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or risk drinking perceive routine inquiry about violence and alcohol consumption in Swedish youth clinics? A qualitative study
Sexual & Reproductive Healthcare 13 (2017) 51–57
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How do youth with experience of violence victimization and/or risk drinking perceive routine inquiry about violence and alcohol consumption in Swedish youth clinics? A qualitative study Anna Palm a,⇑, Ingela Danielsson b, Ulf Högberg a, Karl-Gustav Norbergh c a b c
Department of Women’s and Children’s Health, Uppsala University, SE-751 85 Uppsala, Sweden Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, SE-901 87 Umeå, Sweden Department of Nursing Sciences, Faculty of Human Sciences, Mid Sweden University, SE-851 70 Sundsvall, Sweden
a r t i c l e
i n f o
Article history: Received 6 October 2016 Revised 13 June 2017 Accepted 16 June 2017
a b s t r a c t Objective: To explore perceptions and experiences among youth who underwent structured questions about violence victimization and alcohol consumption when visiting Swedish youth clinics. Methods: This study is part of a larger research project examining the effect of including routine inquiry about violence victimization and alcohol consumption for youth visiting youth clinics. Fifteen youth with experiences of victimization and/or risk drinking (AUDIT-C 5) were interviewed. Content analysis was used. Results: The findings were grouped into three main categories: The first; ‘‘Disclosure – talking about violence” reflected the participants’ experiences of being asked about victimization. Participants were in favor of routine inquiry about violence victimization, even when questions caused distress. The questions helped participants reflect on prior victimization and process what had happened to them. The second; ‘‘Influence on the life situation” demonstrated that many of the participants still were effected by prior victimization, but also how talking about violence sometimes led to the possibility of initiating change such as leaving a destructive relationship or starting therapy. In the third; ‘‘One’s own alcohol consumption in black and white” participants considered it natural to be asked about alcohol consumption. However, most participants did not consider their drinking problematic, even when told they exceeded guidelines. They viewed risk drinking in terms of immediate consequences rather than in quantity or frequency of alcohol intake. Conclusion: Routine inquiry about violence victimization and risk drinking at youth clinics was well received. Questions about violence helped participants to interpret and process prior victimization and sometimes initiated change. Ó 2017 Elsevier B.V. All rights reserved.
Introduction Youth clinics might serve as the pillar for delivering free and accessible health care services to youth [1]. For more than 40 years, almost all Swedish municipalities have operated youth clinics where youth up to the age of 23 can attend for counseling on sexual and reproductive health as well as psychological or physical problems [1]. In recent years, the high rates of violence victimization in youth have gained focus, and the association between victimization and ill health is well documented [2–4]. Youth are also overrepresented in alcohol harm statistics and in the United States and Northern Europe, 18- to 25-year-olds have the highest rates of alcohol consumption. [5]. However, youth rarely seek pro⇑ Corresponding author. E-mail address: [email protected] (A. Palm). http://dx.doi.org/10.1016/j.srhc.2017.06.004 1877-5756/Ó 2017 Elsevier B.V. All rights reserved.
fessional help when victimized, and alcohol drinking is generally hidden from adult society [5–7]. How to incorporate this knowledge into youth-friendly services, such as youth clinics, constitutes a new challenge for health care personnel working with youth. Health care providers are often hesitant to inquire about violence victimization, reporting a lack of training, a fear of offending the patient and time constraints as important barriers [8]. In contrast to these findings, studies have suggested that youth are positive about routine inquiry into violence victimization [9,10]. To date, these studies are scarce and have been conducted using questionnaires with youth [9,10]. Qualitative research addressing victimized youth’s experience of being asked about victimization is lacking. Routine inquiry about alcohol consumption in youth and the effect of brief intervention for those considered being risk drinkers, mainly using motivational interviewing (MI) principles, has been
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examined in several studies [11,12]. The results are mixed: some studies have shown promising results in reducing drinking in youth, whereas a recent Cochrane review found that although there were some significant effects, the effect sizes were too small to be of clinical relevance [13]. However, to our knowledge no qualitative studies have explored how both routine inquiry about alcohol consumption and MI are received by youth with risk drinking. For routine inquiries and intervention strategies to be effective, it is important to understand how they are perceived by the youth they are directed to [14]. The objective of this study was to explore how youth with experiences of violence victimization and/or risk drinking, in this study defined as AUDIT-C 5, perceived undergoing a health dialogue consisting of structured questions about violence and alcohol consumption when visiting Swedish youth clinics. Materials and methods A qualitative approach was used to gain greater knowledge of the youth’s own experiences and feelings during and after the health dialogue and the possible impact on their lives [15]. Since all of the participants had personal experiences of violence victimization and/or risk drinking individual interviews were considered preferable in order to ensure confidentiality. Qualitative inductive content analysis was used to analyze the data [15,16]. Setting and study design In Sweden, most cities have youth clinics staffed by midwives, social workers and physicians. Young women account for about 90% of the visits, probably due to the prescription of contraceptives being the predominant reason for the visits. It is very common for young women in Sweden to attend youth clinics in the Swedish National Public Health Survey 25% of all 16- to 24-year-old women reported having attended a youth clinic in the previous 3 months. In young men the corresponding figure was 5%. The present study is part of a larger research project that includes a randomized controlled intervention study with 1137 (73% participation rate) youth aged 15–22 conducted at four youth clinics in two mid-size towns and two small towns in Sweden in 2012 (ISRCTN40388402) [4]. In addition to the regular visit, the participants in the intervention group underwent a health dialogue with structured questions about lifetime violence victimization modeled on the NorVold Abuse Questionnaire [17] and alcohol consumption using AUDIT-C [18]. Participants who had been victimized were offered further contact and those with risk drinking were offered motivational interviewing.
In a three-month follow-up questionnaire, the participants were asked for consent to be contacted for an interview by one of the researchers. In response, 50% of the participants consented to be contacted and 50% declined. Inclusion criteria and participants Purposeful sampling was used. Inclusion criteria for the participants was being in the health dialogue intervention group, having lifetime experience of violence victimization and/or risk drinking, i.e. scoring 5 at AUDIT-C at the time of the health dialogue, and being 18 years or older. Of those who volunteered to be interviewed, 22 youth met the criteria. Six of these did not respond when contacted and one had moved abroad, leaving 15 youth who completed the interview. Of the 15 youth participating, 13 were victims of violence and eight had risk drinking behavior; six of the participants were both victimized and risk drinkers. Two were male and 13 were female. They were between 18 and 22 years of age. Eight attended or had attended an academic program in high school and seven a vocational program. Three of the participants had been or were presently enrolled in university studies. Ethics An ethical review by an ethics review board is mandatory in Sweden when a research method is used that is aimed at influencing research participants physically or psychologically. When youth are involved in research the ethical concerns are of course even more important. There is a risk that researchers may cause feelings of distress when asking questions about violence victimization. However, it is also momentous for society to gain knowledge to use in finding the best way of offering support and intervening. So far there is a lack of data on youths’ experiences of participating in research entailing routine inquiry about violence victimization. Oral information concerning the study aim, voluntary participation and confidentiality was given to the participants, and a time and a place for the interview were planned. Oral consent was obtained and participants were assured that all information would be kept confidential in accordance with research ethics, and that they could end the interview at any time and without explanation. All participants were also informed that prompt counseling was available after the interviews if needed. At the participating youth clinics, action plans were established on how to handle victimized youth and youth with alcohol risk drinking as well as addressing safety issues if needed. The study was approved by the Regional Ethical Review Board in Umeå (D.nr. 2011-110-31Ö).
