580363 research-article2015
JIVXXX10.1177/0886260515580363Journal of Interpersonal ViolenceAl-Modallal
Article
Depressive Symptoms in College Women: Examining the Cumulative Effect of Childhood and Adulthood Domestic Violence
Journal of Interpersonal Violence 1–21 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260515580363 jiv.sagepub.com
Hanan Al-Modallal, PhD1
Abstract The purpose of this study was to examine the cumulative effect of childhood and adulthood violence on depressive symptoms in a sample of Jordanian college women. Snowball sampling technique was used to recruit the participants. The participants were heterosexual college-aged women between the ages of 18 and 25. The participants were asked about their experiences of childhood violence (including physical violence, sexual violence, psychological violence, and witnessing parental violence), partner violence (including physical partner violence and sexual partner violence), experiences of depressive symptoms, and about other demographic and familial factors as possible predictors for their complaints of depressive symptoms. Multiple linear regression analysis was implemented to identify demographic- and violence-related predictors of their complainants of depressive symptoms. Logistic regression analysis was further performed to identify possible type(s) of violence associated with the increased risk of depressive symptoms. The prevalence of depressive symptoms in this sample was 47.4%. For the violence experience, witnessing parental violence was the most common during childhood, experienced by 40 (41.2%) 1Hashemite
University, Zarqa, Jordan
Corresponding Author: Hanan Al-Modallal, Associate Professor, Department of Community and Mental Health Nursing, College of Nursing, Hashemite University, Zarqa, Jordan. Email: [email protected]
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women, and physical partner violence was the most common in adulthood, experienced by 35 (36.1%) women. Results of logistic regression analysis indicated that experiencing two types of violence (regardless of the time of occurrence) was significant in predicting depressive symptoms (odds ratio [OR] = 3.45, p < .05). Among college women’s demographic characteristics, marital status (single vs. engaged), mothers’ level of education, income, and smoking were significant in predicting depressive symptoms. Assessment of physical violence and depressive symptoms including the cumulative impact of longer periods of violence on depressive symptoms is recommended to be explored in future studies. Keywords college women, depressive symptoms, Jordan, violence
Introduction The purpose of this study was to examine the cumulative effect of domestic violence occurring during childhood and adulthood on Jordanian college women’s experiences of depressive symptoms. College age is a critical time for female college students as their mental health status is vulnerable due to lived situations and demands required in this stage. Depression, anxiety, and suicidal ideation are examples of mental health problems in college years (Amar & Gennaro, 2005; Nilsen, Conner, Murphy, & Blumenthal, 2002). Depression is generally integrated with psychological, social, and familial factors (Orner, Siriwardena, & Dyas, 2004). Considering domestic violence as a social and familial factor associated with psychological outcomes, it is reported that domestic violence is associated with depression (ArboledaFlorez & Wade, 2001; Carlson, McNutt, & Choi, 2003; Nicolaidis, Curry, McFarland, & Gerrity, 2004). Domestic violence experienced during childhood or adulthood has a significant impact on women’s mental health, including the development of depressive symptoms. For example, in a Jordanian study, the odds of depressive symptoms in women increased among victims of intimate partner violence compared with non-victims (adjusted odds ratio [OR] = 3.5, 95% confidence interval [CI] = [1.05, 11.7]; Al-Modallal, Abuidhail, Sowan, & Al-Rawashdeh, 2010).
Background Childhood domestic violence, manifested in different forms such as physical and sexual violence, is influential in altering the health of victims. Physical, social, and psychological outcomes during childhood, adolescence, and adulthood are
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influenced by childhood abuse experiences (Arias, 2004). Social impacts of childhood experiences of violence are exhibited in victims’ use of violence or experiencing violence in adulthood relationships (Haller & Miles, 2003; Stein, Leslie, & Nyamathi, 2002). However, empirical evidence strongly supports the relationship between childhood abuse and experiencing violence in adulthood. Using a nationally representative sample, Desai, Arias, Thompson, and Basile (2002) found that childhood abuse, whether physical or sexual, was associated with victimization of women by their intimate partners. That was congruent with Briere and Elliott’s (2003) findings, which indicated that 188 (39.9%) females reported experiences of adulthood victimization by the partner and that victimization was highly associated with previous experiences of childhood physical and sexual abuse. Furthermore, DiLillo, Giuffre, Tremblay, and Peterson (2001) highlighted the relationship between childhood sexual abuse and physical partner violence. They found that 10% of the women with childhood sexual abuse were beaten by their intimate partners compared with 2% of the women without childhood sexual abuse experience (DiLillo et al., 2001). Such findings imply that the experience of childhood violence could be responsible for conflict in adulthood relationships (Lang, Stein, Kennedy, & Foy, 2004) and thus leads to disrupted healthy adulthood relationships. College women are at risk for violence (Baum & Klaus, 2005; RiveraRivera, Allen, Rodriguez-Ortega, Chavez-Ayala, & Lazcano-Ponce, 2006) similar to the general population of community women (Evans-Campbell, Lindhorst, Huang, & Walters, 2006; Yang, Yang, Chang, Chen, & Ko, 2006). The perpetrator of violence in college women is mainly the dating/intimate partner (Nilsen et al., 2002). Physical and sexual types of violence are the hallmarks of violence exhibited in dating or intimate relationships during college years. Sometimes college women experience one form of violence, and in other cases, they may become victims of more than one form of violence. A longitudinal study following women from high school to the fourth year in college indicated that 88% of the women experienced physical or sexual incidents of dating violence, and 63.5% were victims of both types of violence. The prevalence rates of physical and sexual dating violence were high as well with 77.8% for physical violence and 79.2% for sexual violence (Smith, White, & Holland, 2003). Not only are experiences of violence common in women’s lives, but mental health problems including depressive symptoms are also common in women, including college women (Csoboth, Birkas, & Purebl, 2005). The relationship between different violence experiences and women’s depressive symptoms is significant. Women who experienced any type of violence (e.g., physical, sexual, or psychological) from a dating partner experienced significantly higher
