ContentslistsavailableatSciVerseScienceDirect
Child
Abuse
&
Neglect
Exploring
child
maltreatment
and
its
relationship
to
alcohol
and
cannabis
use
in
selected
Latin
American
and
Caribbean
countries
夽
S.
Longman-Mills
a,
W.Y.
González
b,
M.O.
Meléndez
c,
M.R.
García
d,
J.D.
Gómez
e,
C.G.
Juárez
f,
E.A.
Martínez
g,
S.J.
Pe ˜
nalba
c,
E.M.
Pizzanelli
g,
L.I.
Solórzano
c,
M.G.M.
Wright
h,
F.
Cumsille
h,
W.
De
La
Haye
a,
J.C.
Sapag
i,
A.
Khenti
i,
H.A.
Hamilton
i,j,
P.G.
Erickson
i,j,
B.
Brands
i,j,k,
R.
Flam-Zalcman
i,
S.
Simpson
i,
C.
Wekerle
i,j,l,
R.E.
Mann
i,j,∗aUniversityoftheWestIndies,MonaCampus,Mona,Jamaica bUniversityofPanama,PanamaCity,Panama
cUniversidadNacionalAutónomadeNicaragua,UNAN-León,León,Nicaragua dUniversidaddeLosLlanos,Villavicencio,Colombia
ePontificiaUniversidadJaverianadeBogotá,Bogatá,Colombia fUniversidadEvangélicadeElSalvador,SanSalvador,ElSalvador gUniversdaddelaRepúblicaOrientaldelUruguay,Montevideo,Uruguay hInter-AmericanDrugAbuseControlCommission,Washington,DC,USA iCentreforAddictionandMentalHealth,Toronto,Canada
jUniversityofToronto,Toronto,Canada kHealthCanada,Ottawa,Canada lMcMasterUniversity,Hamilton,Canada
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received13August2012
Receivedinrevisedform31October2012 Accepted2November2012
Available online 7 January 2013
Keywords: Childmaltreatment Substanceuse Religiosity Universitystudents LatinAmerica Caribbean
a
b
s
t
r
a
c
t
Objectives:Researchfromdevelopedcountriesshowsthatchildmaltreatmentincreases theriskforsubstanceuseandproblems.However,littleevidenceonthisrelationshipis availablefromdevelopingcountries,andrecognitionofthisrelationshipmayhave impor-tantimplicationsforsubstancedemandreductionstrategies,includingeffortstoprevent andtreatsubstanceuseandrelatedproblems.LatinAmericaandtheCaribbeanisarichand diverseregionoftheworldwithalargerangeofsocialandculturalinfluences.Aworking groupconstitutedbytheInter-AmericanDrugAbuseControlCommissionandtheCenter forAddictionandMentalHealthinJune,2010identifiedresearchonthisrelationshipasa priorityareaforamultinationalresearchpartnership.
Methods:Thispaperexaminestheassociationbetweenself-reportedchildmaltreatment anduseinthepast12monthsofalcoholandcannabisin2294universitystudentsinseven participatinguniversitiesinsixparticipatingcountries:Colombia,ElSalvador,Jamaica, Nicaragua,PanamaandUruguay.Theresearchalsoconsidersthepossibleimpactof reli-giosityandminimalpsychologicaldistressasfactorscontributingtoresiliencyinthese samples.
Results:Theresultsshowedthatexperienceofmaltreatmentwasassociatedwithincreased useofalcoholandcannabis.However,theeffectsdiffereddependingonthetypeof mal-treatmentexperienced.Higherlevelsofreligiositywereconsistentlyassociatedwithlower levelsofalcoholandcannabisuse,butwefoundnoevidenceofanimpactofminimal psychologicaldistressonthesemeasures.
夽 Theopinionsexpressedinthisarticlearethesoleandexclusiveresponsibilityoftheauthorsanddonotrepresenttheopinionsoftheorganizations andtheadministrationwheretheyareemployed.
∗ Correspondingaddress:CentreforAddictionandMentalHealth,33RussellStreet,Toronto,CanadaM5S2S1.
0145-2134/$–seefrontmatter© 2013 Published by Elsevier Ltd.
Conclusions:Thispreliminarystudyshowsthattheexperienceofmaltreatment may increasetheriskofalcoholandcannabisuseamonguniversitystudentsinLatin Amer-icanandCaribbeancountries,butthathigherlevelsofreligiositymayreducethatrisk. Moreworktodeterminethenatureandsignificanceoftheserelationshipsisneeded.
© 2013 Published by Elsevier Ltd.
