.5 1.13 delinquency
years

Tomori et. D D Slovenia 10; 24; 2; 2,111 Non- 1; M/F N/A

al., 2001 26; 27; 17-18.11 smokers Outcome:
28;29 years (CP and depression and
CSA as risk self-esteem
factors)
Hadi, 2000 D D; 2; 3 Banglades 1; 4,643 Non-abused 2; M/F N/A
h 10-15
years
Khamis, C C C; 2 Palestine 2; 1,000 Non-abused 1; M/F None
2000 12-16 year Outcome: School
performance
Perez, D D USA 1;2;6; 10; 1; (school 2,468 Non-abused 1; M/F All
2000 11; 17; 30 drop out Outcome: Illicit
students drug use
grade 7-12
before
drop
out);2; 12-
18 years

274
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each
CPA or CSA CEA CN Othersg variable typec and size group of data of type partitioned?f
CP included?b age included?d collectione sample
Diaz et al., D D USA 1; 10; 17; 2; 3,015 Non-abused 1; F All
2000 18 Grade 5 to Outcomes:
12 depression, stress,
bingeing and
purging
behaviour;
substance use
Bensley et D D; 4 USA 2; 12 1; Grade 4,790 Non-abused 1; M/F Some (abuse and
al., 1999 8,10,12 molested and
a,b both)
Outcomes:
antisocial
behaviour;
Suicidal ideation
and behaviour
Substance use
Krahe et D D Germany 15; 16 1; 304 Non-abused 1; F None
al., 1999 17-20 Outcome: Sexual
years revictimization in
adolescents

275
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Meston et C C C C Canada 3; 1,052 Non-abused 1; M/F N/A
al., 1999 Age range: *Study ethnic
17-48 differences in child
abuse report.
years (92%
between
age of 18-
25 years)

Yamamoto C C Japan 1; 119 Non-abused 2; M/F None;

et al., 1999 18-21 longitudinal Outcome:
years psychopathology
Fiscella et D&C D C USA 1; 10; 33 6; 1,139 Non-abused 2: F All
al., 1998 registered (pregnant Outcome: first
for young pregnancy.
prenatal women)
care
Mean age:
17.9 years
Perkins et D D USA 11; 17; 2; 15,362 Non-abused 1; M/F All
al., 1998 25; 29; 12-17 Outcome:
34; 35 36; years adolescent’s
37 sexual activity

276
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Buzi et al., D D D D USA 4; 263 Non-abused 1; F None
1998 (reproducti (parentin Outcomes:
ve health g problems of teens:
clinic) adolescen school dropout,
(parenting ts) crime, drugs,
adolescent 257 alcohol,
s) (never – prostitution,
17.2 ± 1.57 pregnant suicide, teen
years adolescen pregnancy
257 (never ts)
– pregnant
adolescent
s)
16.99 ±
1.64 years
Fergusson C C New 1; 13 1; 1,025 Non-abused 2; M/F None
& Zealand 18 years Outcomes:
Lynskey, juvenile
1997 offending;
Substance abuse;
Mental health
Fergusson C C New 1; 14 1; 520 Non-abused 2; F None
et al., 1997 Zealand 18 years Outcomes:
Sex behaviours;
revictimization.

277
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Harrison et D D USA 2; 2; 122,824 Non-abused 1; M/F None
al., 1997 Grade 6,9 Outcome: multiple
and 12 substance use
Stock et D D USA 12; 17; 2; 3,128 Non-abused 1; F All
al., 1997 27; 29; Grade 8, Outcomes:
35; 38; 10 & 12 Adolescent
39; pregnancy and
sexual risk
behaviors
Kendall- D D D USA 1;2 2; 744 Control 3; M/F Some;
Tackett & 14-20 Outcome:
Eckenrode, years Academic
1996 achievement and
disciplinary
problems
Sander et C C C USA 3; 2 Non-abused 1; M/F N/A
al., 1995 17-23 samples: * Scale
years & 897 and development study
18-22 301
years
Smith & C C C C C; USA 1; 2;10;17 2; 1,000 Non-abused 3; M/F None
Thornberry 5;6;7 Grade 7 & Outcome:
1995 8 Adolescent
involvement in
delinquency

278
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Kurtz et D D USA 2; 132 control 3; M/F None
al., 1993 8-16 years Outcome:
School
performance
D D USA 1;2;10; 2; 7,241 Non-suicide 1; M/F None
Grossman 21; 22; Median attempts Outcome:
et al., 1991 23; 24; 25 age of 14.4 (CP and Suicide attempts
CP and years CSA as risk
CSA factors)
Hibbard et D D USA 2; 3,998 Non-abused 1; M/F None
al., 1990 Grade 7-12 Outcomes:
behaviour risks
and emotional
risks
Riggs et D D USA 1;2;10;17 2; 635 Non-abused 1; M/F All
al., 1990 ;30 14-17 Outcomes:
years Health risk
(substance use,
sexual activity’
eating disorders)
and suicide
attempts

279
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Berger et C Dh USA 3; 4,965 Prevalence 3; M/F N/A
al., 1988 Mean age study -
about 19 Support of
range 16- study in
67 years. non-clinical
4; sample
14-17
Chen et al., D China 3; 17.6 351 Non-abused 1 F N/A; Outcomes:
2006 years (SD Depression, risk
=1.1) behaviours;
Hund & C USA 3; 608 Non-abused 1 F N/A
Espelage, Mean age: Outcome: eating
2006 20.3 disorders
(SD=2.54)
Lau et al., D Hong 2; 30; 10; 2; 95,788 Non-abused 1 M/F N/A
2005 Kong 40; 41; Mainly M: 53.9% Outcome:
42; 43; 44 from 12-19 F: 46.1% Substance use
years
Saewyc et D USA 2; 1992: Non-abused 1; collect M/F N/A
al., 2004 Grade 9- M: data of two Outcome:
12 15,446 separate Pregnancy
F: 13,741 cohorts in involvement
1998: 1992 and
M: 1998
12,843
F: 12,159

280
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Perkins & D USA 2; 16,313 Abused 1; M/F N/A
Jones, 12-17 Outcome: Risk
2004 years behaviours

Marin et D Australia 1; 2,485 Non-abused 1; M/F N/A

al., 2004 14 years Outcome:
on average depression;
hopelessness;
suicidality
King et al., D South 2; 939 Non-abused 1; M/F N/A
2004 Africa Mean: 15.7 Outcome:
years Substance abuse;
suicidal dialogue
and attempts; anti-
social behaviours
Kogan, D USA 1; 262 - Prevalence 2; F N/A
2004 12-17 Experienc study (telephone
years e of interview)
unwanted
sex
among
1,958
(48.7%)
females
of the
sample