Table 1 Domains, categories and subcategories. Domains
Categories
Subcategories
Experience of a health dialogue about violence victimization
Disclosure – to talk about violence
Important to ask about violence victimization Questions about violence victimization raised mixed feelings and sometimes no feelings The health dialogue made the victimization visible To have left the victimization behind
Experience of a health dialogue about alcohol risk drinking
Influence on the life situation
The long-time impact of violence The health dialogue as a start of reflection and change Insight of one’s own ability to handle difficult situations
One’s own alcohol consumption in black and white
Questions about alcohol was natural and sometimes led to reflection and change Normalisation Insight on group pressure and expectations
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Data collection The interviews took place 4–5 months after the health dialogue. Eleven of the informants chose to do the interview at their youth clinics and five informants via the telephone. To encourage the participants to narrate their experiences freely the interviews started with an open question: ‘‘Could you please tell me about how it was to have had a health dialogue?” When needed open-ended questions drawn from a semi-structured interview guide, was used in order to assure that the research questions were covered Reflective listening were used to further probe the participants’ perceptions and experiences. The interviewer (AP) was a 43-year-old ethnic Swede who had long experience working with youth as a physician at youth health clinics. The interviews were audiotaped with the participants’ consent and lasted between 20 and 40 min. They were transcribed verbatim by the interviewer, with pauses and expressed emotions noted in the transcript. A pilot study with three interviews was conducted in December 2012 and included in the material. Data analysis Qualitative inductive content analysis is a stepwise process of categorization based on the expressions of feelings, thoughts and actions throughout the text. Using manifest and latent analysis, the surface structure as well as the deep structural meaning of the transcribed interviews emerged [16]. First, the transcribed material was read separately several times by AP, KN and ID, in order to obtain a comprehensive picture of the data. The text was then sorted into two domains that were found in the data: ‘‘Experience of health dialogue about alcohol” and ‘‘Experience of health dialogue about violence victimization.” The text was thereafter reread and divided into meaning units and condensed by the first author (AP) and shared with the other authors [16]. The material was then coded into subcategories, and the subcategories were organized in relation to categories. AP, KN and ID discussed the coding and formation of categories until consensus was reached. In the final step, all authors discussed the preliminary categories and subcategories in order to ensure that the data had trustworthiness and also reflected the selected categories [16]. Results The findings are grouped into the two domains themes of ‘‘Experience of a health dialogue about violence victimization” and ‘‘Experience of a health dialogue about alcohol risk drinking.” Table 1. Experience of a health dialogue about violence victimization This domain contains two main categories, ‘‘Disclosure – talking about violence” and ‘‘Influence on the life situation,” as well as seven subcategories.
Disclosure – talking about violence It is important to ask about violence victimization Most of the participants had never been asked questions about violence victimization by any professionals – for example, health care personnel or teachers – before the health dialogue. Many had only talked about their experience of violence with peers and some had never told anyone before the health dialogue. One young woman said:
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‘‘The health dialogue was the first time I told any, any grownup, about the rape” The participants were in favor of routine inquiry at youth clinics about victimization and considered it a good opportunity for youth to be offered subsequent counseling if needed. Participants thought that if the personnel at the youth clinics initiated the dialogue about victimization, it would make it easier for the youth to talk about their experiences. Participants also referred to the youth clinic personnel’s commitment to confidentiality as an important factor in facilitating disclosure. A young woman with experience of bullying at school said: I think, and almost know for sure, that there are many who don’t dare to open up and ask for help. Instead, many keep things to themselves – stuff that has happened – and don’t dare to trust a grownup. . . . So I think that it would be a great idea to offer everyone a health dialogue. (Participant 1) Although participants were positive about routine inquiry about violence, some raised the concern that youth with experience of victimization might find it uncomfortable to be asked, especially if they had not processed the victimization. However, they did not consider this a reason to refrain from asking about violence. One participant said: I have already processed my experiences . . . but there are many [individuals] who have very difficult experiences, and if you haven’t had time to process it, then it can be hard to bring up. . . . I think it is good to ask, if there is a follow-up for those who want help. (Participant 12) Questions about violence victimization raised mixed feelings Participants responded differently to the questions about violence victimization. Some thought that questions about victimization brought back memories that were hard to face. At the same time, they believed it was important to talk about the victimization and that it was good to tell someone about it. It was, it was a little hard to get questions about violence . . . because you were reminded of it. . . . I think it is good, though, because you still want someone to know. (Participant 3) Other participants described a feeling of relief after they had talked about the victimization. It was important that somebody had listened and acknowledged what had happened. Participants also said it was good to talk to someone professional who did not know them personally. I remember it was a relief. Really. . . . And I appreciated the talk [the health dialogue] because I think it feels good to talk things through with someone who is impartial. (Participant 6) The health dialogue made the victimization visible For some participants, it was not until they were asked questions about violence victimization in the health dialogue that they conceptualized their experience as actually being an experience of violence. Maybe because when you write it down on a paper, or when you answer questions, you realize that it’s something you yourself didn’t think even counted as violence, but then you say it, then you realize that, yes, but it actually was [violence]. (Participant 6) A reason for participants doubting whether an incident counted as violence was the absence of physical violence. Being able to verbalize the experience of victimization in order to understand what had happened was helpful. Participants also expressed that it was
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important that the midwife/social worker confirmed their experience. One young woman reported: I hadn’t been exactly raped . . . there wasn’t any actual direct physical violence . . . it was more a kind of coercive sex or whatever you call it. . . . It actually made me think, that part about the sex; I hadn’t really thought about it before. It was something that surfaced during the health dialogue, so that was really very good. (Participant 11)
The victimization had been left behind Participants also described their experience of violence victimization as something they had recovered from and left behind. They viewed the support from friends and sometimes parents as essential for their ability to put the victimization behind them. Participants who had received professional help described divergent experiences, both as a helpful factor and as an unimportant factor in their healing process. A young woman who had been sexually abused expressed how she already had put the victimization behind her at the time of the health dialogue: Because it happened quite a while ago and I have processed it so much, I don’t feel any need to talk about it anymore. I’ve had very good help from parents and from friends and from my boyfriend and at the psychiatric clinic and then the counselor there. (Participant 9)
Influence on the life situation The long-time impact of violence Some participants reported that the victimization still affected their daily life. A young man who had been bullied most of his elementary school years explained: Of course it has affected me [the bullying] . . . it is a part of it [the reason for the visit to the social worker], you could say that, more than anything else. (Participant 8) Participants described how the questions about violence victimization in the health dialogue had sometimes made them realize how much they were still affected by the victimization. A young woman with experience of an abusive relationship said: It [the prior victimization] affects me. I was surprised at how much it really affects me, because when you sit there and have the health dialogue and then think about all the answers, then you realize . . . it actually affects me a lot in my daily life, although I didn’t think about it [before the health dialogue]. (Participant 2) The participants who described lasting emotional distress after victimization often reported reduced trust in others. They described how they had difficulties in forming new friendships and relationships, as illustrated by a young man who was bullied in school: For example, I haven’t been able, I’ve realized that I can’t handle to be in a relationship, because it’s kind of, I can’t, like, let anyone close. (Participant 8)