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levels of depressive symptoms compared with non-victims (Amar & Gennaro, 2005). In addition, multiple experiences of violence (e.g., a combination of physical and sexual violence) were associated with greater levels of depressive symptoms. For example, the mean depressive symptoms for women with physical violence only was 0.92 (SD = 0.06), whereas it was 1.34 (SD = 0.09) for women with a combination of physical and sexual violence (Messman-Moore, Long, & Siegfried, 2000). Childhood abuse sequels in terms of psychological impact are neither less important nor less influential than that of adulthood abuse. Examples of such sequels include distress (Lang et al., 2004), substance misuse (Coid et al., 2003), and attempted suicide (Bohn, 2003; Thompson, Kaslow, & Kingree, 2002). In addition, childhood abuse was found highly associated with anxiety (Carlson et al., 2003) and adulthood depressive symptoms (Arboleda-Florez & Wade, 2001; Carlson et al., 2003). Focusing on depressive symptoms, a significant relationship was identified between childhood physical abuse that was measured by the Childhood Trauma Questionnaire (CTQ) and depressive symptoms that were measured by the Center for Epidemiologic Studies– Depression (CES-D) Scale (Lang et al., 2004). In summary, it was reported that depressive symptoms are associated with violence (Arboleda-Florez & Wade, 2001; Carlson et al., 2003; Nicolaidis et al., 2004). Furthermore, there is a strong relationship between the cumulative exposure to violence and occurrence of depressive symptoms and other psychological health problems (Arboleda-Florez & Wade, 2001; Carlson et al., 2003; McCauley et al., 1997). For example, 45% of women experiencing 8 to 14 times lifetime abuse developed depressive symptoms compared with only 8.14% of those who experienced 1 lifetime abuse (Carlson et al., 2003). Finally, it was reported that the increase in the number of violence incidents is associated with an increase in the cumulative impact on depression (Bohn, 2003; Carlson et al., 2003; McGuigan & Middlemiss, 2005) and an increase in the odds of occurrence of depressive symptoms (Nicolaidis et al., 2004).
Purpose of the Study In the literature studying college women, some studies were identified focusing on the relationship between violence (physical and sexual) and depressive symptoms during dating relationships (Amar & Gennaro, 2005; Messman-Moore et al., 2000; Rich, Gidycz, Warkentin, Loh, & Weiland, 2005; Sanders & Moore, 1999). Other studies, on the other hand, were focusing on the relationship between violence perpetrated by strangers and the development of depressive symptoms (Harris & Valentiner, 2002).
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In Jordan, few studies focused on identifying women’s experiences of childhood violence (Al-Badayneh, 2012; Clark, Silverman, Shahrouri, Everson-Rose, & Groce, 2010). Partner violence was addressed in a relatively larger number of studies (Al-Modallal, 2012a; Al-Modallal et al., 2010; Clark, Bloom, Hill, & Silverman, 2009). Furthermore, studies that focused on women’s mental health are on the rise (Al-Modallal, 2010, 2012b; Al-Modallal et al., 2012). Yet, little is known about the cumulative effect of different types of domestic violence, occurring during childhood and adulthood, on depressive symptoms among college women. To our knowledge, no studies were identified exploring this relationship in Jordanian college women. The following hypotheses were tested in this study: Hypothesis 1: Depressive symptoms among Jordanian college women are associated with their personal and familial demographics. Hypothesis 2: Childhood violence and adulthood violence are effective in predicting depressive symptoms in Jordanian college women. Hypothesis 3: Different types of domestic violence occurring during childhood and adulthood have a cumulative effect on the increased risk of depressive symptoms in Jordanian college women; that is, as the number of different types of violence increases, college women report higher risk values of depressive symptoms, accordingly.
Method Procedure Inclusion criteria for the study included female college students at the Hashemite University aged 18 to 25 years. Students had to be enrolled as fulltime students regardless of their field of study. Students had to be engaged to a male partner or have a significant male figure and planning to get engaged to that male partner in the future. This criterion was set because intimate relationships between a male and a female are preferred to be within the milieu of either engagement or arranged engagement in the future. Married college students were excluded from this study because our focus was to examine the relationship between violence and depressive symptoms in college women before the beginning of the marital relationship. Furthermore, this study is considered the first to be conducted on Jordanian college women. A snowball sample was implemented due to expected difficulties in recruiting the participants. An announcement about the study was made in one of the classes by the primary investigator. Female students who showed
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interest in the study were asked to complete the study questionnaire either at the end of the class or at the primary investigator’s office. Students who were involved in the study using the snowball sampling method met with the primary investigator in the office where the questionnaire was handed to them and completed accordingly. Attached to the study questionnaire, written information about the study and its purpose was included. Information about voluntariness of participation and confidentiality of given information were stressed. The questionnaire included required data about females’ experiences of childhood violence, partner violence, and depressive symptoms. Information about participants’ demographics was included in the questionnaire as well. Examples of participants’ demographics included age, income, year in college, smoking status, and their grade point average (GPA).
Measures Depressive symptoms. Depressive symptoms are behaviors experienced by non-clinically depressed individuals for an average of 1 week. Depressive symptoms were measured using the CES-D Scale (Radloff, 1977). The major components of depressive symptoms include “depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance” (Radloff, 1977, p. 386). Each of the 20 CES-D Scale items, including the four positively stated items, asks about a behavior or feeling experienced by the individual. The individual is asked to report the frequency of experiencing each of these behaviors in the last 7 days. Responses are scored on a 0 to 3 scale based on the frequency of experiencing each behavior. To prevent response-set bias, the four positively stated items are reverse scored. The total score is calculated by adding the response points of all items. Possible scores range from 0 to 60 with higher scores indicative of higher levels of depressive symptoms. The CES-D was validated in a sample of Jordanian women and revealed a Cronbach’s alpha level of .90 (Al-Modallal, 2010). Physical partner violence. Violence experienced by college students is called “dating violence.” This dating violence is “the term often used to describe adolescent and college student intimate partner violence” (Amar & Gennaro, 2005, p. 235). The Safe Dates–Physical Violence Victimization Scale addresses physical acts inflicted by an abusive intimate partner. Examples of physical violence tactics include “kicked me,” “bent my fingers,” and “tried to choke me.” Each item is rated on a 4-point scale: 0 = never, 1 = 1 to 3 times, 2 = 4 to 9 times, and 3 = 10 or more times (Foshee et al., 1996).