281
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample

Chen et al., D China 3; 892 Non-abused 1; F N/A

2004 Age: N/A Outcomes:
depression, self-
esteem and risk
behaviours,
Health status’ self-
evaluation
Chen et al., D China 2; 3,261 Non-abused 1; M/F N/A
2004 16-24 Outcomes:
years depression; self-
esteem; health risk
behaviours.
Bergen et D Australia 2; 2,603 Non-abused 1; M/F N/A
al., 2003 Mean age: Outcome:
13 years Suicidal behaviour
Lau et al., D Hong 2; 489 Non-abused 1; M/F N/A
2003 Kong Form 2 (13 Outcome:
to >15 psychological
years) = problems;
Grade 8 in Substance use
US
Chen et al., D China 2; 239 Non-abused 1; M None
2003 High Outcomes:
school Depression and
students self-esteem

282
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Swanston D Australia 1 and 4 49 abused Control 3; M/F N/A
et al., 2003 14-25 68 control
years
Zeira et al., D Israel 2; 10,400 Prevalence 1; M/F N/A
2002 12-17 study of
years sexual
harassment
in public
schools
Tang, 2002 D Hong 3; 3,218 prevalence 1; M/F N/A
Kong 18-25 (sent study
years question)
2,327
(sent
back)
Anteghini D Brazil 2; 2,534 Non-abused 1; M/F N/A
et al., 2001 13-17 Health risk
years behaviours
Oaksford UK 3; 213 Prevalence 1; F N/A
& Frude, D Mean age study
2001 21 (18-41
years)

283
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Nagy, D USA 2; 756 Types of 1; F N/A
2000 14-16 female perpetrator- Outcomes:
years (76% SA s Pregnant; suicide;
of sample) victims depression; illegal
from total drug use; multiple
of 3124 partners; young
female sex.
students
Kim et al., C South 2; 498 Prevalence 1; M/F N/A
2000 Korea & Grade: 4-6 (Korea) study
China (how old 483
they are?) (China)
Madu & D South 2; 414 Prevalence 1; M/F N/A
Peltzer, Africa 18.5 ± 2.18 study
2000 (age range
14-30
years)
Edgardh & D Sweden 1; 2 2,583 Prevalence 1; M/F N/A
Ormstad, 17 years study
2000

284
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Lau et al., D Hong 2; 3,355 Non-abused 1; M/F N/A
1999 Kong 13-19 Outcomes:
years Self-perceived bad
health, anxiety,
stress, somatic
illness etc.

Youssef et C Egypt 2; 2,170 Prevalence 1; M/F N/A

al., 1998 Aged: study
a,b 14.58 ±
- CP in 1.740
schools years
and at
home
Choquet et D; France 2; 8,140 Non-abused 1; M/F N/A
al., 1997 rape 16.2 ± Health and
2.02 years behavioral
problems
Kenney et D USA 1; 1,937 Non-abused 1; F N/A
al., 1997 18-22 Outcome: Teenage
years pregnancy
Fatma et D Egypt 3; 798 Prevalence 1; M/F N/A
al., 1997 21.1 ± 1.6 study of PA
years at home and
school

285
Studies Maltreatment formsa Country Influence Sample Sample Comparison Nature Gender Effects of each type
CPA or CSA CEA CN Othersg variable typec and size group of data of partitioned?f
CP included?b age included?d collectione sample
Lodico et D USA 2; 6,224 Non-abused 1; M/F N/A
al., 1996 Mean: 16.2 Outcome: sexual
years victimization
Singh et D Malaysia 3; 616 prevalence 1; M/F N/A
al., 1996) 20-24 study
years
Chandy et D USA 2; 3,051 1; analyse M/F N/A
al., 1996 15.26 ± 1.7 (abused self reported Outcome: gender
(male cases) abuse cases differences in
group) only school
15.37 ± 1.7 performance;
(female suicidal
group) behaviour; eating
disorder; etc.
Pedersen D Norway 6; 31; 32 2; 465 Non-abused 1; M/F N/A
& 12-15 Longitudi- Outcome: Alcohol
Skrondal, years at nal study (6 problem
1996 time 1 years)
Halperin et D Switzerla 2; 1,193 Prevalence 1; M/F N/A
al., 1996 nd 13-17 study
years
Berrien et D Russia 2; 11-16 412 Prevalence 1; M/F N/A
al., 1995 years study

286
a
CPA or CP: child physical abuse or corporal punishment ; CSA: child sexual abuse; CEA: child emotional abuse; CN: child neglect
D = dichotomous variable; C = continuous maltreatment scale
b
Control for:
1: Socio-economic status (SES)
2: Gender
3: Trauma-related symptoms
4. Attitudes justifying dating violence
5: Empathy and self-efficacy with dating partners.
6: Parent-alcohol or drug–related problems
7: Childhood quality rating
8: Body Mass Index
9: Dropout
10: Family structure/configuration
11: Grade point average (obtained during the last full semester of school)
12: Grade
13: Family functioning including change parents, parent conflict, family history of offending, parental illicit drug use, family history of
alcohol and drug abuse, average family in come (0-10 years), family living standards (0-10 years), childhood disadvantage (3 years),
family life events (11-14 years), childhood sexual abuse.
14: Family stability and marital conflict, including change of parents, step-parenthood, marital conflict; parenting and parent/child
relationships, including childhood adversity, parental attachment, parent bonding, parental use of physical punishment.
15: Physical abuse
16: Feeling of worthlessness.
17: Ethnicity
18: Grade level
19: Dissociation
20: Trauma experience, including serious accidents or injuries, witnessing someone die or homicide of family member.
21: Exposure to suicide
22: Self-perception of health status

287
23: Mental health
24: Substance abuse
25: School perception and performance
26: Binge eating
27: Truancy
28: Involvement in sport activities
29: Suicidal behaviour
30: Age
31: Parental smoking
32: Parental norms
33: Adolescent smoking
34: Adolescents’ religiosity
35: Parental monitoring
36: Self-report of family support
37: Membership in negative peer group
38: School activities and sport teams the participants participated in
39: Body image
40: School type
41: Housing
42: Peer influence
43: Self-reported perceptions of academic pressure
44: Self-reported feelings of being blamed for unsatisfactory academic performance.
45: Early adolescent offending
46. Parent education
47: Community poverty
48: Chronic family poverty
49: Care giver changes
50: The lagged measures of earlier behaviours

288
c
1: Community sample; 2: school sample; 3: university sample; 4: clinical sample; 5: vocational training centre; 6: health clinic sample
d
Non-abused = non-abused respondents from the same recruitment source; control = non-abused control respondents recruited from
another source as a comparison.
e
1: Self –report questionnaire; 2: self-report interview (face-to face or telephone); 3: case records; 4: telephone interview with parents/care
givers
f
Multivariate analysis employed to partition the effects of each type of child maltreatment on the measure(s) of consequence(s)
N/A: non-applicable (no outcome measure or examine only one type of abuse)
g
1: Witness parental violence; 2: child labour/work; 3: forced to involve in inappropriate activities; 4: Ask 1 question about abuse in
general (Have you ever been abused or mistreated by an adult?); 5: moral/legal maltreatment; 6: educational maltreatment; 7: lack of
supervision; 8: combine neglect and emotional abuse; 9: witness family violence; Other major violence; Non-victimization trauma and
adversity (serious illness, accidents, parent imprisonment, natural disaster).
h
Applied only for sample from 14- 17 years of age.