affected them. Many of the participants described positive changes in their lives since the health dialogue. They attributed the change both to the health dialogue and/or subsequent therapy and to external conditions outside of therapy. A common description of change was attributed to altered thinking patterns. A young woman commented on how it had made her more able to handle current problems in her life: It is a big difference [since the time of the health dialogue], much better. I received a lot of help from the social worker; she helped me to prioritize, prioritize what made me most upset at the moment and how to solve that. To change my mind frame, kind of. (Participant 12) The altered thinking pattern was also described as a change in thoughts about the prior victimization. A young woman with experience of domestic violence said: What was good for me about the health dialogue was that I realized how badly that person had hurt me. I hadn’t realized that before . . . I thought it was normal. . . . I thought it was my fault that it happened, but now I thought once more and then . . . well, I’ve been able to let go, it feels like I’ve almost forgiven that person, and I think that it wasn’t my fault at all. (Participant 3) Other participants described how they had made changes in their lives – for example: I’ve completely broken with my ex-boyfriend, and I actually ended that relationship after doing that health dialogue. (Participant 2) Participants who visited the youth clinics for unrelated matters such as prescription of contraceptives described how the health dialogue sometimes worked as a door opener for further counseling. A 19-year-old woman with experience of domestic violence stated: You could say that the health dialogue roused was a wake-up call. . . . I felt that it was time to deal with it; I had to talk to someone because otherwise, otherwise it will never be ok. . . . So I have started to see a social worker at the youth clinic. (Participant 7)
Insight into the ability to handle difficult situations Participants described how the victimization, in addition to causing emotional distress, had made them stronger. Participants said that they did not view themselves as victims. Rather, they chose to see the victimization as a learning experience leading to personal growth. Participants described how they had been able to take a disempowering situation and convert it into an empowering event, finding meaning in the experience. As one participant said, It made me feel very bad at the time . . . but it’s more like I have actually gotten stronger from the experience. (Participant 13)
Experience of a health dialogue about alcohol risk drinking One participant referred to alcohol being connected to the victimization and how this had caused her to change her drinking habits: I’ve started to think about in which situations I drink alcohol. . . . I drink much less . . . I don’t get drunk anymore. . . . I want to be in control of the situation. (Participant 10)
The health dialogue as a start of reflection and change Participants stated that the health dialogue made them reflect more on their experience of violence and how it might have
This domain contains one main category, ‘‘One’s own alcohol consumption in black and white,” and three subcategories. One’s own alcohol consumption in black and white Questions about alcohol were natural and sometimes led to reflection and change Participants considered youth clinics as a natural place to inquire about alcohol consumption and referred to questions about
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alcohol as potentially beneficial for individuals who might be at significant risk of drinking too much. The participants reacted in different ways when the midwife/social worker told them that their alcohol consumption was considered to be risk drinking. Mostly participants did not consider themselves as being risk drinkers, even if they were told that they exceeded current drinking guidelines. However, questions about alcohol in the health dialogue made them reflect on their alcohol consumption. One young woman described her response to the inquiry: It was kind of, you kind of got it black on white when you answered the questions . . . and you got in writing like . . .well, how much one actually drinks . . . and well, it was like, damn, I drink quite a lot. (Participant 1) Most participants did not change their drinking because of the health dialogue, whereas some reported a reduction in their consumption – for example, one participant said: Really, I have become more aware now, and it [my drinking] has actually changed a little . . . it has changed to be more positive in that I kind of started to, well, drink less. (Participant 2) Participants also reported that the health dialogue with the midwife/social worker had made them discuss their alcohol consumption with friends. However, after discussing it with friends, they usually came to the conclusion that their own drinking was not a problem. One young woman explained: I discussed it with my sister and girlfriends. . . . We are aware that people view us as having risky drinking behavior . . . but we feel it is our three [university] years now. (Participant 9)
Normalization Participants invariably referred to alcohol drinking as a social thing, a way of spending time with friends. Risk drinkers had different explanations as to why their alcohol consumption was not problematic. They generally considered their drinking as being a temporary phenomenon such as being a student. They clearly stated that they would not drink in this way when they graduated or started a family and hence did not consider their current drinking as a health risk, as the following comment demonstrates: I know how much I drink and that that is considered to be a lot . . . but it is during a period. . . . Alcohol consumption depends a lot on the surroundings you live in. Later, when I have an education and start working, then I won’t have those surroundings anymore. (Participant 9) Participants were aware of the possible negative effects of alcohol but did generally not see themselves as being at risk. Clear distinctions were made between participants’ personal use of alcohol and that of ‘‘others” whom they considered to be at risk because of risk drinking. For example, one participant reported: Well, I realized that she [the midwife] was right, but at the same time I didn’t really take note of it, you see . . . because I’m the best judge to decide that it isn’t anything to worry about. (Participant 4) Participants also perceived the ability to function and behave well as an affirmation of their alcohol consumption not being problematic. Participants defined a risk drinker according to a person’s behavior rather than to the quantity or frequency of alcohol consumption. Participants considered themselves and their friends
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as being responsible and able to handle alcohol, in contrast to those who could not, clearly referred to as ‘‘others.” As one participant stated, For us who can handle alcohol, there are no problems. (Participant 14)
Insight on peer pressure and expectations Participants reported that although there was no overt peer pressure to drink alcohol, they often felt the expectations to drink. A person who did not drink at a party was generally questioned and sometimes looked upon as boring or an outsider. Especially within the university setting, drinking was described as normative and expected, and many of the social encounters evolved around alcohol. One participant commented: It is hard to say no . . . if you come along and don’t drink, you are considered to be kind of boring. . . . The few people who did not drink, they always went home early. Nobody wanted them to come, and you kind of stopped asking them . . . they became outsiders. (Participant 4) In addition, the participants who studied at university spoke about alcohol as an important facilitator in meeting people and forming closer relationships. One participant said: At the same time, I would not have wanted not to drink because I know that I wouldn’t have had such a good three years of student life then. . . . It is how you make contacts and get to know people. (Participant 9) Some participants described difficulties in not drinking since they considered that it was expected, whereas others did not think there would be any pressure to drink if somebody chose not to. Participants referred to the importance of being ‘‘on the same level” as others when at a party or in a bar. That included not being sober, but equally important was to not become too intoxicated, which was also considered as ruining the fun for others. Among the participants who thought they would disappoint their friends by not drinking, some applied strategies in order to avoid drinking without being noticed. One young woman explained that driving was a legitimate reason for not drinking: So instead we say that it’s ok, we can drive, and we drive them to the party. (Participant 5)
Discussion This qualitative study adds to the research field by including the voices of the youth. The participants were in favor of personnel at youth clinics asking about violence victimization as well as alcohol consumption. They highlighted that the midwives/social workers’ commitment to confidentiality was an important factor for disclosure and also stressed follow-up for youth who wanted this. Most of the participants in this study had never told a professional about their victimization before the health dialogue, and some of them had never told anyone. Not talking about upsetting events appears to be a health risk, theoretically because holding back or inhibiting oneself about an emotional topic is a stressor [19]. Some studies on young people have shown that disclosure of victimization is likely to improve physical and psychological outcomes [19–21]. Among health personnel, concern has been raised about the potential harm in asking youth who have been victimized about violence, for fear of opening a Pandora’s box [8]. Participants in this study were clearly in favor of being asked about victimization, even when the questions caused distress. This finding could