Introduction
Childmaltreatmentisany‘actofcommissionoromission’,whetherintendedorunintended,thatresultsinharmtoa child(Gilbert,CathySpatzWidom,etal.,2009).Thisdefinitionincorporatesphysical,sexualandemotionalabuseaswellas neglect.Childmaltreatmentisofgreatconcernwithindevelopednations(Gilbert,Kemp,etal.,2009;Kessleretal.,2010; Westby,2007),however,itsseriousnesshasnotreceivedequivalentsignificancewithinLatinAmerican(LA)andCaribbean countries.InLAandtheCaribbeanover40millionchildrenareexposedtoviolence,abuseandneglect(UNO,ECLAC,& UNICEF,2009),andeffortshavebeenmadebytheUnitedNationstopreventchildmaltreatmentinthisregion(United Nations,1989),Nevertheless,cultural,economicandotherfactorsmaycontinuetoinfluenceratesofmaltreatmentinthe region.Forexample,althoughdiscipliningchildrenthroughcorporalpunishment isnotnecessarily maltreatment,high levelsofacceptanceoftheuseofcorporalpunishmentfordisciplininghavebeenobservedinthesecountries(UNO,ECLAC, &UNICEF,2009).
Researchindevelopednationshasestablishedthatchildmaltreatmenthaslongtermeffectsonbehaviorandhealth(e.g.,
Finkelhor,Ormrod,&Turner,2007;Garbarino,2009;Kessler,Davis,&Kendler,1997;Perry,2009;Widom,1999).Onelong termeffectthathasbeensuggestedisincreaseduseofalcoholanddrugs,andincreasedsubstance-relatedproblems(Adlaf &Smart,1985;Hartzler&Fromme,2003;Johnson&O’Malley,1986;Leventhal&Schmitz,2006;Medrano,Zule,Hatch,& Desmond,1999;Rohsenow,Corbett,&Devine,1988);withthemoresevereformofchildmaltreatment,sexualabuse,being associatedwithahigherriskofsubstancedependence(Kendleretal.,2000).Tonmyr,Thornton,Draca,andWekerle(2010)
reportedacomprehensivereviewofpopulation-basedstudiesexaminingtherelationshipbetweenmaltreatmentand ado-lescentsubstanceabuse.Theirfindingsdemonstratedsubstantialagreementacrossstudiesinfindingthatmaltreatment increasedthelikelihoodofsubstanceabuse.Hovdestad,Tonmyr,Wekerle,andThornton(2011)identifiedthreetheoretical pathwaysbywhichmaltreatmentmightincreasesubstanceuse.Thepost-traumaticstressdisordermodelpositsthat mal-treatedadolescentshaveexperiencedtraumaasaresultofmaltreatment,andfindthatalcoholandotherdrugsmayreduce thestresscreatedbythistrauma.Anothermodellinksmaltreatmenttosubsequentlowself-esteem,withtheseadolescents usingsubstancesmoreinanefforttoescapeemotionalpain.Athirdtheoreticalpathwaysuggeststhatmaltreatmentcan createrelationshipissueswhichmaypredisposetheindividualtosubstanceuseandotherproblems.
SubstanceuseiscurrentlyasignificantconcernwithinLAandCaribbeancountriesassomeofthesecountriesaremajor producersandalsoconsumersoflicitandillicitsubstances(Longman-Millsetal.,2011).Countriesinthisregionare sus-ceptibletodrugproduction,distributionanduse,duetotheireconomic,politicalandsocialclimate(Thoumi,2005),aswell astheirgeographicpositioning.Furthermore,substanceuseanddistributionareassociatedwithincreasedcrimeandsocial disintegration.However,thelikelihoodthatchildmaltreatmentmayalsobeacontributingfactortosubstanceabusein theseregionshasnotyetbeenexplored.
Therelationshipbetweenchildmaltreatmentandadverseoutcomes,however,isnotadirectone(Mrazek&Mrazek, 1987),astheremaybeprotectivefactorsthatmayinfluencethisrelationshipandenhancethechild’sresilience.Resilience afterchildmaltreatmentisaidedbybiological,social,environmentalandpsychologicalfactors(Tonmyr,Wekerle,Zangeneh, &Fallon,2011).