N/A: Not Applicable.

289
 APPENDIX 3

Brief demographic profile of

Vietnam

291
 Vietnam’s profile

Vietnam is located in the heart of South-East Asia. It lies between the People's
Republic of China in the North and the Gulf of Thailand in the South. Vietnam is
bordered by the Pacific Ocean and the East Sea as well as the People's Democratic
Republic of Laos and the Kingdom of Cambodia in the West. Vietnam has one of the
youngest populations in the region, with an estimated 28% of the total population
under the age of 15 years and 45% (about 36 millions) of total population aged from
0-19 (UNESCO, 2002).

Land area (square kilometres) 331,689

Number of Provinces/Municipalities 61
Total population (million) 83.12a
Annual population growth (%) 1.2b
Urban population (%) 26b
GNP per capita (USD) 480c
Life expectancy at birth 70.0b
Infant mortality (per 1000 live birth) 19b
Child malnutrition (% of children under 5) 25.2a
Illiteracy (% of population 15+) 4.6c
Gross enrolment ratio (%)
Primary level 99.9c
Secondary level 71.8c
Tertiary level 10.2c
Private sector enrolment share
Primary level (%) 0.3c
Secondary level (%) 11.5c

From World Bank Database – 2003; 2004 and General Statistics Office of Vietnam-2005
a
Figures estimated for 2005
b
Figures estimated for 2004
c
Data for 2003: the most recent data available

292
 APPENDIX 4

Map of Vietnam and two study sites:

Dongda district, Hanoi city and
Chilinh district, Haiduong province

293
 Haiduong

Hanoi

Map of Vietnam with two study sites: Hanoi city and

Haiduong province

294
 Chilinh
district

Map of Haiduong province and study district-Chilinh

295
 Dongda
district

Map of Hanoi city and study district-Dongda

296
 APPENDIX 5

Guideline for in-depth interview

297
 Guideline for in-depth interview

1. Perception of child maltreatment:

- According to you what is child maltreatment?

- What kind of behaviours you would consider to be child

maltreatment?

2. The nature of child maltreatment phenomenon:

- How often do you experience with cases of child maltreatment?

- In your opinion, what is the most common type of child

maltreatment?

- Who often is the perpetrator?

- What’s kind of child, who most at risk of mistreatment?

- Can you tell us some examples of child maltreatment cases that you

remember most?

- How often do you heard/read about child maltreatment cases and from

what sources?

- Have you observed any trends in cases of child maltreatment (e.g.,

with respect to the type of families/relatives/circumstances in respect

of which child maltreatment occurs, demographic differences, etc.)?

3. Handling child maltreatment:

- What is your attitude about child maltreatment reporting?

- How do people deal with child maltreatment problem?

- Do you have any suggestions about how the handling of cases of child

maltreatment may be improve?

298
 APPENDIX 6

Guideline for focus group

discussion

299
 Guideline for focus group discussion

1. Child maltreatment discussion:

- According to you what is child maltreatment?

- What kind of behaviours you would consider to be child

maltreatment?

- How often do you heard/read about child maltreatment cases and from

what sources?

- Have you observed any trends in cases of child maltreatment (e.g.,

with respect to the type of families/relatives/circumstances in respect

of which child maltreatment occurs, demographic differences, etc.)?

- How do people deal with child maltreatment problem?

- Do you have any suggestions about how the handling of cases of child

maltreatment may be improve?

2. Comment on the questionnaire:

- What do you think about the set of questions you just try to answer?

- Is it understandable? Is any question not clear? Is language used

acceptable? Is there any question/word need to be changed and into

what?

- What about the lay out and length of the questionnaire?

- Overall, what are your suggestions to improve the questionnaire?

300
 APPENDIX 7

Self-administered questionnaire for

the major survey

301
Queensland University of Technology Hanoi School of Public Health
Australia Vietnam

Child maltreatment
Physical and mental health
questionnaire

Please respond to all sections of the following form

as they related to your experiences.

Your co-operation and time to participate in this study

is greatly appreciated
Thank you

302
A. Demographics
1. Sex: Male Female

For questions 2 and 3, please write down your answer

2. Year of birth:_________________________

3. Ethnic Group: ________________________

4. Religion: No Yes (Catholics; Buddhist; etc.)

5. Are your parents (tick (x) in one box only)

Living together
Divorced
Separated
Death (one or both)

6. Did you grow up living together with: (tick (x) in one box only)

Both of your natural parents

Only your natural mother
Only your natural father
Your natural mother and a stepfather
Your natural father and a stepmother
None of your natural parents, if so, who have you lived with? (Write down)
_______________________________________________________

7. How many brothers and sisters do you have? (tick (x) in one box only)

Alone (Go to Q. 9) Two Three and more

8. Which child are you in your family? (tick (x) in one box only)

Eldest Middle Youngest

9. What is the highest education of your natural father/step father/adoptive father?

(tick (x) in one box only)

University degree or higher

TAFE, diploma, technical
High school
Secondary school
Primary school
Never go to school
Do not know

Please turn to the next page

303
 10. What is the highest education of your natural mother/step mother/adoptive
mother? (tick (x) in one box only)

University degree or higher

TAFE, diploma, technical
High school
Secondary school
Primary school
Not go to school
Do not know

11. What do your natural father/step father/adoptive father do? (tick (x) in one box
only)

Government worker
Self-employed
Farmer
Unemployed
Home maker
Others (Write down) _________________________________________

12. What does your natural mother/step mother/adoptive mother do? (tick (x) in one
box only)

Government worker
Self-employed
Farmer
Unemployed
Home maker
Others (Write down) _________________________________________

13. In total, how many vehicles (belong to your parent, you or your siblings) do
your family have? (tick (x) in one or more boxes that applies to you)