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contribute to health care professionals feeling encouraged to ask youth about violence victimization. One possible pathway of improved health after disclosure might be the promotion of a ‘‘sense of coherence” as formulated by Antonovsky [22]. The sense of coherence is a way of reflecting a person’s view of life and capacity to respond to stressful situations including three components: comprehensibility, manageability and meaningfulness [22]. High sense of coherence in an individual is strongly related to better perceived health [23]. Participants described how the routine inquiry about violence led them to address prior victimization and helped them realize how the victimization still affected them. Some participants explained that it was not until they were asked questions about violence victimization that they realized that what had happened to them actually constituted violence. The difficulty for youth to sometimes determine what counts as violence has been described in earlier research [6]. In the present study, participants described how the health dialogue with the midwife/social worker was a factor in understanding their experience of violence, which in turn helped them create meaning and move on. These findings could be interpreted in the terms of what Antonovsky referred to as creating comprehensibility and meaningfulness [22]. Many of the participants in this study experienced changes after the health dialogue. Several attributed these changes to the help they received at the youth clinic in terms of subsequently receiving therapy, learning skills to deal with stress and to alter thinking patterns, and having help in changing destructive behaviors and relationships – what Antonovsky referred to as manageability [22]. Some participants attributed changes to other external factors unrelated to the visits to the youth clinic. An interesting finding was how participants did not view themselves as victims. Instead, they referred to themselves not only as having survived the violence, but also as being more capable and empathic than before the victimization; they turned a traumatic event into one of meaning. Prior research in adults has demonstrated that dealing with trauma can produce positive changes, described as posttraumatic growth, but this has been little studied in youth [24]. Some participants explained that they had already processed and recovered from the victimization at the time of the health dialogue. This report is in line with prior research demonstrating that many individuals who have faced trauma withstand and heal without developing psychological problems [25]. In this study, participants who had processed their victimization invariably referred to the support from friends and sometimes parents and health professionals as essential in their coping. This finding is also in line with earlier research describing social support as a factor in resilience in victimized youth [25,26]. Being influenced by alcohol often coincides with being exposed to violence [27]. However, in this study, only one participant related the victimization to being influenced by alcohol. This finding may be due to the majority of participants being young women. In young women the link between alcohol drinking at the time of violence victimization does not seem to be as evident as for young men [28]. It may also be due to the participants with risk drinking, as found in the study, generally not considering their drinking as problematic and hence not making a connection between drinking and victimization. The participants with risk drinking generally downplayed their own drinking as possibly harmful. They used different ways to normalize risk drinking, such as referring to their present drinking as a temporary phenomenon of being a student. Earlier studies have demonstrated that youth do not perceive unit-based alcohol drinking guidelines to be useful [29,30]. They find it difficult to translate their drinking into units and also do not find unit-based guidelines adequate in determining whether or not drinking habits are prob-
lematic. Instead, young people generally look at the consequences of drinking alcohol, such as becoming too drunk and missing classes or sports practice, as indicators for the drinking being harmful [29,31], as is also reported in this study. However, the participants also reported that the health dialogue made them reflect on their drinking, and for some this reflection led to a reduction in their alcohol consumption. Others talked to friends about their alcohol consumption being considered risk drinking. Several studies have concluded that youth’s drinking behaviors are strongly influenced by their peers [29,31]. In this study, the participants invariably referred to drinking as a social activity. Even if most participants did not admit to any overt peer pressure, several of them referred to an expectation of drinking at parties and other social events. Some of the participants employed strategies such as driving in order to have a legitimate excuse not to drink. Methodological discussion In qualitative research, the trustworthiness of the data in terms of credibility, dependability and transferability is the main criterion of quality [32]. The credibility of this study was enhanced by using an interview guide and having the same person conduct all the interviews. Research bias may have been unintentionally communicated to the participants, but we believe that the interviewer’s awareness and experience of working with youth allowed the participants to talk freely about their experiences. Dependability was enhanced through the detailed description of how the analysis was performed and illustrated with quotations in the text. Transferability was promoted by being careful in describing both typical and atypical views expressed by the participants. Several of the findings were consistent with previous studies, which further strengthen the transferability. Only two of the participants were young men, reflecting the dominance of young women as visitors at youth clinics. Even though no apparent differences in perceptions of the health dialogue between young men and young women were detected in this study the low number of participating men may of course have influenced results. It is also possible that participants who agreed to participate in an interview in general viewed the health dialogue conducted at the youth clinics more positively than those who declined to participate. At the time of the health dialogue all victimized youth were offered further counseling. Some of the participants in this study had accepted this offer and started therapy after the health dialogue which may have altered their experience of the health dialogue in retrospect. Conclusion Routine inquiry about violence victimization gives youth a chance to disclose victimization, and even if they are not prepared to disclose at the time, they will know where to turn should they need support later. It is also an opportunity for health personnel to acknowledge the youth’s experience and to direct adequate support and treatment. In this study routine enquiry about violence victimization and risk drinking at youth clinics was well received by the study participants. Questions about violence helped them interpret and process prior victimization, which led to the possibility of initiating change such as leaving a destructive relationship or starting therapy. Participants viewed risk drinking in terms of consequences rather than in quantity or frequency of alcohol, and did not find unit-based drinking guidelines useful when addressing risk drinking. It may be more successful to ask youth about possible problematic behaviors when drinking and about health and
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socioeconomic problems in general, instead of only using alcohol consumption-based questions when designing screening and prevention strategies at youth-friendly services. Funding This work was supported by the Swedish Crime Victim Compensation and Support Authority; and the Research and Development Department, Västernorrland County Council, Sweden. References [1] Goicolea I, Christianson M, Hurtig AK, Marchal B, San Sebastian M, Wiklund M. Searching for best practices of youth friendly services - a study protocol using qualitative comparative analysis in Sweden. BMC Health Serv Res 2016;16:321. PubMed PMID: 27473421. Pubmed Central PMCID: PMC4966742. Epub 2016/07/31. eng.. [2] Pinheiro PS. World Report on Violence against Children - Unicef. World Health Organization; 2006. [3] Finkelhor D, Ormrod R, Turner H, Hamby SL. The victimization of children and youth: a comprehensive, national survey. Child Maltreatment 2005 Feb;10 (1):5–25. PubMed PMID: 15611323. [4] Palm A, Danielsson I, Skalkidou A, Olofsson N, Hogberg U. Violence victimisation-a watershed for young women’s mental and physical health. Eur J Pub Health 2016 Jan 7. PubMed PMID: 26743590. [5] World Health organization. Global status report on alcohol and health 2014; 2014. [6] Crisma M, Bascelli E, Paci D, Romito P. Adolescents who experienced sexual abuse: fears, needs and impediments to disclosure. Child Abuse Negl 2004;28 (10):1035–48. PubMed PMID: 15519434. Epub 2004/11/03. eng. [7] Priebe G, Svedin CG. Child sexual abuse is largely hidden from the adult society. An epidemiological study of adolescents’ disclosures. Child Abuse Negl 2008;32(12):1095–108. PubMed PMID: 19038448. [8] Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325(7359):314. Aug 10, PubMed PMID: 12169509. Pubmed Central PMCID: 117773. [9] Rickert VI, Davison LL, Breitbart V, Jones K, Palmetto NP, Rottenberg L, et al. A randomized trial of screening for relationship violence in young women. J Adolescent Health: Off Pub Soc Adolescent Med 2009 Aug;45(2):163–70. PubMed PMID: 19628143. [10] Zeitler MS, Paine AD, Breitbart V, Rickert VI, Olson C, Stevens L, et al. Attitudes about intimate partner violence screening among an ethnically diverse sample of young women. J Adolescent Health: Off Publ Soc Adolescent Med 2006;39 (1):119 e1–8. PubMed PMID: 16781970. Epub 2006/06/20. eng. [11] Monti PM, Barnett NP, Colby SM, Gwaltney CJ, Spirito A, Rohsenow DJ, et al. Motivational interviewing versus feedback only in emergency care for young adult problem drinking. Addiction 2007;102(8):1234–43. PubMed PMID: 17565560. [12] Cunningham RM, Chermack ST, Zimmerman MA, Shope JT, Bingham CR, Blow FC, et al. Brief motivational interviewing intervention for peer violence and alcohol use in teens: one-year follow-up. Pediatrics 2012;129(6):1083–90. PubMed PMID: 22614776. Pubmed Central PMCID: 4074654.