Religionhasbeenidentifiedasanimportantfactorthatmayenhanceresilience(Doxey,Jensen,&Jensen,1997).The primaryreligionthatispracticedinLAandCaribbeancountriesisChristianity,andreligiousbeliefsareconsideredtobe particularlystrongintheregion(CentralIntelligenceAgency,2012).Religiousbeliefshavebeenfoundtoenhanceresilience aftertrauma(Chu,Pineda,DePrince,&Freyd,2011;Doxeyetal.,1997)andalsoactasaprotectivefactoragainstsubstanceuse (Jang&Johnson,2010).Becausestrongreligiousbeliefsarecharacteristicofthisregion,religiousbeliefsmaybeparticularly salientasafactorthatmaypromoteresilienceinthesecountries.
Psychologicaldistresshasbeenidentifiedasbotha negativeoutcomeofchildmaltreatmentaswellasa mediating factorbetweenchildmaltreatmentandotherseriousadverseoutcomessuchassubstanceuse(Afifi&MacMillan,2011; Hamilton,Paglia-Boak,Wekerle,Danielson,&Mann,2011).Theseverityofmaltreatmentexperiencedisdirectlyrelatedto theseverityofpsychologicaldistressexperiencedinlaterlife(Medrano,Hatch,Zule,&Desmond,2002)withsexualabuse beingassociatedwithagreaterriskfactorforpsychologicaldistress(Whiffen&Macintosh,2005).Whilenotallchildren whohaveexperiencedmaltreatmentexperiencesignificantpsychologicaldistress,nonethelessitappearsthatthegreater thepsychologicaldistressexperienced,thegreaterthelikelihoodoflatersubstanceuse(Medranoetal.,2002).Therefore, ifdistressincreaseslikelihoodofadversereactionsaftermaltreatment,thenlackofdistressmayacttoenhanceachild’s resilienceaftermaltreatment(Afifi&MacMillan,2011).SimilarrelationshipsareexpectedtobeobservedwithintheLAand Caribbeanpopulation.
affordedbyreligiousbeliefsandtheabsenceofpsychologicaldistress.Thesecountriesexhibitsubstantialsocial,culturaland economicdifferences.However,theymaybemoresimilarwithregardstotheirdruguse.Themostextensivelyandfrequently usedlicitandillicitsubstancesinthisregiontendtobealcoholandcannabis,respectively(Longman-Millsetal.,2011).These nationsalsodifferintermsofthelegalprotectionaffordedtotheirchildrenandthealsotheirratesofmaltreatment.
Colombia
In2006,theCodeforChildrenandAdolescentsAct,wascreatedtolegallyenshrinetheprotectionofchildrenand ado-lescentsinaccordancewithinternationalhumanrights.However,Botero(2010)hasnotedthatratesofchildmaltreatment inColombiaremainhigh,particularlyinareassuchasthePacificCoast(Botero,2010).
ElSalvador
OnMarch26,2009thenewLawofIntegralProtectionofChildhoodandAdolescencewasenactedandbecameeffective April16,2010.Theobjectiveofthislawwastoguaranteeprotectionandhumanrightstoallchildrenandadolescentsin ElSalvador(AsambleaLegislativadeElSalvador,2009).ThemostfrequentlyreportedtypesofmaltreatmentinElSalvador arephysicalabuseandpsychological/emotionalabuse.However,onlysevereorextremecasestendtobereported.Child maltreatmenthasbeenrecognizedasasignificantconcerninElSalvadoranditsimpactneedsfurtherinvestigation(OCAVI, 2009).Duringtheperiod2004–2007,reportedcasesofchildabuseincreasedfrom1,818casesreportedin2004to4,403 reportedin2007.
Jamaica
ThephysicaldiscipliningofchildreniswidelyusedinJamaicaeventhoughTheJamaicanChildCareandProtectionAct 2004declaredthatpersonsundereighteenyearsoldshouldbeprotectedfromabuse,neglect,harmoreventhreatofharm. Between2007and2011approximately7245casesofsexualabuseand6276casesofphysicalabusewerereported(Officeof theChildren’sRegistry,2012).TheJamaicanchildprotectionlawsareinconsistentwiththeculturaltreatmentofchildren. Theparentingstyleemployedbyparentsorcaregiverstendstobeauthoritarianwiththeconsequencesforanytypeof disobediencebeingaflogging(Smith&Mosby,2003).However,childrenarebroughtuptobelievethattheyareflogged becausetheyareloved,withfloggingbythemotherusuallybeingtemperedbyaffectionafterwards(Leo-Rhynie,1997).