No
1 bicycle
2 or more bicycles
1 motorbike
2 or more motorbikes
Car(s)
Others (Write down) _________________________________________

14. Who do you most often talk to when you need help (eg. sharing feelings, asking
for advice etc.)? (tick (x) in one box only that applies to you)

Your natural father/step father/adoptive father

Your natural mother/step mother/adoptive mother
Brother/ Sister
Relative
Friend
Other, please specify__________________________________________
Nobody

304
B. Family environment

15. Did any of your natural parents/stepparents/ adoptive parents ever have
problems with drugs or alcohol? (tick (x) in one box only)

Yes No

16. Have you ever witnessed your parents had serious argument with each other
(such as shouting, yelling, or fierce argument etc.)? (tick (x) in one box only)

Never Rarely Sometimes Often

17. Have you ever witnessed a fight between your parents? (tick (x) in one box
only)

Never Rarely Sometimes Often

18. Overall, do you think your family is (tick (x) in one box only)

Very happy Happy Not sure Unhappy Very unhappy

Please turn to the next page

305
 C. School

19. What was your academic achievement last semester? (tick (x) in one box only)

Excellent Good Average Poor

20. Have you repeated any class since you started going to school? (tick (x) in one
box only)

No Repeated one time Repeated 2 times or more

21. How often have you been punished for breaking the rules at school? (tick (x) in
one box only)

Never (Go to question 22)

Rarely
Sometimes
Often
Always

21p.If you have ever been punished at school, what types of punishment did you
received? (Tick (x) in one or more boxes)

Your name was recorded into the weekly class discipline book
You had to write a written agreement
You were rebuked in front of the whole school
Your parents were asked to meet the teacher or the principal
Other, please write down _______________________

Please turn to the next page

306
D. Your experiences
Section 1:

22. Do you often have any of the following health problems? (Tick (x) in one box
only for each item)

22.1 Aches or pains Never Sometimes Often

(not stomach or headaches)

22.2 Headaches Never Sometimes Often

22.3 Nausea Never Sometimes Often

22.4 Problems with eyes Never Sometimes Often

(not if corrected by glasses)

22.5 Rashes or other skin problems Never Sometimes Often

22.6 Stomach aches Never Sometimes Often

22.7 Vomiting Never Sometimes Often

22.8 Tired for no reason Never Sometimes Often

22.9 Other, please write down:

__________________________________________________________

23. Have you ever been hospitalised because of health problems?

(Tick (x) in one box only)

Yes No

24. Have you ever been taken to a doctor because of health problems?
(Tick (x) in one box only)

Yes No

25. Do you have any following diseases that have been diagnosed? (Tick (x) in one
or more boxes)

Asthma Heart disease Sinus

Diabetes Liver disease Oral diseases
Others, please write down: __________________________________

26. In general, would you say your health is (Tick (x) in one box only)

Very good Good Fair Poor Very poor

27. Overall, are you satisfied with your body appearance? (Tick (x) in one box only)

Very satisfied Satisfied Dissatisfied Very dissatisfied

307
Section 2:
28. Below is a list of statements that describe how people feel. For each item, please
tick (x) in only one box that is true to you.

For example, when the statement is “I feel excited”, if this statement sometimes
happens to you, then you tick in the box saying “Sometimes”

Statement Never Sometimes Often

I feel excited x

Now, for each statement in the table below, please tick in only one box that is true to
you. That is, how you generally feel most of the time

Statement Never Sometimes Often

a. When I feel frightened, it is hard to breath
or I sweat a lot
b. I worry about sleeping alone

c. I worry about being as good as other kids

d. I get really frightened for no reason at all

e. I worry that something bad will happen to

me or to my family
f. I worry about how well I do things

g. I feel nervous with people I don’t know

well
h. I cry easily

i. I startle easily

j. I get scared if I sleep away from home

k. I am afraid to be alone in the house

l. I have nightmares about something bad

happening to myself or to my family
m. I have difficulty falling asleep

Please turn to the next page

308
29. Below are statements about how you have been feeling during the last week.
For each item, please tick (x) in only one box that is true to you.
For example, when the statement is “I felt excited”, if this happened to you occasionally
during last week, then you tick in the box saying “Occasionally”

Statement Most or all Occasionally Some of the Rarely or

of the time time none
I felt excited x

Now, for each statement in the table below, please tick in only one box that is true to
you.
Statement Most or all Occasionally Some or Rarely or
of the time or moderate little of the none of the
(5-7 days) amount of time (1-2 time (less
time (3-4 days) than 1 day)
days)
a. I was bothered by things that
usually don’t bother me
b. I did not feel like eating; my
appetite was poor
c. I wasn’t able to feel happy,
even when my family or
friends tried to make me feel
better
d. I felt that I was just as good as
other people
e. I had trouble keeping my mind
on what I was doing
f. I felt down and unhappy
g. I felt like I was too tired to do
things
h. I felt hopeful about the future.
i. I thought my life had been a
failure
j. I felt scared
k. I didn’t sleep as well as I
usually sleep
l. I was happy
m. I was more quiet than usual
n. I felt lonely

o. I felt like people I knew were

not friendly or that they didn’t
want to be with me
p. I had a good time last week
q. I felt like crying last week
r. I felt sad last week
s. I felt people didn’t like me last
week
t. It was hard to get started doing
things last weeks

309
30. Below are statements about general feelings that people may feel about themselves.
For each item, please tick (x) in only one box that is true to you.

For example, when the statement is “I am excited”, if you strongly agree with this
statement, then you tick in the box saying “Strongly agree”

Statement Strongly Agree Disagree Strongly

agree disagree
I am excited x

Now, for each statement in the table below, please tick in only one box that is true to
you.

Statement Strongly Agree Disagree Strongly

agree disagree
a. On the whole, I am satisfied with
myself.
b.At times I think I am no good at all.

c. I feel that I have a number of good

qualities.
d.I am able to do things as well as most
other people.
e. I feel I do not have much to be proud
of.
f. I certainly feel useless at times.

g.I feel that I'm a person of worth, at least

on an equal plane with others.
h.I wish I could have more respect for
myself.
i. All in all, I am inclined to feel that I am
a failure
j. I take a positive attitude toward myself.

Please turn to the next page

310
31. Below are statements about some events children may experience. For each item,
please tick (x) in only one box that is true to you.