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Cronbach’s alpha in a sample of school adolescents was .92 (Foshee et al., 1996; Thompson, Basile, Hertz, & Sitterle, 2006). Scoring of the scale includes summing the point values of the items. The final scores range between 0 and 48 with greater scores indicative of greater physical violence victimization experienced by the participant. Sexual partner violence. Two questions adopted from the Safe Dates Scale were used to measure sexual partner violence. These questions were as follows: “Forced to have sex” and “Forced to do other sexual things.” The participant who indicated a positive response (yes) to at least one of the two questions was considered a victim of sexual violence. Childhood violence. Four types of childhood violence (physical violence, psychological violence, sexual violence, and witnessing parental violence) inflicted by parents, guardians, or caretakers were investigated in this study. Respondents were asked to report whether they were physically or psychologically abused as children by a parent, guardian, or caretaker. Positive (yes) response to physical violence indicated physical violence victimization, and absence of the experience (no) indicated non-victimization. Similarly, positive response to psychological violence indicated childhood psychological violence victimization, and negative response indicated absence of psychological violence victimization. Coding was either “1” for positive responses or “0” for negative responses, for childhood physical violence and for childhood psychological violence. Sexual violence was assessed by a single item asking women to report whether they were sexually abused during childhood by an adult (relative or non-relative). Responses to this item were coded as “1” for the sexual victimization and “0” for the no victimization history. Finally, college women were asked to report whether they (as children) ever witnessed parental violence. Responses indicating witnessing parental violence were coded as “1,” and “0” otherwise. Witnessing parental violence was included by many researchers with childhood violence/maltreatment (Hornor, 2005; Linder & Collins, 2005; Teicher, Samson, Polcari, & McGreenery, 2006). Similarly, and like other types of childhood violence, witnessing parental violence has influential effects on children’s physical, mental, and developmental health (Hornor, 2005). For this reason, we included witnessing parental violence with participants’ experiences of childhood violence. Demographic variables. A set of demographic data was collected from the participants. All demographic variables were categorical. Demographic characteristics that were included in this study were marital status (single and
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married), place of residence (Amman, Irbid, Zarqa, Mafraq, and other), class standing (first through fourth year), father’s level of education (less than high school, high school, college, and graduate), mother’s level of education (less than high school, high school, college, and graduate), the person the college woman is living with (alone, with parents, and other), income (≤500 Jordanian Dinar [JD], 501-1,000 JD, and ≥1,001 JD), and finally smoking status (smoker and non-smoker).
Statistical Analysis Prior to data analysis, distributions of the continuous variables were examined to identify outliers. Based on our hypotheses and types of variables that were collected, some of the variables were re-coded. Physical partner violence was used as a continuous variable to test Hypothesis 2 and as a dichotomous variable to test Hypothesis 3. Scores of the physical violence variable were dichotomized as “0” when the total violence score was 0 and “1” when the total violence score was 1 or greater. Similar coding of “0” and “1” was used for the sexual violence variable. Those who had no sexual violence experience were coded as “0,” and those who experienced sexual violence were coded as “1.” Furthermore, depressive symptoms scores (using the CES-D Scale) were used as a continuous variable to test Hypothesis 2 and as a dichotomous variable to test Hypothesis 3. Depressive symptoms scores were dichotomized as “0” if women’s depressive symptoms scores were 16 or less, and “1” if their depressive symptoms scores were greater than 16 (Radloff, 1977). Data were analyzed using SPSS, Version 17. Descriptive statistics were used for demographic characteristics and to present frequencies and percentages of depressive symptoms and types of violence. In an effort to find out significant predictors associated with college women’s depressive symptoms, we attempted to identify these predictors from college women’s demographic profile and their experiences of violence (during childhood and adulthood) using multiple regression. Two regression models were included. The first regression model included college women’s demographic characteristics, and the second regression model included demographic characteristics in addition to all types of violence examined in this study. The relationship between the experiences of violence during childhood and adulthood (the independent variables) and college women’s experiences of depressive symptoms (the dependent variable) was examined using logistic regression. Logistic regression is a stringent statistical test that can be used to identify the risk of an outcome (depressive symptoms) as a response to an exposure (violence). Logistic regression necessitates dichotomizing the
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exposure and the outcome variables, which is why we dichotomized depressive symptoms and physical partner violence in this study. An alpha level of .05 was set for the analysis.