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[13] Foxcroft DR, Coombes L, Wood S, Allen D, Almeida Santimano NM. Motivational interviewing for alcohol misuse in young adults. The Cochrane database of systematic reviews, vol. 8; 2014, CD007025. [14] Barbour RS. The role of qualitative research in broadening the ’evidence base’ for clinical practice. J Eval Clin Pract 2000 May;6(2):155–63. PubMed PMID: 10970009. [15] Patton MQ. Qualitative research & evaluation methods. 3rd ed. London: Sage Publications; 2002. [16] Krippendorff K. Content analysis - an introduction to its methodology. 3rd ed.: SAGE Publications, Inc.; 2012. [17] Swahnberg IM, Wijma B. The NorVold Abuse Questionnaire (NorAQ): validation of new measures of emotional, physical, and sexual abuse, and abuse in the health care system among women. Eur J Public Health 2003;13 (4):361–6. [18] Dawson D, Grant B, Stinson F, Zhou Y. Effectiveness of the derived alcohol use disorders identification test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res 2005;2005 (29):844–54. [19] Pennebaker JW, Susman JR. Disclosure of traumas and psychosomatic processes. Soc Sci Med 1988;26(3):327–32. PubMed PMID: 3279521. [20] Arata C. To tell or not to tell: current functioning of child sexual abuse survivors who disclosed their victimization. Child Maltreat 1998;3(1):63–71. [21] Graham-Bermann SA, Kulkarni MR, Kanukollu SN. Is disclosure therapeutic for children following exposure to traumatic violence? J Interpersonal Violence 2011;26(5):1056–76. PubMed PMID: 20448228. [22] Antonovsky A. Unravelling the mysteries of health. San Francisco: Jossey-Bass; 1988. [23] Simonsson B, Nilsson KW, Leppert J, Diwan VK. Psychosomatic complaints and sense of coherence among adolescents in a county in Sweden: a crosssectional school survey. BioPsychoSocial Med 2008;2:4. PubMed PMID: 18261203. Pubmed Central PMCID: 2265297. [24] Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. J Trauma Stress 1996;9(3):455–71. PubMed PMID: 8827649. [25] Masten AS. Ordinary magic. Resilience processes in development. Am Psychol 2001;56(3):227–38. PubMed PMID: 11315249. [26] Tremblay C, Hebert M, Piche C. Coping strategies and social support as mediators of consequences in child sexual abuse victims. Child Abuse Negl 1999 Sep;23(9):929–45. PubMed PMID: 10505906. [27] Svensson J, Landberg J. Is youth violence temporally related to alcohol? A timeseries analysis of binge drinking, youth violence and total alcohol consumption in Sweden. Alcohol Alcoholism 2013;48(5):598–604. [28] Ellonen N, Aaltonen M. Association between drinking and victimisation among Finnish adolescents: estimating the extent of the spurious effect. Nordic Stud Alcohol Drugs 2012;29:125–38. [29] de Visser RO, Wheeler Z, Abraham C, Smith JA. ’Drinking is our modern way of bonding’: young people’s beliefs about interventions to encourage moderate drinking. Psychol Health 2013;28(12):1460–80. PubMed PMID: 23947783. [30] Strunin L. Assessing alcohol consumption: developments from qualitative research methods. Soc Sci Med 2001 Jul;53(2):215–26. PubMed PMID: 11414388. [31] Frederiksen NJ, Bakke SL, Dalum P. ‘‘No alcohol, no party”: an explorative study of young Danish moderate drinkers. Scand J Public Health 2012;40(7):585–90. PubMed PMID: 23027894. [32] Polit DFBCT. Nursing research: principles and methods. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
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Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
How do youth with experience of violence victimization and/or risk drinking perceive routine inquiry about violence and alcohol consumption in Swedish youth clinics? A qualitative study Anna Palm a,⇑, Ingela Danielsson b, Ulf Högberg a, Karl-Gustav Norbergh c a b c
Department of Women’s and Children’s Health, Uppsala University, SE-751 85 Uppsala, Sweden Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, SE-901 87 Umeå, Sweden Department of Nursing Sciences, Faculty of Human Sciences, Mid Sweden University, SE-851 70 Sundsvall, Sweden
a r t i c l e
i n f o
Article history: Received 6 October 2016 Revised 13 June 2017 Accepted 16 June 2017
a b s t r a c t Objective: To explore perceptions and experiences among youth who underwent structured questions about violence victimization and alcohol consumption when visiting Swedish youth clinics. Methods: This study is part of a larger research project examining the effect of including routine inquiry about violence victimization and alcohol consumption for youth visiting youth clinics. Fifteen youth with experiences of victimization and/or risk drinking (AUDIT-C 5) were interviewed. Content analysis was used. Results: The findings were grouped into three main categories: The first; ‘‘Disclosure – talking about violence” reflected the participants’ experiences of being asked about victimization. Participants were in favor of routine inquiry about violence victimization, even when questions caused distress. The questions helped participants reflect on prior victimization and process what had happened to them. The second; ‘‘Influence on the life situation” demonstrated that many of the participants still were effected by prior victimization, but also how talking about violence sometimes led to the possibility of initiating change such as leaving a destructive relationship or starting therapy. In the third; ‘‘One’s own alcohol consumption in black and white” participants considered it natural to be asked about alcohol consumption. However, most participants did not consider their drinking problematic, even when told they exceeded guidelines. They viewed risk drinking in terms of immediate consequences rather than in quantity or frequency of alcohol intake. Conclusion: Routine inquiry about violence victimization and risk drinking at youth clinics was well received. Questions about violence helped participants to interpret and process prior victimization and sometimes initiated change. Ó 2017 Elsevier B.V. All rights reserved.
Introduction Youth clinics might serve as the pillar for delivering free and accessible health care services to youth [1]. For more than 40 years, almost all Swedish municipalities have operated youth clinics where youth up to the age of 23 can attend for counseling on sexual and reproductive health as well as psychological or physical problems [1]. In recent years, the high rates of violence victimization in youth have gained focus, and the association between victimization and ill health is well documented [2–4]. Youth are also overrepresented in alcohol harm statistics and in the United States and Northern Europe, 18- to 25-year-olds have the highest rates of alcohol consumption. [5]. However, youth rarely seek pro⇑ Corresponding author. E-mail address: [email protected] (A. Palm). http://dx.doi.org/10.1016/j.srhc.2017.06.004 1877-5756/Ó 2017 Elsevier B.V. All rights reserved.
fessional help when victimized, and alcohol drinking is generally hidden from adult society [5–7]. How to incorporate this knowledge into youth-friendly services, such as youth clinics, constitutes a new challenge for health care personnel working with youth. Health care providers are often hesitant to inquire about violence victimization, reporting a lack of training, a fear of offending the patient and time constraints as important barriers [8]. In contrast to these findings, studies have suggested that youth are positive about routine inquiry into violence victimization [9,10]. To date, these studies are scarce and have been conducted using questionnaires with youth [9,10]. Qualitative research addressing victimized youth’s experience of being asked about victimization is lacking. Routine inquiry about alcohol consumption in youth and the effect of brief intervention for those considered being risk drinkers, mainly using motivational interviewing (MI) principles, has been
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examined in several studies [11,12]. The results are mixed: some studies have shown promising results in reducing drinking in youth, whereas a recent Cochrane review found that although there were some significant effects, the effect sizes were too small to be of clinical relevance [13]. However, to our knowledge no qualitative studies have explored how both routine inquiry about alcohol consumption and MI are received by youth with risk drinking. For routine inquiries and intervention strategies to be effective, it is important to understand how they are perceived by the youth they are directed to [14]. The objective of this study was to explore how youth with experiences of violence victimization and/or risk drinking, in this study defined as AUDIT-C 5, perceived undergoing a health dialogue consisting of structured questions about violence and alcohol consumption when visiting Swedish youth clinics. Materials and methods A qualitative approach was used to gain greater knowledge of the youth’s own experiences and feelings during and after the health dialogue and the possible impact on their lives [15]. Since all of the participants had personal experiences of violence victimization and/or risk drinking individual interviews were considered preferable in order to ensure confidentiality. Qualitative inductive content analysis was used to analyze the data [15,16]. Setting and study design In Sweden, most cities have youth clinics staffed by midwives, social workers and physicians. Young women account for about 90% of the visits, probably due to the prescription of contraceptives being the predominant reason for the visits. It is very common for young women in Sweden to attend youth clinics in the Swedish National Public Health Survey 25% of all 16- to 24-year-old women reported having attended a youth clinic in the previous 3 months. In young men the corresponding figure was 5%. The present study is part of a larger research project that includes a randomized controlled intervention study with 1137 (73% participation rate) youth aged 15–22 conducted at four youth clinics in two mid-size towns and two small towns in Sweden in 2012 (ISRCTN40388402) [4]. In addition to the regular visit, the participants in the intervention group underwent a health dialogue with structured questions about lifetime violence victimization modeled on the NorVold Abuse Questionnaire [17] and alcohol consumption using AUDIT-C [18]. Participants who had been victimized were offered further contact and those with risk drinking were offered motivational interviewing.