Statement Yes No
a. Past 12 months, ever felt so sad or hopeless almost every day for
the two weeks or more that stopped doing some usual activities

b. Pat 12 months, ever seriously considered attempting suicide

c. Past 12 months, ever made a plan about would attempt suicide

d. Past 30 days, had ever smoked cigarettes

e. Past 30 days, had one or more drink of alcohol

f. Have ever been drunk (during lifetime)

g. Ever accidentally injured while drunk (like falling down, hurt in

fight, falling off a bicycle/motorbike)

h. Past 30 days, have gone without eating for 24 hours or more to

lose weight or to keep from gaining weight

i. Past 30 days, had carried a weapon such as knife or club

j. Past 12 months, have been threatened or injured by somebody

with a weapon on school property

k. Past 12 months, have been involved in fighting

Please turn to the next page

311
Section 3:

32. When children grew up, their parents/ guardians or adult in family may have treated
them in some ways as in the incidents below. Is there any of these incidents
happening to you? (Tick (x) in one box only for each item)

a. Yell at you Never Rarely Sometimes Often Always

b. Insult you Never Rarely Sometimes Often Always

c. Try to make you feel Never Rarely Sometimes Often Always

guilty
d. Embarrass you in front Never Rarely Sometimes Often Always
of others

e. Make you feel like Never Rarely Sometimes Often Always

you were a bad person

f. Wish you were never born Never Rarely Sometimes Often Always

33. When you grew up, did any adults in your family threaten to hurt or kill you?
(Tick (x) in one box only)

Never (Goes to section 4) Rarely Sometimes Often Always

33p. If this ever happened, who often did this to you?

(Tick (x) in one box only)

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Brother/ Sister
Relatives
Others, please specify _______________________

Please turn to the next page

312
Section 4:

Sometimes, parents or caretakers do not take care of children properly. Please answer
the following questions about your life.

34. When you grew up, have any of the following things happened to you?
(Tick (x) in one box only for each item)

a. You did not get enough food to eat

Never Rarely Sometimes Often Always

b. You had to wear dirty or torn clothes, or clothes that were not warm enough

Never Rarely Sometimes Often Always

c. You were not taken care of when you were sick

Never Rarely Sometimes Often Always

35. When you were growing up, did your parents/ guardians do the following things to
you? (Tick (x) in one box only for each item)

a. Didn’t make you feel important

Never Rarely Sometimes Often Always

b. Didn’t care about you

Never Rarely Sometimes Often Always

c. Were not close to you

Never Rarely Sometimes Often Always

d. Were not sources of strength to you

Never Rarely Sometimes Often Always

Please turn to the next page

313
Section 5:
From now on, all questions are about your experiences with any adult,
including those in your family or outside your family.

36. When you grew up, did any adults ever do something like pushing, grabbing, or
shoving you, throwing something at you? (Tick (x) in one box only)

Never (Go to Q. 36) Rarely Sometimes Often Always

If this ever happened,

36.1. Who often did this to you (Tick (x) in one or more boxes)?

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Older brother/ sister
Relatives
Neighbour
Stranger
Other adults, please write down _______________________

36.2. Did you do any thing that made them do that? (Tick (x) in one box only)

Yes No

37. When you grew up, did any adults do something like locking you up in a small
place? (Tick (x) in one box only)

Never (Go to Q. 38) Rarely Sometimes Often Always

If this ever happened,

37.1. Who often did this to you (Tick (x) in one or more boxes)?

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Older brother/ sister
Relatives
Neighbour
Stranger
Other adults, please write down _______________________

37.2. Did you do any thing that made them do that? (Tick (x) in one box
only)

Yes No

Please turn to the next page

314
38. When you grew up, did any adults ever do something like tying you up or chaining
you with something? (Tick (x) in one box only)

Never (Go to Q. 39) Rarely Sometimes Often Always

If this ever happened,

38.1 Who often did this to you (Tick (x) in one or more boxes)?

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Older brother/ sister
Relatives
Neighbour
Stranger
Other adults, please write down _______________________

38.2. Did you do any thing that made them do that? (Tick (x) in one box
only)

Yes No

39. When you grew up, did any adults ever do something like spanking you? (Tick (x)
in one box only)

Never (Go to Q. 40) Rarely Sometimes Often Always

If this ever happened,

39.1. Who often did this to you (Tick (x) in one or more boxes)?

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Older brother/ sister
Relatives
Neighbour
Stranger
Other adults, please write down _______________________

39.2. Did you do any thing that made them do that? (Tick (x) in one box
only)

Yes No

Please turn to the next page

315
 40. When you grew up, did any adults ever do something like kicking or hitting you
with a fist or other objects, beating you up? (Tick (x) in one box only)

Never (Go to Q.41) Rarely Sometimes Often Always

If this ever happened,

40.1 Who did this to you? (Tick (x) in one or more boxes)

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Older brother/ sister
Relatives
Neighbour
Stranger
Other adults, please write down _______________________

40.2. Did you do any thing that made them do that? (Tick (x) in one box
only)

Yes No

41. When you grew up, did any adults ever do something like choking you, or burning
or scalding you? (Tick (x) in one box only)

Never (Go to Q.42) Rarely Sometimes Often Always

If this ever happened,

41.1. Who did this to you? (Tick (x) in one or more boxes)

Father/ Step father/ Adoptive father

Mother/ Step mother/ Adoptive mother
Older brother/ sister
Relatives
Neighbour
Stranger
Other adults, please write down _______________________

41.2. Did you do any thing that made them do that? (Tick (x) in one box
only)
Yes No

42. How often did these incidents leave you with bruises or scratches, broken bones or
loss teeth or make you bleed? (tick (x) in one box only)

Never Rarely Sometimes Often Always

43. How often were you hurt badly enough that you need medical treatment (go to
hospital, to see a doctor or to take medicines)? (tick (x) in one box only)

Never Rarely Sometimes Often Always

316
 Section 6:
44. When you were growing up, did any adult ever do any of the following acts to
you, but you didn’t want? (Tick (x) in one box only for each item)

44.1 Spoken to you in an obscene way or talk to Never Once More than once
you in sexual way

44.2 Exposed their private parts to you Never Once More than once

44.3 Made you see sexual scenes Never Once More than once
on video, or porn magazines/ photos

44.4 Touched or fondled your private parts Never Once More than once

44.5 Made you touch or fondle their private Never Once More than once
parts

44.6 Tried to have sexual intercourse Never Once More than once
with you but was unsuccessful

44.6.1 If this happened, which of the following people have done this to
you?
(Tick (x) in one or more boxes

Father/ Step father/ Adoptive father Uncle

Mother/ Step mother/ Adoptive mother Aunt
Older brother Other relatives
Older sister Neighbour
Male cousins Male stranger
Female cousins Female stranger

Other, please describe your relationship with them___________________

44.6.2 If this happened to you, how old were you the first time this thing
happened

_____________________________________

Please turn to the next page

317
 44.7 Had sexual intercourse with you Never Once More than once

42.7.1 If this happened, which of the following people have done this to
you?
(Tick (x) in one or more boxes

Father/ Step father/ Adoptive father Uncle

Mother/ Step mother/ Adoptive mother Aunt
Older brother Other relatives
Older sister Neighbour
Male cousins Male stranger
Female cousins Female stranger

Other, please describe your relationship with them___________________

44.7.2 If this happened to you, how old were you the first time this thing
happened

_____________________________________

44.8 Did other things to you in sexual way, Never Once More than once
please write down

______________________________________________________

You have answered all the questions

Thank you very much!