Results Ninety-seven college women participated in the study. The age of the participants ranged between 19 and 25 with a mean of 21.1 years (SD = 1.02). By the time of data collection, 66 (68%) females were engaged, and 54 (55.7%) were in the fourth year of college. Their GPA ranged between 1.73 and 3.64 (M = 2.9, SD = 0.43). Table 1 presents detailed information about participants’ characteristics. For the major variables of the study (violence and depressive symptoms), the most common type of violence experienced by college women in childhood was witnessing parental violence, which was experienced by 40 (41.2%) participants followed by psychological violence, which was experienced by 34 (35.1%) participants. During adulthood, 35 (36.1%) college women experienced physical partner violence, and 19 (19.6%) experienced sexual partner violence. Depressive symptoms were evident in 46 (47.4%) participants. Prediction of depressive symptoms using college women’s demographic profile indicated that the first regression model (including age, marital status, income, place of residence, father’s level of education, mother’s level of education, person with whom the student lives, school level, smoking status, and students’ overall GPA as independent variables and the depressive symptom variable as the dependent variable) was significant (F = 2.67, p value = .008). Four of the factors (predictors) were significant in the regression model. These factors were marital status (β = −.23, p value = .03), mother’s level of education (β = −.24, p value = .03), income (β = −.23, p value = .046), and smoking status (β = .22, p value = .04). Other demographic factors were not significant in predicting depressive symptoms in college women. The second regression model including all types of violence in addition to women’s demographic profile as predictors for depressive symptoms was also significant (F = 2.81, p value = .002). In addition to the four significant demographic predictors identified in the first regression model, physical partner violence appeared to be significant in predicting depressive symptoms (β = .31, p value = .01). The change in the variability of depressive symptoms (represented in R2 change value) associated with the run of the two regression models was .41 (p = .002; see Table 2 for more information). Regarding the relationship between experiences of violence (during childhood and in adulthood) and college women’s depressive symptoms, results indicated that no single violence experience in childhood or adulthood was
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Table 1. Demographic Characteristics of the College Women Participated in the Study. Characteristic Marital status Single (planning for engagement) Engaged Place of residence Amman Irbid Zarqa Mafraq Other Class standing First year in college Second year in college Third year in college Fourth year in college Father’s level of education Less than high school High school College Graduate Mother’s level of education Less than high school High school College Graduate Live with . . . Alone Parents Other Income ≤500 JD 501-1,000 JD ≥1,001 JD Smoker Yes No
Frequency (n)
%
30 66
30.9 68.1
32 7 49 3 5
33 7.2 50.5 3.1 5.2
2 17 22 54
2.1 17.5 22.7 55.7
26 25 38 7
26.8 25.8 39.2 7.2
28 24 43 1
28.9 24.7 44.3 1
2
2.1
88 6
90.7 6.2
41 49 6
42.3 50.5 6.2
17 79
17.5 81.4
Note. JD = Jordanian Dinar. aAll p values associated with chi-square were not significant.
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χ2,a 0.39 6.1 2.9 5.56 4.1 5.56 2.74 1.57
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Al-Modallal Table 2. Predictors of Depressive Symptoms in College Women. Model 1 Variables in the Model Age Marital status Place of residence Class standing Father’s education Mother’s education Person living with Income Smoker grade point average (GPA) Childhood physical violence Childhood sexual violence Childhood psychological violence Witnessing parental violence Physical partner violence Sexual partner violence
B
β
−2.65 −3.04 0.99 0.25 −1.17 −2.59 −3.96 −2.54 7.88 −2.50
−0.21 −0.23 .09 .02 −.13 −.24 −.11 −.23 .22 −.09
Model 2 p Value ns .03 ns ns ns .03 ns .046 .04 ns
B
β
p Value
−2.09 −0.17 −3.20 1.34 2.06 .19 0.40 .03 −1.44 −.16 −3.15 −.29 −2.40 −.07 −2.50 −.23 8.73 .24 −0.96 −.04 −7.44 −.24 6.99 .18 2.60 .10
ns .02 ns ns ns .006 ns .047 .02 ns ns ns ns
−3.96 2.27 1.15
ns .01 ns
−.16 .31 .05
Note. Model 1: F(10, 81) = 2.67, p = .008; R2 adjusted = 17.1%. Model 2: F(16, 80) = 2.81, p = .002; R2 adjusted = 27%; R2 change = .41 (p = .002).
significant in increasing the risk of depressive symptoms in women. In addition, no any combination of violence experienced either in childhood or adulthood was significant in the development of depressive symptoms (see Table 3). Finally, women’s experience of any two types of violence (regardless of the time of violence occurrence) was associated with complaints of depressive symptoms. All other types of violence did not provide enough evidence to establish significant association with the increased risk of depressive symptoms (see Table 4 for results of logistic regression examining these associations).
Discussion This study examined the relationship between violence (during childhood and in adulthood) and depressive symptoms in a sample of college women. One result highlighted the effect of physical partner violence in developing depressive symptoms in college women. Also, the study highlighted the
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Table 3. Risk of Depressive Symptoms Associated With Violence. Type of Violence Childhood physical violence Yes No Childhood sexual violence Yes No Childhood psychological violence Yes No Witnessing parental violence Yes No Physical partner violence Yes No Sexual partner violence Yes No Any one type of childhood violence Yes No Any two types of childhood violence Yes No Any three types of childhood violence Yes No Any four types of childhood violence Yes No Any one type of adulthood violence Yes No Any two types of adulthood violence Yes No
Frequency (n)
%
19 77
19.6 79.4
11 85
11.3 87.6
34 62
35.1 63.9
40 56
41.2 57.7
35 58
36.1 59.8
19 78
19.6 80.4
22 74
22.9 77.1
19 77
19.8 80.2
12 84
12.5 87.5
2 94
2.1 97.9
29 64
31.2 68.8
11 82
11.8 88.2
Odds Ratios p Value 0.61
3.32
1.64
1.11
0.99
1.78
1.08
0.32
1.29
1.18
1.08
0.62
.36 .15 .29 .82 .97 .30 .88 .07 .54 .91 .88 1.48
effect of marital status, smoking status, income, and mothers’ level of education in predicting depressive symptoms in young college women. The overall
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Table 4. Risk of Depressive Symptoms Associated With Multiple Experiences of Violence. Type of Violence
Frequency (n)
Any one type of violence Yes No Any two types of violence Yes No Any three types of violence Yes No Any four types of violence Yes No Any five types of violence Yes No Any six types of violence Yes No
22 61
17 66
9 74
8 75
3 80
1 82
%
Odds Ratios
p Value
1.26
.64
3.45
.047*
1.06
.93
0.83
.80
1.72
.66
0.00
1.00
26.5 73.5
20.5 79.5
10.8 89.2
9.6 90.4
3.6 96.4
1.2 98.8
*Significance level
JIVXXX10.1177/0886260515580363Journal of Interpersonal ViolenceAl-Modallal
Article
Depressive Symptoms in College Women: Examining the Cumulative Effect of Childhood and Adulthood Domestic Violence
Journal of Interpersonal Violence 1–21 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260515580363 jiv.sagepub.com
