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Prevalence and correlates of physical abuse in Hong Kong Chinese adolescents: a population-based approach
Child Abuse & Neglect, Vol. 23, No. 6, pp. 549 –557, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0145-2134/99/$–see front matter
Pergamon
PII S0145-2134(99)00029-0
PREVALENCE AND CORRELATES OF PHYSICAL ABUSE IN HONG KONG CHINESE ADOLESCENTS: A POPULATION-BASED APPROACH JOSEPH TF LAU, JOSEPH LY LIU,
AND
JACKY CK CHEUNG
Center for Clinical Trials and Epidemiological Research, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
AARON YU Department of Pediatrics, Pamela Youde Nethersole Eastern Hospital, Hong Kong Island, Hong Kong
CK WONG Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
ABSTRACT Objective: The objectives were to estimate the prevalence and correlates of physical abuse-related outcomes in the family setting in Hong Kong’s adolescent population. Method: A cross-sectional study design was used. A randomly selected sample of 3,355 secondary school students in Kwai Tsing District of Hong Kong was surveyed. The response rate was 98%. Results: The prevalence rates of corporal punishment, being beaten by parents for no apparent reason, being beaten to injury by family members in the past 3 months and any one of the above three were 4.9% (95% CI, 4.2% to 5.6%), 2.0% (95% CI, 1.5% to 2.5%), 1.1% (95% CI, .98% to 1.2%) and 6.6% (95% CI, 5.7% to 7.5%), respectively. Students who had experienced the above physical abuse-related outcomes were at a significant disadvantage for a wide range of morbidity indicators, including self-perceived bad health, anxiety and stress, somatic illnesses (such as asthma and epigastric pain), injuries and accidents, and hospitalization. They were more likely to have poor familial relations and coping skills, and to take up habits which potentially put their health at risk, such as smoking, alcohol consumption, and fighting with others. Conclusions: Our prevalence estimates of physical abuse in the family setting for a student population in Hong Kong is an improvement over previous local estimates of physical abuse occurrence, which were mainly based on case notifications and clinical samples. The results also show that the abused adolescents are growing up in an environment filled with physical, psychological, and familial adversities. © 1999 Elsevier Science Ltd Key Words—Physical abuse, Adolescents, Prevalence, Risk factors, Hong Kong.
INTRODUCTION PREVIOUS STUDIES HAVE shown that in Hong Kong, child abuse tends to occur at a later age in childhood than in the West (Lieh-Mak, Chung, & Liu, 1983). In Chinese societies, infants are
Received for publication May 27, 1998; final revision received May 27, 1998; accepted October 15, 1998. Requests for reprints should be sent to Dr. Joseph Tak-fai Lau, Center for Clinical Trials and Epidemiological Research, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong. 549
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treated with attention and loving care, but this gives way to strict discipline (and thus the risk of abuse) after the age of 4 or 5 to ensure filial piety (Tang & Davis, 1996). The extent to which abuse continues in adolescence has not been a widely explored issue, in both Asian and Western contexts. One exception is a study of the experience of 375 university students in Hong Kong by Tang (1996), which estimated the prevalence of respondents who had experienced minor and severe physical violence from parents in the past year. However, Tang’s figures were based on a selected sample of university students, which could not be generalized to a larger community. According to a Medline search, a population-based estimate of the prevalence of physical abuse in Hong Kong children had not previously been published. The small number of published community-based studies on the prevalence and correlates of child abuse is explained by methodological and logistical difficulties in carrying out such studies (Basharov, 1981; Bertolli, Morgenstern, & Sorenson, 1995; MacMillan, Fleming, Trocme, Boyle, Wong, Racine, Beardslee, & Offord, 1997). MATERIALS AND METHODS Background to Study Kwai Tsing, one of Hong Kong’s 18 geographical districts and located in the Northwest New Territories, is the territory’s most important manufacturing and commercial shipping district, with a residential population of 471,000 (Hong Kong Government, 1996). Previous epidemiological studies have been carried out in Kwai Tsing; they focused on somatic conditions in its preadolescent children (Ong, Liu, Wong, Lam, Tam, Daniel, & Hedley, 1991; Peters, Hedley, Wong, Lam, Ong, Liu, & Spiegelhalter, 1996). A general population-based health needs assessment study of adolescent secondary school students in Kwai Tsing carried out by the authors included questions about respondents’ experience with corporal punishment and indicators of being physically abused by parents and family members in the past 3 months. The results are reported here. Study Population and Data Collection Methods The study consisted of a cross-sectional survey of students from 12 randomly selected secondary schools in Kwai Tsing District, using self-administered structured questionnaires. Secondary schools in Hong Kong cover the equivalent of grades seven through 12 in junior-high and high schools in America. Hong Kong has a compulsory 9-year education policy, which