318
 APPENDIX 8

Main themes emerging from the

qualitative study

319
 Main themes emerging from the qualitative study

1. Perception of child maltreatment (understanding of child maltreatment):

“…exploitative child labour or behaviours that affect children’s health in terms of

physical or mental aspects…also sexual abuse nowadays features frequently in
newspapers and media”.
(Male teacher, Hanoi)

“A common type of child maltreatment now is lack of care for children in the
broader sense that is not only lack of care for materials but now many families in
cities can earn a lot of money and give money to children and they think that is
enough. It really creates a new social problem. On the other hand, in many rural
areas in Vietnam parents still have perception that - God produces elephants and
God produces grass - and they never think that failing to provide children with care
could be considered maltreatment”
(Female teacher, Hanoi)

“Child abuse is understood that now many families do not treat children well, for
example, not supporting children studying, parents travelling for doing business and
leaving children with their relatives. In Chilinh now increasing numbers of parents
are working abroad; their children stay at home and those children are at risk of
maltreatment”.
(Female teacher, Chilinh)

“According to me some abusive behaviours that happen in the family may be due to
the parents not knowing they actually did abuse their children”.
(Mother, Hanoi)

All children FGDs mentioned the following idea about child maltreatment:

Force children to work to make money especially doing something illegally… in

general any actions that not support the rights of the child that they know something

320
about from schools such as physical violence toward children, humiliate children, do
not respect children’s voice, not supporting children studying …

2. Type of abuse: (listed in order from high to low frequency mentioned by

informants)
- Sexual abuse (mainly referring to severe acts such as rape, attempted rape);
- Don’t love children; insult children; threaten children;
- Do not support children’s studies;
- Beating children up by parents and family members;
- Adults hit children in the streets, public areas…;
- Parents are not emotionally available for children such as too focus on
making money and not close to children (especially happed nowadays in
economic better off families);
- Violence towards children mainly in school by older school-mates
(predominantly boys).

3. Different thinking about physical punishment

“Beaten by parents when you did something wrong is OK but beaten for no reason
that is abuse”.
(Boy FGD1, Hanoi)

“I saw my friend beaten up badly by his parents but I am not sure whether he did
something wrongly that made them do that”.
(15 year old boy, Hanoi)

“Beating is only partly abuse because it is to educate children. It is necessary to be

tolerant to parents as sometimes they beat children hardly just because parents are
angry about something and then beating children instead, as expressed by the phrase
- Angry with fish, chop the chopper board-”; “Beating children to educate them is not
abuse”.
(Girl FGD1, Chilinh)

321
“Teachers beating students is not always abuse, if the student is too naughty beating
is OK. Also partly because of the parents, if the parents are busy with work they ask
teacher for help to support children studying better”.
(Girl FGD2, Chilinh)

“I am asked by parents to conduct corporal punishment with their children, and I

think it is necessary for them to become good people”.
(Female teacher, Chilinh)

“Beating children in family or outside family all are unacceptable. Even some
parents beat their children for no reason such as parents are angry with somebody but
beat their own children instead”.
(Boy FGD1, Chilinh)

“We wish not to be beaten by parents but not sure whether corporal punishment is
good method of raising children or not”.
(Boy FGD2, Chilinh)

“I know some parents kick or beat their child badly, it is not good they maltreat their
child, they wrongly assume that children have to do what parents want”.
(Father, Chilinh)

“In family, parents hit their children only if they are too angry or want children to be
better or children are too naughty so that is not abuse”.
(16 year old boy, Chilinh)

4. Child maltreatment examples

“My friend has to leave school for several days whenever her family has some work
that they have to do during school hours”.
(Girl FGD1, Chilinh)

322
“Whenever my mother is angry she insults me as a dog and it happens very often. I
feel very upset but I have to get use with that and to take it easy now”.
(15 year old boy, Hanoi)

“My parent hit me hard when they are very angry”.

(16 year old boy, Hanoi)

“My friends often talk about their corporal punishment experiences at home, for
example one of my friends said to me that ‘I was physically punished by my parents
because I got a bad mark”.
(14 year old girl, Chilinh)

“In my neighbourhood there are many children aged about 12-14 working as maids
in families and being treated badly”.
(15 year old girl, Hanoi)

“I heard my friends living in this town say that many families have maids as children
now and they shout at or beat up those children very often. I also know 1 case like
that (a girl about 12-13 years old) working for my neighbour’s family”.
(13 year old boy, Chilinh)

“A boy, he is my neighbour always beaten up by his drunk father and another boy
living in my alley was forced by his parents to leave school from grade 5 or 6 to
work for his family street vender to earn money…. But I do not think his family are
too poor to afford for his schooling …. poor him!!!”
(15 year old boy, Hanoi)

323
“I know quite a few cases that fathers of my students “strictly educate” their children
but those fathers actually physically and emotionally abused children because fathers
kick or beat children up or even tie up or chain them and using electric wire to hit
them leaving children with bruises and scratches. Parents also lock and insult
children by saying that - if you don’t study I will feed you as a dog under the bed”.
(Female teacher, Chilinh)

“My friend, she is 2 years older than me, told me her experience as that her
neighbour, this guys is 5 or 6 years older than her – I also know this man. He
followed her to behind of the house where she had to do housework and hugged her
and wanted to do something… she is too scared and ran away but does not dare to
talk to anybody about that”.
(15 year old girl, Chilinh)

“One of my relatives, she also told me that a man – a friend of her family - he
hugged and kissed her when he drunk and she was lucky to escape otherwise she
does not know what terrible thing would have happened”.
(16 year old girl, Chilinh)

“I could not forget the true case in my village: a 12 year old girl had been raped to
death by a man, he is friend of her family, with several other men, in an abandoned
shelter”
(17 year old girl, Chilinh)

5. Who are perpetrators (listed in order from high to low frequency reported by
informants)

- Strangers
- Parents/guardians
- Neighbours
- Relatives
- Family friends

324
 - Older adolescents
- Teachers

6. Trend of child abuse prevalence

All key informants agree that child abuse in Vietnam is increasing. The main reasons
inspire them to give this comment are: it is frequently mentioned on newspapers,
mass media, adults in the family (parents, grandparents) and because of the social
changes nowadays.