In a three-month follow-up questionnaire, the participants were asked for consent to be contacted for an interview by one of the researchers. In response, 50% of the participants consented to be contacted and 50% declined. Inclusion criteria and participants Purposeful sampling was used. Inclusion criteria for the participants was being in the health dialogue intervention group, having lifetime experience of violence victimization and/or risk drinking, i.e. scoring 5 at AUDIT-C at the time of the health dialogue, and being 18 years or older. Of those who volunteered to be interviewed, 22 youth met the criteria. Six of these did not respond when contacted and one had moved abroad, leaving 15 youth who completed the interview. Of the 15 youth participating, 13 were victims of violence and eight had risk drinking behavior; six of the participants were both victimized and risk drinkers. Two were male and 13 were female. They were between 18 and 22 years of age. Eight attended or had attended an academic program in high school and seven a vocational program. Three of the participants had been or were presently enrolled in university studies. Ethics An ethical review by an ethics review board is mandatory in Sweden when a research method is used that is aimed at influencing research participants physically or psychologically. When youth are involved in research the ethical concerns are of course even more important. There is a risk that researchers may cause feelings of distress when asking questions about violence victimization. However, it is also momentous for society to gain knowledge to use in finding the best way of offering support and intervening. So far there is a lack of data on youths’ experiences of participating in research entailing routine inquiry about violence victimization. Oral information concerning the study aim, voluntary participation and confidentiality was given to the participants, and a time and a place for the interview were planned. Oral consent was obtained and participants were assured that all information would be kept confidential in accordance with research ethics, and that they could end the interview at any time and without explanation. All participants were also informed that prompt counseling was available after the interviews if needed. At the participating youth clinics, action plans were established on how to handle victimized youth and youth with alcohol risk drinking as well as addressing safety issues if needed. The study was approved by the Regional Ethical Review Board in Umeå (D.nr. 2011-110-31Ö).
Table 1 Domains, categories and subcategories. Domains
Categories
Subcategories
Experience of a health dialogue about violence victimization
Disclosure – to talk about violence
Important to ask about violence victimization Questions about violence victimization raised mixed feelings and sometimes no feelings The health dialogue made the victimization visible To have left the victimization behind
Experience of a health dialogue about alcohol risk drinking
Influence on the life situation
The long-time impact of violence The health dialogue as a start of reflection and change Insight of one’s own ability to handle difficult situations
One’s own alcohol consumption in black and white
Questions about alcohol was natural and sometimes led to reflection and change Normalisation Insight on group pressure and expectations
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Data collection The interviews took place 4–5 months after the health dialogue. Eleven of the informants chose to do the interview at their youth clinics and five informants via the telephone. To encourage the participants to narrate their experiences freely the interviews started with an open question: ‘‘Could you please tell me about how it was to have had a health dialogue?” When needed open-ended questions drawn from a semi-structured interview guide, was used in order to assure that the research questions were covered Reflective listening were used to further probe the participants’ perceptions and experiences. The interviewer (AP) was a 43-year-old ethnic Swede who had long experience working with youth as a physician at youth health clinics. The interviews were audiotaped with the participants’ consent and lasted between 20 and 40 min. They were transcribed verbatim by the interviewer, with pauses and expressed emotions noted in the transcript. A pilot study with three interviews was conducted in December 2012 and included in the material. Data analysis Qualitative inductive content analysis is a stepwise process of categorization based on the expressions of feelings, thoughts and actions throughout the text. Using manifest and latent analysis, the surface structure as well as the deep structural meaning of the transcribed interviews emerged [16]. First, the transcribed material was read separately several times by AP, KN and ID, in order to obtain a comprehensive picture of the data. The text was then sorted into two domains that were found in the data: ‘‘Experience of health dialogue about alcohol” and ‘‘Experience of health dialogue about violence victimization.” The text was thereafter reread and divided into meaning units and condensed by the first author (AP) and shared with the other authors [16]. The material was then coded into subcategories, and the subcategories were organized in relation to categories. AP, KN and ID discussed the coding and formation of categories until consensus was reached. In the final step, all authors discussed the preliminary categories and subcategories in order to ensure that the data had trustworthiness and also reflected the selected categories [16]. Results The findings are grouped into the two domains themes of ‘‘Experience of a health dialogue about violence victimization” and ‘‘Experience of a health dialogue about alcohol risk drinking.” Table 1. Experience of a health dialogue about violence victimization This domain contains two main categories, ‘‘Disclosure – talking about violence” and ‘‘Influence on the life situation,” as well as seven subcategories.