Nicaragua
Nicaraguahasenactedlegislationtopreventtheviolationofthehumanrightsofchildrenandadolescents.Oneexample isAct287:Codeofchildhoodandadolescence,approvedMarch24,1998.ThisActidentifiesinArticle.5Paragraph1that, “...nochildoradolescentwillbesubjectedtoanyformofdiscrimination,exploitation,illicittransferwithinoroutside thecountry,violence,abuseorphysical,psychologicalandsexualviolence,inhumanetreatment,terrorizing,humiliating, oppressive,cruel,attackornegligence,byactoromissionoftheirrightsandfreedoms.”Howevergovernmententities, especiallytheMinistryoftheFamily,donothavethebudgetrequiredforimplementationandenforcement.Themainrisk factorsassociatedwithchildmaltreatmentinNicaraguaarepoverty,loweducationallevelandalsoacultureofviolence (PlanNicaragua,2004).Thesefactorsareseriousbarrierstotheprosecutionofoffendersandtotrackingandmonitoring casesofabuse(PlanNicaragua,2004).AccordingtotheLegalMedicineInstitute,amongcasesofDomesticViolence,4.54% wereclassifiedasChildAbusein2006and2.87%involvedgirlsunder10yearsold(CEPAL,UNICEF,&UNICEFTACRO,2009). Incasesofsexualabuse,theperpetratorsaretypicallymenbetween18and30yearsold,andaremostcommonlyafather, step-father,neighbor,uncle,cousin,orbrother(PlanNicaragua,2004).
Panama
In2002,theCommitteeoftheRightsoftheChildreported1,465casesrequiringtheprotectionofchildrenagainstchild abuse;ofthese758(14.2%)casesinvolvedgirlsand691(13.2%)involvedboys.OneofthegoalsoftheNationalPlanof ActionofChildhoodandAdolescence2003–2006wastoreducethenumberofchildabuseandchildabandonmentcasesby 25%.However,policestatisticsfor2003–2006indicatethatcasesofchildabuseincreasedby38%overthatperiod(Panamá Government,NationalPlanofActionoftheChildhoodandtheAdolescence,2007).
Uruguay
Thus,childmaltreatmentappearstobeasignificantissueinLAandCaribbeancountries(UNO,ECLAC,&UNICEF,2009). Thereisevidencethatlargenumbersofchildrenaremaltreated,andinspiteoflegaleffortsdirectedattheissuetheresources tounderstandandaddresschildmaltreatmentinthesecountriesmaybelacking.Addressingmaltreatmentintheregion willalsorequireanunderstandingofhowitaffectsotherproblems,suchassubstanceuseandabuse.Inthisresearchwe reportpreliminaryinformationontherelationshipofchildmaltreatmentwiththereporteduseofalcoholandcannabis amonguniversitystudentsinsixLAandCaribbeancountries.Wealsoexploretheimpactoftwopotentialresiliencefactors, religiosityandlowlevelsofpsychologicaldistress,onuseofthesetwosubstances.
Methods
Thisresearchwasconductedaspartofamulticountrystudyofchildmaltreatmentandassociatedfactorsamong univer-sitystudentsinLAandCaribbeancountries(Longman-Millsetal.,2011).Theprojectwasinitiatedbyamultinationalworking groupin2010undertheauspicesoftheGovernmentofCanada(DepartmentofForeignAffairsandInternationalTrade); theInternationalDrugAbuseControlCommission(CICAD)oftheSecretariatforMultidimensionalSecurity(SMS)ofthe OrganizationofAmericanStates(OAS),andtheCenterforAddictionandMentalHealth(CAMH).Participatinginvestigators representedColombia,ElSalvador,Jamaica,Nicaragua,PanamaandUruguay.
Sample
Universitystudentvolunteers fromselecteduniversitiesin Colombia,El Salvador,Jamaica, Nicaragua, Panama and Uruguayparticipatedintheresearch.Atotalof1167femaleand1127malestudentsparticipated,fromoneuniversity withineachcountry(withtheexceptionofColumbiawheretwouniversitiesparticipated).Thesamplewaspredominantly inlateadolescenceandearlyadulthood,with42.4%beingunder20yearsofageand49.4%between20and24yearsold(the remaining8.2%were25yearsandolder).
Procedures
ThestudywasapprovedbyResearchEthicsBoardsofeachparticipatinginstitution.Thesamplingwaspurposive,sincea randomsamplerepresentativeoftheuniversitypopulationsinparticipatingcountrieswasnotfeasibleatthisearlystageof research.Theinvestigatorsatparticipatinguniversitiesfirstidentifiedthoseclassesthatwereavailabletoparticipateinthe research.Next,eachinvestigatorselectedfromamongaccessibleclassesthosethatbestrepresentedthepopulationofthe participatinguniversityandwouldprovideasamplesizeofapproximately300.Next,courseinstructorsofselectedclasses wereapproachedtoapprovein-classadministrationofthesurveyatanagreed-upondatebetweenOctober2010andMarch 2011.