Hanan Al-Modallal, PhD1
Abstract The purpose of this study was to examine the cumulative effect of childhood and adulthood violence on depressive symptoms in a sample of Jordanian college women. Snowball sampling technique was used to recruit the participants. The participants were heterosexual college-aged women between the ages of 18 and 25. The participants were asked about their experiences of childhood violence (including physical violence, sexual violence, psychological violence, and witnessing parental violence), partner violence (including physical partner violence and sexual partner violence), experiences of depressive symptoms, and about other demographic and familial factors as possible predictors for their complaints of depressive symptoms. Multiple linear regression analysis was implemented to identify demographic- and violence-related predictors of their complainants of depressive symptoms. Logistic regression analysis was further performed to identify possible type(s) of violence associated with the increased risk of depressive symptoms. The prevalence of depressive symptoms in this sample was 47.4%. For the violence experience, witnessing parental violence was the most common during childhood, experienced by 40 (41.2%) 1Hashemite
University, Zarqa, Jordan
Corresponding Author: Hanan Al-Modallal, Associate Professor, Department of Community and Mental Health Nursing, College of Nursing, Hashemite University, Zarqa, Jordan. Email: [email protected]
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women, and physical partner violence was the most common in adulthood, experienced by 35 (36.1%) women. Results of logistic regression analysis indicated that experiencing two types of violence (regardless of the time of occurrence) was significant in predicting depressive symptoms (odds ratio [OR] = 3.45, p < .05). Among college women’s demographic characteristics, marital status (single vs. engaged), mothers’ level of education, income, and smoking were significant in predicting depressive symptoms. Assessment of physical violence and depressive symptoms including the cumulative impact of longer periods of violence on depressive symptoms is recommended to be explored in future studies. Keywords college women, depressive symptoms, Jordan, violence
Introduction The purpose of this study was to examine the cumulative effect of domestic violence occurring during childhood and adulthood on Jordanian college women’s experiences of depressive symptoms. College age is a critical time for female college students as their mental health status is vulnerable due to lived situations and demands required in this stage. Depression, anxiety, and suicidal ideation are examples of mental health problems in college years (Amar & Gennaro, 2005; Nilsen, Conner, Murphy, & Blumenthal, 2002). Depression is generally integrated with psychological, social, and familial factors (Orner, Siriwardena, & Dyas, 2004). Considering domestic violence as a social and familial factor associated with psychological outcomes, it is reported that domestic violence is associated with depression (ArboledaFlorez & Wade, 2001; Carlson, McNutt, & Choi, 2003; Nicolaidis, Curry, McFarland, & Gerrity, 2004). Domestic violence experienced during childhood or adulthood has a significant impact on women’s mental health, including the development of depressive symptoms. For example, in a Jordanian study, the odds of depressive symptoms in women increased among victims of intimate partner violence compared with non-victims (adjusted odds ratio [OR] = 3.5, 95% confidence interval [CI] = [1.05, 11.7]; Al-Modallal, Abuidhail, Sowan, & Al-Rawashdeh, 2010).
Background Childhood domestic violence, manifested in different forms such as physical and sexual violence, is influential in altering the health of victims. Physical, social, and psychological outcomes during childhood, adolescence, and adulthood are
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influenced by childhood abuse experiences (Arias, 2004). Social impacts of childhood experiences of violence are exhibited in victims’ use of violence or experiencing violence in adulthood relationships (Haller & Miles, 2003; Stein, Leslie, & Nyamathi, 2002). However, empirical evidence strongly supports the relationship between childhood abuse and experiencing violence in adulthood. Using a nationally representative sample, Desai, Arias, Thompson, and Basile (2002) found that childhood abuse, whether physical or sexual, was associated with victimization of women by their intimate partners. That was congruent with Briere and Elliott’s (2003) findings, which indicated that 188 (39.9%) females reported experiences of adulthood victimization by the partner and that victimization was highly associated with previous experiences of childhood physical and sexual abuse. Furthermore, DiLillo, Giuffre, Tremblay, and Peterson (2001) highlighted the relationship between childhood sexual abuse and physical partner violence. They found that 10% of the women with childhood sexual abuse were beaten by their intimate partners compared with 2% of the women without childhood sexual abuse experience (DiLillo et al., 2001). Such findings imply that the experience of childhood violence could be responsible for conflict in adulthood relationships (Lang, Stein, Kennedy, & Foy, 2004) and thus leads to disrupted healthy adulthood relationships. College women are at risk for violence (Baum & Klaus, 2005; RiveraRivera, Allen, Rodriguez-Ortega, Chavez-Ayala, & Lazcano-Ponce, 2006) similar to the general population of community women (Evans-Campbell, Lindhorst, Huang, & Walters, 2006; Yang, Yang, Chang, Chen, & Ko, 2006). The perpetrator of violence in college women is mainly the dating/intimate partner (Nilsen et al., 2002). Physical and sexual types of violence are the hallmarks of violence exhibited in dating or intimate relationships during college years. Sometimes college women experience one form of violence, and in other cases, they may become victims of more than one form of violence. A longitudinal study following women from high school to the fourth year in college indicated that 88% of the women experienced physical or sexual incidents of dating violence, and 63.5% were victims of both types of violence. The prevalence rates of physical and sexual dating violence were high as well with 77.8% for physical violence and 79.2% for sexual violence (Smith, White, & Holland, 2003). Not only are experiences of violence common in women’s lives, but mental health problems including depressive symptoms are also common in women, including college women (Csoboth, Birkas, & Purebl, 2005). The relationship between different violence experiences and women’s depressive symptoms is significant. Women who experienced any type of violence (e.g., physical, sexual, or psychological) from a dating partner experienced significantly higher