Disclosure – talking about violence It is important to ask about violence victimization Most of the participants had never been asked questions about violence victimization by any professionals – for example, health care personnel or teachers – before the health dialogue. Many had only talked about their experience of violence with peers and some had never told anyone before the health dialogue. One young woman said:
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‘‘The health dialogue was the first time I told any, any grownup, about the rape” The participants were in favor of routine inquiry at youth clinics about victimization and considered it a good opportunity for youth to be offered subsequent counseling if needed. Participants thought that if the personnel at the youth clinics initiated the dialogue about victimization, it would make it easier for the youth to talk about their experiences. Participants also referred to the youth clinic personnel’s commitment to confidentiality as an important factor in facilitating disclosure. A young woman with experience of bullying at school said: I think, and almost know for sure, that there are many who don’t dare to open up and ask for help. Instead, many keep things to themselves – stuff that has happened – and don’t dare to trust a grownup. . . . So I think that it would be a great idea to offer everyone a health dialogue. (Participant 1) Although participants were positive about routine inquiry about violence, some raised the concern that youth with experience of victimization might find it uncomfortable to be asked, especially if they had not processed the victimization. However, they did not consider this a reason to refrain from asking about violence. One participant said: I have already processed my experiences . . . but there are many [individuals] who have very difficult experiences, and if you haven’t had time to process it, then it can be hard to bring up. . . . I think it is good to ask, if there is a follow-up for those who want help. (Participant 12) Questions about violence victimization raised mixed feelings Participants responded differently to the questions about violence victimization. Some thought that questions about victimization brought back memories that were hard to face. At the same time, they believed it was important to talk about the victimization and that it was good to tell someone about it. It was, it was a little hard to get questions about violence . . . because you were reminded of it. . . . I think it is good, though, because you still want someone to know. (Participant 3) Other participants described a feeling of relief after they had talked about the victimization. It was important that somebody had listened and acknowledged what had happened. Participants also said it was good to talk to someone professional who did not know them personally. I remember it was a relief. Really. . . . And I appreciated the talk [the health dialogue] because I think it feels good to talk things through with someone who is impartial. (Participant 6) The health dialogue made the victimization visible For some participants, it was not until they were asked questions about violence victimization in the health dialogue that they conceptualized their experience as actually being an experience of violence. Maybe because when you write it down on a paper, or when you answer questions, you realize that it’s something you yourself didn’t think even counted as violence, but then you say it, then you realize that, yes, but it actually was [violence]. (Participant 6) A reason for participants doubting whether an incident counted as violence was the absence of physical violence. Being able to verbalize the experience of victimization in order to understand what had happened was helpful. Participants also expressed that it was
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important that the midwife/social worker confirmed their experience. One young woman reported: I hadn’t been exactly raped . . . there wasn’t any actual direct physical violence . . . it was more a kind of coercive sex or whatever you call it. . . . It actually made me think, that part about the sex; I hadn’t really thought about it before. It was something that surfaced during the health dialogue, so that was really very good. (Participant 11)
The victimization had been left behind Participants also described their experience of violence victimization as something they had recovered from and left behind. They viewed the support from friends and sometimes parents as essential for their ability to put the victimization behind them. Participants who had received professional help described divergent experiences, both as a helpful factor and as an unimportant factor in their healing process. A young woman who had been sexually abused expressed how she already had put the victimization behind her at the time of the health dialogue: Because it happened quite a while ago and I have processed it so much, I don’t feel any need to talk about it anymore. I’ve had very good help from parents and from friends and from my boyfriend and at the psychiatric clinic and then the counselor there. (Participant 9)
Influence on the life situation The long-time impact of violence Some participants reported that the victimization still affected their daily life. A young man who had been bullied most of his elementary school years explained: Of course it has affected me [the bullying] . . . it is a part of it [the reason for the visit to the social worker], you could say that, more than anything else. (Participant 8) Participants described how the questions about violence victimization in the health dialogue had sometimes made them realize how much they were still affected by the victimization. A young woman with experience of an abusive relationship said: It [the prior victimization] affects me. I was surprised at how much it really affects me, because when you sit there and have the health dialogue and then think about all the answers, then you realize . . . it actually affects me a lot in my daily life, although I didn’t think about it [before the health dialogue]. (Participant 2) The participants who described lasting emotional distress after victimization often reported reduced trust in others. They described how they had difficulties in forming new friendships and relationships, as illustrated by a young man who was bullied in school: For example, I haven’t been able, I’ve realized that I can’t handle to be in a relationship, because it’s kind of, I can’t, like, let anyone close. (Participant 8)
affected them. Many of the participants described positive changes in their lives since the health dialogue. They attributed the change both to the health dialogue and/or subsequent therapy and to external conditions outside of therapy. A common description of change was attributed to altered thinking patterns. A young woman commented on how it had made her more able to handle current problems in her life: It is a big difference [since the time of the health dialogue], much better. I received a lot of help from the social worker; she helped me to prioritize, prioritize what made me most upset at the moment and how to solve that. To change my mind frame, kind of. (Participant 12) The altered thinking pattern was also described as a change in thoughts about the prior victimization. A young woman with experience of domestic violence said: What was good for me about the health dialogue was that I realized how badly that person had hurt me. I hadn’t realized that before . . . I thought it was normal. . . . I thought it was my fault that it happened, but now I thought once more and then . . . well, I’ve been able to let go, it feels like I’ve almost forgiven that person, and I think that it wasn’t my fault at all. (Participant 3) Other participants described how they had made changes in their lives – for example: I’ve completely broken with my ex-boyfriend, and I actually ended that relationship after doing that health dialogue. (Participant 2) Participants who visited the youth clinics for unrelated matters such as prescription of contraceptives described how the health dialogue sometimes worked as a door opener for further counseling. A 19-year-old woman with experience of domestic violence stated: You could say that the health dialogue roused was a wake-up call. . . . I felt that it was time to deal with it; I had to talk to someone because otherwise, otherwise it will never be ok. . . . So I have started to see a social worker at the youth clinic. (Participant 7)
Insight into the ability to handle difficult situations Participants described how the victimization, in addition to causing emotional distress, had made them stronger. Participants said that they did not view themselves as victims. Rather, they chose to see the victimization as a learning experience leading to personal growth. Participants described how they had been able to take a disempowering situation and convert it into an empowering event, finding meaning in the experience. As one participant said, It made me feel very bad at the time . . . but it’s more like I have actually gotten stronger from the experience. (Participant 13)
Experience of a health dialogue about alcohol risk drinking One participant referred to alcohol being connected to the victimization and how this had caused her to change her drinking habits: I’ve started to think about in which situations I drink alcohol. . . . I drink much less . . . I don’t get drunk anymore. . . . I want to be in control of the situation. (Participant 10)
The health dialogue as a start of reflection and change Participants stated that the health dialogue made them reflect more on their experience of violence and how it might have
This domain contains one main category, ‘‘One’s own alcohol consumption in black and white,” and three subcategories. One’s own alcohol consumption in black and white Questions about alcohol were natural and sometimes led to reflection and change Participants considered youth clinics as a natural place to inquire about alcohol consumption and referred to questions about
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alcohol as potentially beneficial for individuals who might be at significant risk of drinking too much. The participants reacted in different ways when the midwife/social worker told them that their alcohol consumption was considered to be risk drinking. Mostly participants did not consider themselves as being risk drinkers, even if they were told that they exceeded current drinking guidelines. However, questions about alcohol in the health dialogue made them reflect on their alcohol consumption. One young woman described her response to the inquiry: It was kind of, you kind of got it black on white when you answered the questions . . . and you got in writing like . . .well, how much one actually drinks . . . and well, it was like, damn, I drink quite a lot. (Participant 1) Most participants did not change their drinking because of the health dialogue, whereas some reported a reduction in their consumption – for example, one participant said: Really, I have become more aware now, and it [my drinking] has actually changed a little . . . it has changed to be more positive in that I kind of started to, well, drink less. (Participant 2) Participants also reported that the health dialogue with the midwife/social worker had made them discuss their alcohol consumption with friends. However, after discussing it with friends, they usually came to the conclusion that their own drinking was not a problem. One young woman explained: I discussed it with my sister and girlfriends. . . . We are aware that people view us as having risky drinking behavior . . . but we feel it is our three [university] years now. (Participant 9)