Inclasseswheretheinstructorapprovedparticipationintheresearch,amemberofthestudyteamwasintroducedbythe classinstructor.Thestudyteammemberthenprovidedabriefdescriptionoftheproject,andinvitedstudentstoparticipate. Participationwascompletelyvoluntary,andthosewhodidnotwishtoparticipatesimplylefttheclassandincurredno penaltyfordoingso.Thosewhoremainedcompletedaconsentform,andthenwereprovidedwiththequestionnairetofill out.Participationwasanonymousandnoname-relatedinformationwaslinkedtoresponses.Informationonmentalhealth resourceswasavailableforstudentswhomayhavebeenaffectedbythenatureofthequestions.
Measures
Thequestionnaireobtainedinformationonbasicdemographicvariables,includingage,sexandyearinprogram,aswell asalcoholandcannabisuse,theexperienceofmaltreatmentasachild,psychologicaldistressandreligiosity.Alcoholand cannabisuseinthepastyearweremeasuredwithquestionsdrawnfromtheCICADdrugusequestionnaire(Organisationof AmericanStates,Inter-AmericanDrugAbuseControlCommission,2010;CICADistheacronymbasedontheSpanish trans-lationofInter-AmericanDrugAbuseControlCommission–ComisiónInter-AmericanaparaelControldelAbusodeDrogas). TheCICADquestionshavebeenusedextensivelyinsurveyresearchinLAandCaribbeancountriesandhavedemonstrated theirreliabilityandvalidityinthesepopulations(OrganisationofAmericanStates,Inter-AmericanDrugAbuseControl Commission,2010).
TheAdverseChildhoodExperiences(ACE;Felittietal.,1998)questionnairewasincludedtoobtainmeasuresof maltreat-ment.Thequestionnaireisa28-itemself-reportinstrumentthatyieldsfivemeasuresofmaltreatmentduringchildhood (sexual,physical,emotionalandtwoscalesreflectingneglect).TheACEquestionnairehasbeenusedinmanystudiesin avarietyofculturalsettingsandhasbeenfoundtodemonstrateadequatereliabilityandvalidity(e.g.,Dube,Williamson, Thompson,Felitti,&Anda,2004;Rothman,Edwards,Heeren,&Hingson,2008).Wereportonthethreemaltreatment meas-uresinthiswork,andtheneglectscaleswillbediscussedelsewhere.Neglectmaybereflectiveofadversesocioeconomic conditions,andthusconsiderationofscoresonthesemeasuresfromdevelopingcountriesthatmayhavehigherpoverty ratesthanfoundindevelopedcountriesneedtoaddressthisissue.
Table1
Logisticregressionmodelspredictingpast12monthsalcoholuse.a
Variables WaldChi-square p Oddsratio Lower95%confidence
limitforoddsratio
Upper95%confidence limitforoddsratio
Analysesincludingphysicalabuse
Gender 15.386 <0.0001 0.686 0.568 0.828
Age 0.691 0.406 0.986 0.955 1.019
K10scale 0.060 0.807 1.002 0.989 1.015
Religiosity 42.336 <0.0001 1.415 1.274 1.571
Physicalabuse 16.117 <0.0001 1.514 1.236 1.853
Analysesincludingemotionalabuse
Gender 16.226 <0.0001 0.680 0.564 0.821
Age 0.351 0.554 0.990 0.959 1.023
K10scale 0.371 0.542 1.004 0.991 1.017
Religiosity 44.232 <0.0001 1.421 1.282 1.577
Emotionalabuse 5.670 0.017 1.295 1.047 1.601
Analysesincludingsexualabuse
Gender 17.013 <0001 0.673 0.557 0.812
Age 0.185 0.667 0.993 0.961 1.026
K10scale 0.785 0.376 1.006 0.993 1.019
Religiosity 44.990 <0001 1.428 1.287 1.584
Sexualabuse 1.633 0.201 1.290 0.873 1.907
aControllingfortheeffectsofcountry/institution.
30days.Ithasbeenusedcross-culturallyinepidemiologicalsurveysandhasbeentranslatedintonumerouslanguages,and
isutilizedinWorldHealthOrganization(2008)mentalhealthsurveys(Kessleretal.,2003).Itconsistsofquestionsthat
screenforanxietyanddepressivesymptomswhichareassociatedwithmanyotherpsychologicaldisorders.TheK10has beenvalidatedacrossculturesandhasalsobeenfoundtoberelatedtoarangeofpsychologicaldiagnoses(Andrews&Slade, 2001).