Child abuse is on the rise… because we hear about it more often on mass media but
we also think it really increases because parents now are too busy with earning
money; as a result, they have not got time to take care of their children so more
adolescents are being abused.
(Girl FGD1 and 2, Chilinh; Boy FGD 2, Hanoi; Teachers from Hanoi, teachers from
Chilinh)

“I think child maltreatment is an issue that seems to increase because the society is
changing and becoming more complicated. Parents now are too busy earning a living
so have less time to take care of their children, especially for poor families”.
(17 year old boy, Chilinh)

7. Source of information on child abuse:

- Newspapers, especially adolescent newspapers and magazines;

- Television;
- Adults in family;
- Friends; and
- Their own observations on the streets, neighbourhood, in schools.

325
8. Expected measures to prevent child maltreatment

- Parent should spend more time with children;

- Educate both parents and children;
- Provide more information and campaigns;
- Community system should strengthen to consider child maltreatment issues in
families as a social issue rather than an individual family business;
- Clear and effective report systems.

326
 APPENDIX 9

Results of confirmatory factor

analysis of depression and
self-esteem scale data

327
 .46
e17 SMEAN(LIK_CRY)
.31
e3 SMEAN(UNAB_HAP) .68
.45 .56
e6 SMEAN(FE_DOWN) .67
.31
.55 depressed affect
e9 SMEAN(FE_SCARE) .56
.32
.67
e10 SMEAN(FAILURE) .80
.45
e14 SMEAN(LONELY)
.64
.43
e18 SMEAN(SAD)
.19
e4 SMEAN(GOOD_AS)
.10 .44
e8 SMEAN(HOPE_FU) .31
.61 .78 1.00
positive affect
e12 SMEAN(HAPPY) .73
.53
e16 SMEAN(GOO_WEEK)
.15 .79
e1 SMEAN(BOTHER)
.22 .43
e2 SMEAN(NLIK_EAT)
.31 .39
.47
e5 SMEAN(NO_ATTEN) .56
.33 .28
.58
e7 SMEAN(M_TIRED) somatic and retarded
.26
.07
.48
e11 SMEAN(NO_WESLE) .61
.23
e13 SMEAN(QUIET)
.37 .79
e20 SMEAN(HARD_STA)
.49
e15 SMEAN(NOFRI_LY) .70
.59 .77 interpersonal
e19 SMEAN(NO_LIKE)

Confirmatory factor analysis of depression scale (CES-D)

328
 .26

e1 SMEAN(SATISFY)

.48
.51
e3 SMEAN(GO_QUAL)
.70
.36
.60 self-esteem_1
e4 SMEAN(AS_OTHER)

.53
.28
.68
e7 SMEAN(PE_WORTH)

.46

e10 SMEAN(PO_ATTI)
.58
.19

e2 SMEAN(NO_GOOD)

.43
.44
e5 SMEAN(NO_PROUN)
.66
.52
.72 self-esteem_2
e6 SMEAN(USELESS)
.26
.07
.67
e8 SMEAN(MO_RESP)

.45

e9 SMEAN(FE_FAIL)

Confirmatory factor analysis of self-esteem scale (RSES)

329
 APPENDIX 10

Estimated prevalence of each form

of child maltreatment
(with confidence intervals)

331
 Proportion of child maltreatment in Chilinh district

Female Male Total

n Pro 95% CI n Pro 95% CI n Pro 95% CI
CEM
No 379 .58 .52-.62 381 .64 .59-.69 760 .61 .58-.64
Minor 195 .30 .24-.36 152 .26 .19-.33 347 .28 .22-32
Severe 85 .13 .06-.20 64 .11 .03-.19 149 .12 .07-.17
Minor + Severe 280 .43 .39-.47 216 .36 .32-.40 496 .40 .36-42
CPM
No 388 .59 .54-.64 260 .44 .38-.50 648 .52 .48-.56
Minor 225 .34 .28-.40 269 .45 .39-.51 494 .39 .35-.43
Severe 45 .07 .00-.14 68 .11 .04-.18 113 .09 .04-.14
Minor + Severe 270 .41 .37.45 337 .56 .52-.60 607 .48 .45-.51
CSA
No 538 .82 .79-.85 442 .74 .70-.78 980 .78 .75-.81
Minor 105 .16 .09-.23 111 .19 .12-.26 216 .17 .12-.22
Severe 16 .02 -.05-.09* 44 .07 -.01-.15* 60 .05 -.01-.11*
Minor + Severe 121 .18 .15-.21 155 .26 .22-.30 276 .22 .20-.24
CN
No 485 .70 .66-.74 456 .76 .72-.80 914 .73 .70-.76
Minor 104 .16 .09-.23 80 .13 .06-.20 184 .15 .10-.20
Severe 97 .15 .08-.22 61 .10 .02-.18 158 .13 .08-.18
Minor + Severe 201 .31 .28-.34 141 .24 .21-.27 342 .27 .25-.29
CMM
No 224 .34 .28-.40 170 .29 .22-.35 394 .31 .27-.36
1 type 161 .25 .18-.31 172 .29 .22-.36 333 .27 .22-.31
2 types 150 .23 .16-.30 132 .22 .15-.29 282 .23 .18-.27
3 types 82 .13 .05-.20 79 .13 .06-.21 161 .13 .08-.18
4 types 41 .06 -.01-.14* 44 .07 .00-.15 85 .07 .01-.12

Pro = Proportion
* Effectively a lower bound of 0.