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levels of depressive symptoms compared with non-victims (Amar & Gennaro, 2005). In addition, multiple experiences of violence (e.g., a combination of physical and sexual violence) were associated with greater levels of depressive symptoms. For example, the mean depressive symptoms for women with physical violence only was 0.92 (SD = 0.06), whereas it was 1.34 (SD = 0.09) for women with a combination of physical and sexual violence (Messman-Moore, Long, & Siegfried, 2000). Childhood abuse sequels in terms of psychological impact are neither less important nor less influential than that of adulthood abuse. Examples of such sequels include distress (Lang et al., 2004), substance misuse (Coid et al., 2003), and attempted suicide (Bohn, 2003; Thompson, Kaslow, & Kingree, 2002). In addition, childhood abuse was found highly associated with anxiety (Carlson et al., 2003) and adulthood depressive symptoms (Arboleda-Florez & Wade, 2001; Carlson et al., 2003). Focusing on depressive symptoms, a significant relationship was identified between childhood physical abuse that was measured by the Childhood Trauma Questionnaire (CTQ) and depressive symptoms that were measured by the Center for Epidemiologic Studies– Depression (CES-D) Scale (Lang et al., 2004). In summary, it was reported that depressive symptoms are associated with violence (Arboleda-Florez & Wade, 2001; Carlson et al., 2003; Nicolaidis et al., 2004). Furthermore, there is a strong relationship between the cumulative exposure to violence and occurrence of depressive symptoms and other psychological health problems (Arboleda-Florez & Wade, 2001; Carlson et al., 2003; McCauley et al., 1997). For example, 45% of women experiencing 8 to 14 times lifetime abuse developed depressive symptoms compared with only 8.14% of those who experienced 1 lifetime abuse (Carlson et al., 2003). Finally, it was reported that the increase in the number of violence incidents is associated with an increase in the cumulative impact on depression (Bohn, 2003; Carlson et al., 2003; McGuigan & Middlemiss, 2005) and an increase in the odds of occurrence of depressive symptoms (Nicolaidis et al., 2004).
Purpose of the Study In the literature studying college women, some studies were identified focusing on the relationship between violence (physical and sexual) and depressive symptoms during dating relationships (Amar & Gennaro, 2005; Messman-Moore et al., 2000; Rich, Gidycz, Warkentin, Loh, & Weiland, 2005; Sanders & Moore, 1999). Other studies, on the other hand, were focusing on the relationship between violence perpetrated by strangers and the development of depressive symptoms (Harris & Valentiner, 2002).
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In Jordan, few studies focused on identifying women’s experiences of childhood violence (Al-Badayneh, 2012; Clark, Silverman, Shahrouri, Everson-Rose, & Groce, 2010). Partner violence was addressed in a relatively larger number of studies (Al-Modallal, 2012a; Al-Modallal et al., 2010; Clark, Bloom, Hill, & Silverman, 2009). Furthermore, studies that focused on women’s mental health are on the rise (Al-Modallal, 2010, 2012b; Al-Modallal et al., 2012). Yet, little is known about the cumulative effect of different types of domestic violence, occurring during childhood and adulthood, on depressive symptoms among college women. To our knowledge, no studies were identified exploring this relationship in Jordanian college women. The following hypotheses were tested in this study: Hypothesis 1: Depressive symptoms among Jordanian college women are associated with their personal and familial demographics. Hypothesis 2: Childhood violence and adulthood violence are effective in predicting depressive symptoms in Jordanian college women. Hypothesis 3: Different types of domestic violence occurring during childhood and adulthood have a cumulative effect on the increased risk of depressive symptoms in Jordanian college women; that is, as the number of different types of violence increases, college women report higher risk values of depressive symptoms, accordingly.
Method Procedure Inclusion criteria for the study included female college students at the Hashemite University aged 18 to 25 years. Students had to be enrolled as fulltime students regardless of their field of study. Students had to be engaged to a male partner or have a significant male figure and planning to get engaged to that male partner in the future. This criterion was set because intimate relationships between a male and a female are preferred to be within the milieu of either engagement or arranged engagement in the future. Married college students were excluded from this study because our focus was to examine the relationship between violence and depressive symptoms in college women before the beginning of the marital relationship. Furthermore, this study is considered the first to be conducted on Jordanian college women. A snowball sample was implemented due to expected difficulties in recruiting the participants. An announcement about the study was made in one of the classes by the primary investigator. Female students who showed
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Journal of Interpersonal Violence
interest in the study were asked to complete the study questionnaire either at the end of the class or at the primary investigator’s office. Students who were involved in the study using the snowball sampling method met with the primary investigator in the office where the questionnaire was handed to them and completed accordingly. Attached to the study questionnaire, written information about the study and its purpose was included. Information about voluntariness of participation and confidentiality of given information were stressed. The questionnaire included required data about females’ experiences of childhood violence, partner violence, and depressive symptoms. Information about participants’ demographics was included in the questionnaire as well. Examples of participants’ demographics included age, income, year in college, smoking status, and their grade point average (GPA).
Measures Depressive symptoms. Depressive symptoms are behaviors experienced by non-clinically depressed individuals for an average of 1 week. Depressive symptoms were measured using the CES-D Scale (Radloff, 1977). The major components of depressive symptoms include “depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance” (Radloff, 1977, p. 386). Each of the 20 CES-D Scale items, including the four positively stated items, asks about a behavior or feeling experienced by the individual. The individual is asked to report the frequency of experiencing each of these behaviors in the last 7 days. Responses are scored on a 0 to 3 scale based on the frequency of experiencing each behavior. To prevent response-set bias, the four positively stated items are reverse scored. The total score is calculated by adding the response points of all items. Possible scores range from 0 to 60 with higher scores indicative of higher levels of depressive symptoms. The CES-D was validated in a sample of Jordanian women and revealed a Cronbach’s alpha level of .90 (Al-Modallal, 2010). Physical partner violence. Violence experienced by college students is called “dating violence.” This dating violence is “the term often used to describe adolescent and college student intimate partner violence” (Amar & Gennaro, 2005, p. 235). The Safe Dates–Physical Violence Victimization Scale addresses physical acts inflicted by an abusive intimate partner. Examples of physical violence tactics include “kicked me,” “bent my fingers,” and “tried to choke me.” Each item is rated on a 4-point scale: 0 = never, 1 = 1 to 3 times, 2 = 4 to 9 times, and 3 = 10 or more times (Foshee et al., 1996).