Religiositywasassessedwithasingleitem(“Howimportantarereligiousbeliefstoyou”)withresponseoptionsvery important,important,somewhatimportant,andnotimportant.Thisitemwasbasedononeofthereligiosityitemssuggested byGorsuchandMcFarland(1972),whofoundthatithadsimilarpsychometriccharacteristics(reliabilityandvalidity)to longerscales.
Datapreparationandanalyses
Datafromeachsitewerecollectedbythesite investigatorandenteredintoanExcelfile.TheExcelfileswerethen forwardedtothefirstauthor(S.L.)forcombiningandcleaning.DatawerethenforwardedtoTorontoforanalysesconducted usingSAS.
Toinvestigatetheimpactofmaltreatmentonalcoholandcannabisuse,logisticregressionanalyseswereconducted. Sep-arateanalyseswereconductedfortheuseofalcoholandcannabis.Wealsoenteredageandsexintheseanalysestocontrol fortheirimpactonsubstanceuse.Religiosityandpsychologicaldistresswereenteredtoprovideaninitialconsiderationof theirpotentialresilience-enhancingeffects.Sinceweobservedsubstantialassociationsbetweenmeasuresofmaltreatment, weconductedseparateanalysesfortheseaswell,resultinginatotalofsixlogisticregressionanalysesconducted. Coun-try/universityeffectswerealsocontrolledforineachanalysis,butnotreportedbecauseofagreementswithparticipating institutionsnottoidentifytheirresultsinanycomparativemanner.
Log-regressionmodelswerebuiltusingastheoutcomevariablesanyuseofalcoholandanyuseofcannabisinthepast 12months.InthemodelsshowninTable1(alcoholusemodels,withseparatemodelsforeachmaltreatmentmeasure)and
Table2(cannabisusemodels,withseparatemodelsforeachmaltreatmentmeasure)theoutcomemeasureisabinaryvariable withvalues0=No,1=Yes.Theexplanatoryvariablesaregender,age,country/university,religiosity(coded1=very impor-tant,2=important,3=somewhatimportant,4=notimportant),K10(psychologicaldistressmeasure)andabuse(emotional, physicalorsexual).
Thelogregressionmodelscanbeexpressedwiththefollowingequation:
Logit[P(Y=1)]=c0+c1X1+c2X2+c3X3+c4X4+c5X5+c6X6 (1)
Table2
Logisticregressionanalysespredictingcannabisuseinthepast12months.a
Variables WaldChi-square p Oddsratio Lower95%confidence
limitforoddsratio
Upper95%confidence limitforoddsratio
Analysesincludingphysicalabuse
Gender 3.224 0.073 0.786 0.604 1.022
Age 2.931 0.087 1.039 0.995 1.085
K10scale 0.133 0.715 1.003 0.986 1.021
Religiosity 70.385 <0.0001 1.766 1.546 2.016
Physicalabuse 7.711 0.005 1.491 1.125 1.977
Analysesincludingemotionalabuse
Gender 3.358 0.067 0.783 0.603 1.017
Age 3.796 0.051 1.043 1.000 1.089
K10scale 0.337 0.562 1.005 0.988 1.023
Religiosity 71.134 <0.0001 1.769 1.550 2.020
Emotionalabuse 3.402 0.065 1.324 0.983 1.783
Analysesincludingsexualabuse
Gender 3.105 0.078 0.790 0.608 1.027
Age 4.612 0.032 1.049 1.004 1.096
K10scale 0.889 0.346 1.009 0.991 1.026
Religiosity 70.714 <0.0001 1.768 1.548 2.019
Sexualabuse 0.187 0.665 0.879 0.490 1.576
aControllingfortheeffectsofcountry/institution.
Logit[P(Y=1)]equalstolog[P(y=1)/1−P(y=1)],orthelogoftheoddsratio.TheexpressionP(Y=1)=[P(y=1)/1−P(y=1)]
correspondstothe“oddsratio”.Thisratiomeasurestheratiobetweentheoddsof“Useofalcoholorcannabisinthepast12
months”andtheoddsof“Nouseofalcoholorcannabisinthepast12months”.