Normalization Participants invariably referred to alcohol drinking as a social thing, a way of spending time with friends. Risk drinkers had different explanations as to why their alcohol consumption was not problematic. They generally considered their drinking as being a temporary phenomenon such as being a student. They clearly stated that they would not drink in this way when they graduated or started a family and hence did not consider their current drinking as a health risk, as the following comment demonstrates: I know how much I drink and that that is considered to be a lot . . . but it is during a period. . . . Alcohol consumption depends a lot on the surroundings you live in. Later, when I have an education and start working, then I won’t have those surroundings anymore. (Participant 9) Participants were aware of the possible negative effects of alcohol but did generally not see themselves as being at risk. Clear distinctions were made between participants’ personal use of alcohol and that of ‘‘others” whom they considered to be at risk because of risk drinking. For example, one participant reported: Well, I realized that she [the midwife] was right, but at the same time I didn’t really take note of it, you see . . . because I’m the best judge to decide that it isn’t anything to worry about. (Participant 4) Participants also perceived the ability to function and behave well as an affirmation of their alcohol consumption not being problematic. Participants defined a risk drinker according to a person’s behavior rather than to the quantity or frequency of alcohol consumption. Participants considered themselves and their friends
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as being responsible and able to handle alcohol, in contrast to those who could not, clearly referred to as ‘‘others.” As one participant stated, For us who can handle alcohol, there are no problems. (Participant 14)
Insight on peer pressure and expectations Participants reported that although there was no overt peer pressure to drink alcohol, they often felt the expectations to drink. A person who did not drink at a party was generally questioned and sometimes looked upon as boring or an outsider. Especially within the university setting, drinking was described as normative and expected, and many of the social encounters evolved around alcohol. One participant commented: It is hard to say no . . . if you come along and don’t drink, you are considered to be kind of boring. . . . The few people who did not drink, they always went home early. Nobody wanted them to come, and you kind of stopped asking them . . . they became outsiders. (Participant 4) In addition, the participants who studied at university spoke about alcohol as an important facilitator in meeting people and forming closer relationships. One participant said: At the same time, I would not have wanted not to drink because I know that I wouldn’t have had such a good three years of student life then. . . . It is how you make contacts and get to know people. (Participant 9) Some participants described difficulties in not drinking since they considered that it was expected, whereas others did not think there would be any pressure to drink if somebody chose not to. Participants referred to the importance of being ‘‘on the same level” as others when at a party or in a bar. That included not being sober, but equally important was to not become too intoxicated, which was also considered as ruining the fun for others. Among the participants who thought they would disappoint their friends by not drinking, some applied strategies in order to avoid drinking without being noticed. One young woman explained that driving was a legitimate reason for not drinking: So instead we say that it’s ok, we can drive, and we drive them to the party. (Participant 5)
Discussion This qualitative study adds to the research field by including the voices of the youth. The participants were in favor of personnel at youth clinics asking about violence victimization as well as alcohol consumption. They highlighted that the midwives/social workers’ commitment to confidentiality was an important factor for disclosure and also stressed follow-up for youth who wanted this. Most of the participants in this study had never told a professional about their victimization before the health dialogue, and some of them had never told anyone. Not talking about upsetting events appears to be a health risk, theoretically because holding back or inhibiting oneself about an emotional topic is a stressor [19]. Some studies on young people have shown that disclosure of victimization is likely to improve physical and psychological outcomes [19–21]. Among health personnel, concern has been raised about the potential harm in asking youth who have been victimized about violence, for fear of opening a Pandora’s box [8]. Participants in this study were clearly in favor of being asked about victimization, even when the questions caused distress. This finding could
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contribute to health care professionals feeling encouraged to ask youth about violence victimization. One possible pathway of improved health after disclosure might be the promotion of a ‘‘sense of coherence” as formulated by Antonovsky [22]. The sense of coherence is a way of reflecting a person’s view of life and capacity to respond to stressful situations including three components: comprehensibility, manageability and meaningfulness [22]. High sense of coherence in an individual is strongly related to better perceived health [23]. Participants described how the routine inquiry about violence led them to address prior victimization and helped them realize how the victimization still affected them. Some participants explained that it was not until they were asked questions about violence victimization that they realized that what had happened to them actually constituted violence. The difficulty for youth to sometimes determine what counts as violence has been described in earlier research [6]. In the present study, participants described how the health dialogue with the midwife/social worker was a factor in understanding their experience of violence, which in turn helped them create meaning and move on. These findings could be interpreted in the terms of what Antonovsky referred to as creating comprehensibility and meaningfulness [22]. Many of the participants in this study experienced changes after the health dialogue. Several attributed these changes to the help they received at the youth clinic in terms of subsequently receiving therapy, learning skills to deal with stress and to alter thinking patterns, and having help in changing destructive behaviors and relationships – what Antonovsky referred to as manageability [22]. Some participants attributed changes to other external factors unrelated to the visits to the youth clinic. An interesting finding was how participants did not view themselves as victims. Instead, they referred to themselves not only as having survived the violence, but also as being more capable and empathic than before the victimization; they turned a traumatic event into one of meaning. Prior research in adults has demonstrated that dealing with trauma can produce positive changes, described as posttraumatic growth, but this has been little studied in youth [24]. Some participants explained that they had already processed and recovered from the victimization at the time of the health dialogue. This report is in line with prior research demonstrating that many individuals who have faced trauma withstand and heal without developing psychological problems [25]. In this study, participants who had processed their victimization invariably referred to the support from friends and sometimes parents and health professionals as essential in their coping. This finding is also in line with earlier research describing social support as a factor in resilience in victimized youth [25,26]. Being influenced by alcohol often coincides with being exposed to violence [27]. However, in this study, only one participant related the victimization to being influenced by alcohol. This finding may be due to the majority of participants being young women. In young women the link between alcohol drinking at the time of violence victimization does not seem to be as evident as for young men [28]. It may also be due to the participants with risk drinking, as found in the study, generally not considering their drinking as problematic and hence not making a connection between drinking and victimization. The participants with risk drinking generally downplayed their own drinking as possibly harmful. They used different ways to normalize risk drinking, such as referring to their present drinking as a temporary phenomenon of being a student. Earlier studies have demonstrated that youth do not perceive unit-based alcohol drinking guidelines to be useful [29,30]. They find it difficult to translate their drinking into units and also do not find unit-based guidelines adequate in determining whether or not drinking habits are prob-
lematic. Instead, young people generally look at the consequences of drinking alcohol, such as becoming too drunk and missing classes or sports practice, as indicators for the drinking being harmful [29,31], as is also reported in this study. However, the participants also reported that the health dialogue made them reflect on their drinking, and for some this reflection led to a reduction in their alcohol consumption. Others talked to friends about their alcohol consumption being considered risk drinking. Several studies have concluded that youth’s drinking behaviors are strongly influenced by their peers [29,31]. In this study, the participants invariably referred to drinking as a social activity. Even if most participants did not admit to any overt peer pressure, several of them referred to an expectation of drinking at parties and other social events. Some of the participants employed strategies such as driving in order to have a legitimate excuse not to drink. Methodological discussion In qualitative research, the trustworthiness of the data in terms of credibility, dependability and transferability is the main criterion of quality [32]. The credibility of this study was enhanced by using an interview guide and having the same person conduct all the interviews. Research bias may have been unintentionally communicated to the participants, but we believe that the interviewer’s awareness and experience of working with youth allowed the participants to talk freely about their experiences. Dependability was enhanced through the detailed description of how the analysis was performed and illustrated with quotations in the text. Transferability was promoted by being careful in describing both typical and atypical views expressed by the participants. Several of the findings were consistent with previous studies, which further strengthen the transferability. Only two of the participants were young men, reflecting the dominance of young women as visitors at youth clinics. Even though no apparent differences in perceptions of the health dialogue between young men and young women were detected in this study the low number of participating men may of course have influenced results. It is also possible that participants who agreed to participate in an interview in general viewed the health dialogue conducted at the youth clinics more positively than those who declined to participate. At the time of the health dialogue all victimized youth were offered further counseling. Some of the participants in this study had accepted this offer and started therapy after the health dialogue which may have altered their experience of the health dialogue in retrospect. Conclusion Routine inquiry about violence victimization gives youth a chance to disclose victimization, and even if they are not prepared to disclose at the time, they will know where to turn should they need support later. It is also an opportunity for health personnel to acknowledge the youth’s experience and to direct adequate support and treatment. In this study routine enquiry about violence victimization and risk drinking at youth clinics was well received by the study participants. Questions about violence helped them interpret and process prior victimization, which led to the possibility of initiating change such as leaving a destructive relationship or starting therapy. Participants viewed risk drinking in terms of consequences rather than in quantity or frequency of alcohol, and did not find unit-based drinking guidelines useful when addressing risk drinking. It may be more successful to ask youth about possible problematic behaviors when drinking and about health and
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