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Cronbach’s alpha in a sample of school adolescents was .92 (Foshee et al., 1996; Thompson, Basile, Hertz, & Sitterle, 2006). Scoring of the scale includes summing the point values of the items. The final scores range between 0 and 48 with greater scores indicative of greater physical violence victimization experienced by the participant. Sexual partner violence. Two questions adopted from the Safe Dates Scale were used to measure sexual partner violence. These questions were as follows: “Forced to have sex” and “Forced to do other sexual things.” The participant who indicated a positive response (yes) to at least one of the two questions was considered a victim of sexual violence. Childhood violence. Four types of childhood violence (physical violence, psychological violence, sexual violence, and witnessing parental violence) inflicted by parents, guardians, or caretakers were investigated in this study. Respondents were asked to report whether they were physically or psychologically abused as children by a parent, guardian, or caretaker. Positive (yes) response to physical violence indicated physical violence victimization, and absence of the experience (no) indicated non-victimization. Similarly, positive response to psychological violence indicated childhood psychological violence victimization, and negative response indicated absence of psychological violence victimization. Coding was either “1” for positive responses or “0” for negative responses, for childhood physical violence and for childhood psychological violence. Sexual violence was assessed by a single item asking women to report whether they were sexually abused during childhood by an adult (relative or non-relative). Responses to this item were coded as “1” for the sexual victimization and “0” for the no victimization history. Finally, college women were asked to report whether they (as children) ever witnessed parental violence. Responses indicating witnessing parental violence were coded as “1,” and “0” otherwise. Witnessing parental violence was included by many researchers with childhood violence/maltreatment (Hornor, 2005; Linder & Collins, 2005; Teicher, Samson, Polcari, & McGreenery, 2006). Similarly, and like other types of childhood violence, witnessing parental violence has influential effects on children’s physical, mental, and developmental health (Hornor, 2005). For this reason, we included witnessing parental violence with participants’ experiences of childhood violence. Demographic variables. A set of demographic data was collected from the participants. All demographic variables were categorical. Demographic characteristics that were included in this study were marital status (single and
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Journal of Interpersonal Violence
married), place of residence (Amman, Irbid, Zarqa, Mafraq, and other), class standing (first through fourth year), father’s level of education (less than high school, high school, college, and graduate), mother’s level of education (less than high school, high school, college, and graduate), the person the college woman is living with (alone, with parents, and other), income (≤500 Jordanian Dinar [JD], 501-1,000 JD, and ≥1,001 JD), and finally smoking status (smoker and non-smoker).
Statistical Analysis Prior to data analysis, distributions of the continuous variables were examined to identify outliers. Based on our hypotheses and types of variables that were collected, some of the variables were re-coded. Physical partner violence was used as a continuous variable to test Hypothesis 2 and as a dichotomous variable to test Hypothesis 3. Scores of the physical violence variable were dichotomized as “0” when the total violence score was 0 and “1” when the total violence score was 1 or greater. Similar coding of “0” and “1” was used for the sexual violence variable. Those who had no sexual violence experience were coded as “0,” and those who experienced sexual violence were coded as “1.” Furthermore, depressive symptoms scores (using the CES-D Scale) were used as a continuous variable to test Hypothesis 2 and as a dichotomous variable to test Hypothesis 3. Depressive symptoms scores were dichotomized as “0” if women’s depressive symptoms scores were 16 or less, and “1” if their depressive symptoms scores were greater than 16 (Radloff, 1977). Data were analyzed using SPSS, Version 17. Descriptive statistics were used for demographic characteristics and to present frequencies and percentages of depressive symptoms and types of violence. In an effort to find out significant predictors associated with college women’s depressive symptoms, we attempted to identify these predictors from college women’s demographic profile and their experiences of violence (during childhood and adulthood) using multiple regression. Two regression models were included. The first regression model included college women’s demographic characteristics, and the second regression model included demographic characteristics in addition to all types of violence examined in this study. The relationship between the experiences of violence during childhood and adulthood (the independent variables) and college women’s experiences of depressive symptoms (the dependent variable) was examined using logistic regression. Logistic regression is a stringent statistical test that can be used to identify the risk of an outcome (depressive symptoms) as a response to an exposure (violence). Logistic regression necessitates dichotomizing the
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exposure and the outcome variables, which is why we dichotomized depressive symptoms and physical partner violence in this study. An alpha level of .05 was set for the analysis.