Thusauniversitystudentwithgenderx1,countryx2,agex3,K10scalex4,religiosityx5andabuse(emotional,physicalor
sexual)x6hastheprobabilityofabusingalcoholorcannabisinthepast12monthscalculatedatparticularpredictorvalues
usingtheequation:
P(y=1)= ec0+c1X1+c2X2+c3X3+c4X4+c5X5+c6X6
1+ec0+c1X1+c2X2+c3X3+c4X4+c5X5+c6X6
wherec0,c1,c2,c3,c4,c5andc6areestimatesfromthelogregressionmodels.Theoddsratios(ORs)areshowninTables1and2
foreachoftheindependentvariablesinthealcoholandcannabisusemodels(forexample,intheORestimationforthe independentvariableX1,thecoefficientsc2,c3,c4,c5andc6areequalto0).
Results
Past12-monthuseofbothalcoholandcannabiswasfoundtoberelativelycommoninthesample.Alcoholusewas reportedby59.8%ofthestudentsandcannabisusewasreportedby19.1%.Sexualabusewastheleastcommonformof maltreatment(reportedby6.1%ofthesample)whilephysicalabuseandemotionalabusewereeachreportedbyabouta thirdofrespondents(33.9%and30.4%,respectively).
Alcoholuse
ThethreelogisticregressionanalysesexaminingpredictorsofalcoholusearesummarizedinTable1.Ascanbeseen,the resultsforphysicalabuseandemotionalabuseareverysimilar.Femalesaresignificantlylesslikelytoreportusingalcohol thanmales(OR=0.686and0.680,respectively).Ageandpsychologicaldistressdidnotsignificantlyaffectwhetherornot respondentsreporteddrinkingintheseanalyses.Religiositywasassociatedwithdrinkingstatusinbothanalyses,with higherlevelsofreligiositybeingassociatedwithnotusingalcohol(OR=1.415and1.421,respectively).Bothmeasuresof maltreatmentwerealsostronglyassociatedwithdrinkingaswell.Experiencingphysicalabuseandexperiencingemotional abusesignificantlypredictedusingalcoholamongstudentrespondents(OR=1.514and1.295,respectively).
Theresultsforsexualabuseweresomewhatdifferent.Femalesweresignificantlylesslikelytousealcohol(OR=0.673). Similarly,ageandpsychologicaldistressdidnotpredictalcoholuse,whilereligiositydid(OR=1.428).However,incontrast tophysicalandemotionalabuse,experiencingsexualabusedidnotsignificantlypredictdrinkingstatus.
Cannabisuse
butnosignificantrelationshipwasobservedbetweenageandphysicaloremotionalabuse.Psychologicaldistressdidnot significantlypredictcannabisuseinanyoftheanalyses.Religiositywasastrongpredictorofcannabisuse,withhigherlevels ofreligiousinvolvementpredictingnotusingthedrugineachanalysis(ORs=1.766,1.769and1.768).Effectsof maltreat-mentdependedonthemeasureconsidered.Experiencingphysicalabusesignificantlypredictedcannabisuse(OR=1.491). However,experiencingemotionalabuseandsexualabusedidnot.
Discussion
Thelimitationsofthisresearchmustbekeptinmindwheninterpretingtheseresults.First,thesamplecannotbe consid-eredtoberepresentativeofuniversitystudentsintheparticipatingcountries,andthustheresultsshouldnotbegeneralized tothispopulation.Nevertheless,thesedataprovideasignificantfirstlookatpotentiallyimportantfactorsthatmayinfluence substanceusebyyoungpeopleinLAandCaribbeancountries.Second,thedataarebasedonself-report,andcouldbesubject toassociatedformsofbias,e.g.,innotwantingtodisclosepotentiallysensitivepersonalinformation.Third,ouroutcomes arerestrictedtomeasuresofalcoholandcannabisuse,anddonotconsideruseofothersubstancesormeasuresofabuse ordependence.Arelatedpointisthatitisimportanttorecognizethatuseofalcohol,andcannabisarecommonanddonot necessarilyreflectmaltreatment.
Childmaltreatment hasbeenidentified asa significantpublichealth probleminternationally (Kessler etal.,2010; Longman-Millsetal.,2011).Indevelopedcountriesasubstantialbodyofresearchlinks experienceofmaltreatmentto substanceuseandsubstanceproblemsinadolescenceandlater(Rothmanetal.,2008;Tonmyretal.,2010).However,while thereisevidencetosuggestsimilarlinksinthedevelopingworld(Kessleretal.,2010), muchlessresearchfromthese countrieshasappeared.Theexistenceinthedevelopingworldofverydifferentculturesandsocialpracticeswithregards toalcoholanddruguse,ononehand,andwithregardstothetreatmentofchildren,ontheother,suggestthatsimple extrapolationofresultsfromdevelopedcountriestodevelopingcountriesisunwise.