332
 Proportion of child maltreatment in Dongda district

Female Male Total

n Pro 95% CI n Pro 95% CI n Pro 95% CI
CEM
No 397 .57 .52-.62 410 .64 .59-.69 807 .60 .57-.63
Minor 178 .26 .20-.32 149 .23 .16-.30 327 .25 .20-.30
Severe 116 .17 .10-.24 85 .13 .06-.20 201 .15 .10-.20
Minor + 294 .43 .39-.47 234 .36 .32-.40 528 .40 .37-.43
severe
CPM
No 398 .58 .53-.63 310 .48 .42-.54 708 .53 .49-.57
Minor 244 .36 .30-.42 257 .40 .34-.46 501 .38 .34-.42
Severe 45 .07 .00-.14 74 .12 .05-.19 119 .09 .04-.14
Minor + 289 .42 .38-.46 331 .52 .48-.56 620 .47 .44-.50
Severe
CSA
No 562 .81 .78-.84 538 .84 .81-.85 1,100 .83 .81-.85
Minor 114 .17 .10-.24 75 .12 .05-.19 189 .14 .09-.19
Severe 14 .02 -.05- 09* 31 .05 -.03- .13* 45 .03 -.02- .08*
Minor + 128 .19 .16-.22 106 .17 .14-.20 234 .18 .16-.20
Severe
CN
No 441 .64 .60-.68 476 .74 .70-.78 917 .69 .66-.72
Minor 126 .18 .11-.25 96 .15 .08-.22 222 .17 .12-.22
Severe 124 .18 .11-.25 72 .11 .04-.18 196 .15 .10-.20
Minor + 250 .36 .32-.40 168 .26 .23-.29 418 .31 .29-.33
Severe
CMM
No 226 .33 .27-.39 220 .34 .28-.41 446 .34 .29-.38
1 type 170 .25 .18-.31 168 .26 .20-.33 338 .26 .21-.30
2 types 126 .18 .12-.25 127 .20 .13-.27 253 .19 .14-.24
3 types 124 .18 .11-.25 89 .14 .07-.21 213 .16 .11-.21
4 types 40 .06 -.01-.13* 37 .06 -.02- 13* 77 .06 .01-.11

Pro = Proportion
* Effectively a lower bound of 0.

333
 Proportion of child maltreatment in the whole sample

Female Male Total

n Pro 95%CI n Pro 95%CI n Pro 95%CI
CEM
No 776 .58 .54-.60 791 .64 .61-.67 1,567 .61 .59-.63
Minor 373 .28 .23-.33 301 .24 .19-.29 674 .26 .23-.29
Severe 201 .15 .10-.20 149 .12 .07-.17 350 .14 .10-.18
Minor + 574 .43 .40-.46 450 .36 .33-.39 1,024 .40 .38-.42
Severe
CPM
No 786 .58 .55-.61 570 .46 .42-.50 1,356 .53 .50-.56
Minor 469 .35 .31-.39 526 .43 .39-.47 995 .39 .36-.42
Severe 90 .07 .02-.12 142 .12 .07-.17 232 .09 .05-.13
Minor + 559 .42 .39-.45 668 .54 .51-.57 1,227 .48 .46-.50
Severe
CSA
No 1,100 .82 .80-.84 980 .79 .76-.82 2,080 .80 .78-.82
Minor 219 .16 .11-.21 186 .15 .10-.20 405 .16 .12-.20
Severe 30 .02 -.03-.07* 75 .06 .01-.11 105 .05 .00-.08
Minor + 249 .19 .17-.21 261 .21 .19-.23 510 .20 .18-.22
Severe
CN
No 899 .67 .64-.70 932 .75 .72-.78 1,831 .71 .69-.73
Minor 230 .17 .12-.22 176 .14 .09-.19 406 .16 .12-.20
Severe 221 .16 .11-.21 133 .11 .06-.16 354 .14 .10-.18
Minor + 451 .33 .30-.36 309 .25 .23-.27 760 .29 .27-.31
Severe
CMM
No 450 .34 .29-.38 390 .32 .27-.36 840 .33 .20-.36
1 type 331 .25 .20-.29 340 .28 .23-.32 671 .26 .23-.29
2 types 276 .21 .16-.25 259 .21 .16-.26 535 .21 .17-.24
3 types 206 .15 .10-.20 168 .14 .08-.19 374 .15 .11-.18
4 types 81 .06 .01-.11 81 .07 .01-.12 162 .06 .03-.10

Pro = Proportion
* Effectively a lower bound of 0.

334
 APPENDIX 11

Mean scores of depression,

anxiety, self-esteem, and physical
health by levels of maltreatment
exposure, age groups and gender

335
Mean scores of depression, anxiety, self-esteem, and physical health by levels of
maltreatment exposure, age groups and gender.

Maltreatment exposure Age group Female Male

Mean SD Mean SD
Depression
No maltreatment 12-15 years 11.66 6.69 10.66 6.57
16-18 years 12.14 7.38 10.17 4.76

1 form of maltreatment 12-15 years 14.72 8.04 12.08 6.19

16-18 years 13.71 7.80 11.58 6.25

2 forms of maltreatment 12-15 years 18.10 8.44 15.85 7.38

16-18 years 18.89 9.21 14.79 8.16

3 forms of maltreatment 12-15 years 21.22 10.24 18.15 8.89

16-18 years 19.67 9.87 19.39 9.27

4 forms of maltreatment 12-15 years 22.30 9.79 23.02 9.95

16-18 years 25.63 11.21 21.57 11.20

Anxiety
No maltreatment 12-15 years 19.47 3.61 17.44 3.12
16-18 years 20.57 3.37 17.26 3.29

1 form of maltreatment 12-15 years 20.81 3.68 17.80 3.24

16-18 years 20.73 3.79 18.67 2.92

2 forms of maltreatment 12-15 years 22.01 3.79 19.70 4.09

16-18 years 22.32 3.53 19.52 3.79

3 forms of maltreatment 12-15 years 22.87 4.52 20.36 4.04

16-18 years 22.99 4.02 20.12 3.50

4 forms of maltreatment 12-15 years 24.09 4.18 21.59 4.04

16-18 years 24.18 4.60 20.77 4.54

Self-esteem
No maltreatment 12-15 years 18.79 3.60 19.46 3.86
16-18 years 18.22 3.89 18.42 3.27

1 form of maltreatment 12-15 years 17.63 3.65 18.49 3.61

16-18 years 18.14 3.679 18.06 3.55

2 forms of maltreatment 12-15 years 16.04 3.83 16.99 3.87

16-18 years 16.39 3.53 16.88 3.77

336
Maltreatment exposure Age group Female Male
Mean SD Mean SD
3 forms of maltreatment 12-15 years 15.43 4.14 15.87 3.74
16-18 years 16.75 4.32 15.98 3.99
4 forms of maltreatment 12-15 years 15.51 3.43 15.91 4.19
16-18 years 15.50 4.04 14.46 3.88

Physical health
No maltreatment 12-15 years 12.46 2.43 11.82 2.45
16-18 years 13.08 2.46 12.48 2.74

1 form of maltreatment 12-15 years 13.17 2.62 12.38 2.34

16-18 years 13.49 2.44 12.60 2.49

2 forms of maltreatment 12-15 years 13.95 2.47 12.79 2.39

16-18 years 14.06 2.11 13.72 2.54

3 forms of maltreatment 12-15 years 14.27 2.51 13.63 2.34

16-18 years 14.44 2.14 13.82 2.25

4 forms of maltreatment 12-15 years 14.42 2.44 14.17 2.31

16-18 years 15.63 2.14 13.97 3.13

337