Results Ninety-seven college women participated in the study. The age of the participants ranged between 19 and 25 with a mean of 21.1 years (SD = 1.02). By the time of data collection, 66 (68%) females were engaged, and 54 (55.7%) were in the fourth year of college. Their GPA ranged between 1.73 and 3.64 (M = 2.9, SD = 0.43). Table 1 presents detailed information about participants’ characteristics. For the major variables of the study (violence and depressive symptoms), the most common type of violence experienced by college women in childhood was witnessing parental violence, which was experienced by 40 (41.2%) participants followed by psychological violence, which was experienced by 34 (35.1%) participants. During adulthood, 35 (36.1%) college women experienced physical partner violence, and 19 (19.6%) experienced sexual partner violence. Depressive symptoms were evident in 46 (47.4%) participants. Prediction of depressive symptoms using college women’s demographic profile indicated that the first regression model (including age, marital status, income, place of residence, father’s level of education, mother’s level of education, person with whom the student lives, school level, smoking status, and students’ overall GPA as independent variables and the depressive symptom variable as the dependent variable) was significant (F = 2.67, p value = .008). Four of the factors (predictors) were significant in the regression model. These factors were marital status (β = −.23, p value = .03), mother’s level of education (β = −.24, p value = .03), income (β = −.23, p value = .046), and smoking status (β = .22, p value = .04). Other demographic factors were not significant in predicting depressive symptoms in college women. The second regression model including all types of violence in addition to women’s demographic profile as predictors for depressive symptoms was also significant (F = 2.81, p value = .002). In addition to the four significant demographic predictors identified in the first regression model, physical partner violence appeared to be significant in predicting depressive symptoms (β = .31, p value = .01). The change in the variability of depressive symptoms (represented in R2 change value) associated with the run of the two regression models was .41 (p = .002; see Table 2 for more information). Regarding the relationship between experiences of violence (during childhood and in adulthood) and college women’s depressive symptoms, results indicated that no single violence experience in childhood or adulthood was
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Table 1. Demographic Characteristics of the College Women Participated in the Study. Characteristic Marital status Single (planning for engagement) Engaged Place of residence Amman Irbid Zarqa Mafraq Other Class standing First year in college Second year in college Third year in college Fourth year in college Father’s level of education Less than high school High school College Graduate Mother’s level of education Less than high school High school College Graduate Live with . . . Alone Parents Other Income ≤500 JD 501-1,000 JD ≥1,001 JD Smoker Yes No
Frequency (n)
%
30 66
30.9 68.1
32 7 49 3 5
33 7.2 50.5 3.1 5.2
2 17 22 54
2.1 17.5 22.7 55.7
26 25 38 7
26.8 25.8 39.2 7.2
28 24 43 1
28.9 24.7 44.3 1
2
2.1
88 6
90.7 6.2
41 49 6
42.3 50.5 6.2
17 79
17.5 81.4
Note. JD = Jordanian Dinar. aAll p values associated with chi-square were not significant.
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χ2,a 0.39 6.1 2.9 5.56 4.1 5.56 2.74 1.57
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Al-Modallal Table 2. Predictors of Depressive Symptoms in College Women. Model 1 Variables in the Model Age Marital status Place of residence Class standing Father’s education Mother’s education Person living with Income Smoker grade point average (GPA) Childhood physical violence Childhood sexual violence Childhood psychological violence Witnessing parental violence Physical partner violence Sexual partner violence
B
β
−2.65 −3.04 0.99 0.25 −1.17 −2.59 −3.96 −2.54 7.88 −2.50
−0.21 −0.23 .09 .02 −.13 −.24 −.11 −.23 .22 −.09
Model 2 p Value ns .03 ns ns ns .03 ns .046 .04 ns
B
β
p Value
−2.09 −0.17 −3.20 1.34 2.06 .19 0.40 .03 −1.44 −.16 −3.15 −.29 −2.40 −.07 −2.50 −.23 8.73 .24 −0.96 −.04 −7.44 −.24 6.99 .18 2.60 .10
ns .02 ns ns ns .006 ns .047 .02 ns ns ns ns
−3.96 2.27 1.15
ns .01 ns
−.16 .31 .05
Note. Model 1: F(10, 81) = 2.67, p = .008; R2 adjusted = 17.1%. Model 2: F(16, 80) = 2.81, p = .002; R2 adjusted = 27%; R2 change = .41 (p = .002).
significant in increasing the risk of depressive symptoms in women. In addition, no any combination of violence experienced either in childhood or adulthood was significant in the development of depressive symptoms (see Table 3). Finally, women’s experience of any two types of violence (regardless of the time of violence occurrence) was associated with complaints of depressive symptoms. All other types of violence did not provide enough evidence to establish significant association with the increased risk of depressive symptoms (see Table 4 for results of logistic regression examining these associations).
Discussion This study examined the relationship between violence (during childhood and in adulthood) and depressive symptoms in a sample of college women. One result highlighted the effect of physical partner violence in developing depressive symptoms in college women. Also, the study highlighted the
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Journal of Interpersonal Violence
Table 3. Risk of Depressive Symptoms Associated With Violence. Type of Violence Childhood physical violence Yes No Childhood sexual violence Yes No Childhood psychological violence Yes No Witnessing parental violence Yes No Physical partner violence Yes No Sexual partner violence Yes No Any one type of childhood violence Yes No Any two types of childhood violence Yes No Any three types of childhood violence Yes No Any four types of childhood violence Yes No Any one type of adulthood violence Yes No Any two types of adulthood violence Yes No
Frequency (n)
%
19 77
19.6 79.4
11 85
11.3 87.6
34 62
35.1 63.9
40 56
41.2 57.7
35 58
36.1 59.8
19 78
19.6 80.4
22 74
22.9 77.1
19 77
19.8 80.2
12 84
12.5 87.5
2 94
2.1 97.9
29 64
31.2 68.8
11 82
11.8 88.2
Odds Ratios p Value 0.61
3.32
1.64
1.11
0.99
1.78
1.08
0.32
1.29
1.18
1.08
0.62
.36 .15 .29 .82 .97 .30 .88 .07 .54 .91 .88 1.48
effect of marital status, smoking status, income, and mothers’ level of education in predicting depressive symptoms in young college women. The overall
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Table 4. Risk of Depressive Symptoms Associated With Multiple Experiences of Violence. Type of Violence
Frequency (n)
Any one type of violence Yes No Any two types of violence Yes No Any three types of violence Yes No Any four types of violence Yes No Any five types of violence Yes No Any six types of violence Yes No
22 61
17 66
9 74
8 75
3 80
1 82
%
Odds Ratios
p Value
1.26
.64
3.45
.047*
1.06
.93
0.83
.80
1.72
.66
0.00
1.00
26.5 73.5
20.5 79.5
10.8 89.2
9.6 90.4
3.6 96.4
1.2 98.8
*Significance level