Inthisresearchweexaminedtherelationshipbetweenself-reportedexperienceofphysical,emotionalandsexualabuse inchildhoodandtheuseofcannabisandalcoholinstudentsfromselecteduniversitiesinsixLAandCaribbeancountries. Theresultsshowanimpactofmaltreatmentonalcoholandcannabisuseinthesesamples,consistentwithexpectations derivedfromresearchindevelopedcountries(Hovdestadetal.,2011;Tonmyretal.,2010).Whilethenatureofthesamples doesnotpermitgeneralizationofthesefindingstothegeneralstudentpopulationintheregion,thefindingssupportthe hypothesisthat,asindevelopedcountries,experienceofchildhoodmaltreatmentindevelopingcountriesmayincreasethe likelihoodofalcoholandcannabisuseinadolescenceandyoungadulthood.
Theprevalence,natureandstrengthofreligiousbeliefvarysubstantiallyinternationally.Evidencefromstudiesin devel-opedcountriessuggeststhatstrongreligiousbeliefsmaycontributetoresilienceandhelpindividualscopewithadversity. Religiositymaymitigatetheeffectsofmaltreatment(Doxeyetal.,1997;Kim,2008).Ourfindingsprovidesupportforthis suggestion.Strongerreligiousbeliefswereassociatedwithreducedlikelihoodofusingbothcannabisandalcoholacrossall analyses.TheseeffectsmaybeparticularlysalientinsomeLAandCaribbeancountries,wherestrongreligiousbeliefsmay becommon.
Interestingly,wefoundnoevidenceforabeneficialimpactofminimalpsychologicaldistress,asmeasuredbytheK10,on alcoholandcannabisuse.Someevidencesuggeststhatbothstressandmaltreatmentmaypredictalcoholanddruguse(e.g.,
Young-Wolff,Kendler,&Prescott,2012)andthatminimallevelsofstresscouldcounteracttheeffectsofmaltreatmenton substanceuse(Medranoetal.,2002).However,wefoundnosignificantrelationshipbetweentheK10measureandsubstance useinanyoftheanalyses.Onepossibleinterpretationoftheseresultsisthattherelationshipofstresstosubstanceusein thisregionisdifferentthanitisindevelopedcountrieswherethisrelationshiphasbeenreportedpreviously.
Whileweobservedthatmeasuresofmaltreatmentwereassociatedwithalcoholandcannabisuse,thisrelationshipwas notuniformacrossmeasuresofmaltreatment.Specifically,physicalabusewasassociatedwithincreaseduseofbothalcohol andcannabis,emotionalabusewasassociatedwithincreasedalcoholusebutnotcannabisuse,andsexualabusewasnot significantlyassociatedwitheitheralcoholorcannabisuse.Theseresultsaresimilartostudiesfromdevelopedcountriesthat findconsistentassociationswithphysicalabusemeasures(e.g.,Rothmanetal.,2008),butmaydifferfromstudiesthatfind similarlyconsistentrelationshipsofemotionalandsexualabusewithalcoholandcannabisuse(Rothmanetal.,2008).This possiblevarianceofeffectsofthedifferingformsofmaltreatmentcouldreflectmethodologicalfactors.Forexample,these differingrelationshipsmayresultinpartfromthedifferingprevalenceofphysical,emotionalandsexualabuse,andalso consistentrelationshipsmightemergewithalargersample.However,theymayalsoreflectculturallyinfluenceddifferences inhowmaltreatmentaffectssubstanceuse.
abuseanddependence.Additionally,theimpactofexperiencingmultipleformsofmaltreatmentneedstobeconsidered, andadditionalresearchonfactorsthatpromoteresilienceinthefaceoftheseadversitiesisnecessary(Garbarino,2009).
Acknowledgements
Theauthorsaregratefulforvaluableinput,supportandencouragementfromDrs.D.A.Wolf,N.Giesbrecht,C.Strike, L.Simich,Ms.K.Lo,Mr.R.ChungandMs.G.Stoduto.TheInter-AmericanDrugAbuseControlCommission,theCentrefor AddictionandMentalHealth,andtheDepartmentofForeignAffairsandInternationalTradeofCanadasupportedthework reportedhere.Theauthorsacknowledgethesupportoftheirhomeinstitutionsforthisinitiative,andDrs.Hamilton,Erickson andMannalsoacknowledgeongoingfundingsupportfromtheOntarioMinistryofHealthandLong-TermCare.Theauthors alsoexpresstheirappreciationtothreeanonymousreviewerswhosevaluablecommentshavehelpedtoimproveandclarify thisworksubstantially.
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