means that all children are required by law to attain a junior high-school level education. Eighty-five percent of students who complete junior high school continue their education in high school (Hong Kong Government, 1997). The questionnaires were completed in class in the presence of a trained survey administrator, who was available to answer in a standard manner queries from students concerning the interpretation and meaning of questionnaire items. Students were encouraged to be honest in their responses and were assured that absolute confidentiality would be maintained. The students were asked whether they had: 1. Received corporal punishment from their parents in the past 3 months; 2. Been beaten by their parents for no apparent reason in the past 3 months; 3. Been beaten to injury by family members in the past 3 months. In addition, questions were asked about the students’ sociodemographic background (e.g., sex and age, type of living quarters, and father’s occupation and educational attainment), health-related behaviors (cigarette smoking, alcohol consumption, and fighting with others in the past 3 months), health status (whether respondents had experienced various illnesses in the past 3 months, whether they had stayed in the hospital in the past 3 months, and whether they agreed with the statement
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“Your health status is very bad”), anxiety and stress, ability to cope with everyday problems, and familial relationships. For the last three types of questions, students were presented with statements indicative of stress, coping ability (e.g., “suicide is a way to solve problems”) or familial relations and asked whether these statements accurately depicted their situation or state of mind. The broad-ranging scope of this inquiry provided us with an opportunity to assess in detail the prevalences and correlates of physical abuse-related outcomes in Kwai Tsing adolescents. The study sample consisted of 3,355 13- to 19-year-old students. The response rate was 98%. Data Analysis Initially, the prevalence rates of physically abused students in sociodemographic and other subgroups were compared using chi-square tests and odds ratio estimates. The odds ratio is defined as the ratio of the odds of experiencing an outcome (e.g., corporal punishment) when exposed to a factor of interest (e.g., students having a father with primary level education or less) to the odds of experiencing the outcome when not exposed (in this example, having a father with better education). An odds ratio of greater than one indicates that a higher proportion of students with poorly educated fathers are inflicted with corporal punishment. An odds ratio of one indicates that there is no difference between the two educational subgroups. An odds ratio of less than one indicates that a lower proportion of students with poorly educated fathers have experienced corporal punishment than students with better educated ones. Logistic regression was used to standardize odds ratio estimates for potentially important confounding effects, such as age and sex (see Fleiss, 1981 for a discussion of the odds ratio and Hosmer and Lemeshow, 1989 for a detailed treatment of the logistic regression model). All analyses were carried out using SPSS for Windows Version 7.5. RESULTS Physical Abuse and Sociodemographic Factors The study sample had slightly more boys than girls (51.5% vs. 48.5%) and had an age distribution as follows: 32.8% were 14 years old or below, 24.5% were 15, 18.9% 16, and 23.7% 17 or above. The prevalence rates of corporal punishment, being beaten by parents for no apparent reason and being beaten to injury in the past 3 months were 4.9% (95% CI, 4.2% to 5.6%), 2.0% (95% CI, 1.5% to 2.5%) and 1.1% (95% CI, .98% to 1.2%), respectively (Table 1). The prevalence of students who had experienced any of the three physical abuse-related outcomes was 6.6% (95% CI, 5.7% to 7.5%). Corporal punishment was found to be significantly associated with age—the younger the respondents the more likely they had received corporal punishment from their parents (Table 1). A similar pattern was observed between age and being beaten by parents for no apparent reason, but the association was not statistically significant. Fifteen- and 16-year-olds were significantly more likely to have been beaten to injury by family members than students aged 17 and above. Girls were marginally significantly (p , .10) more likely than boys to have been beaten by parents for no apparent reason. Socioeconomic factors (father’s educational attainment, father’s occupation, birth place, and type of living quarters) were found not to be associated with any of the three physical abuse-related outcomes (results not shown). Physical Abuse and Health-Related Behavior Generally speaking, students who consumed alcohol, smoked cigarettes, and got into fights were significantly more likely to have experienced all three physical abuse-related outcomes (Table 2).
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J. TF Lau, J. LY Liu, J. CK Cheung, A. Yu, and CK Wong Table 1. Physical Abuse Indicators by Demographic Factors
Overall Prevalence Socio-demographic Factors Age group 14 years or below 15 years 16 years 17 years or above Sex Male Female
Corporal Punishment by Parents in Past 3 Months
Beaten by Parents for no Apparent Reason in Past 3 Months
%
%
Odds Ratio
4.9
Odds Ratio
2.0
Beaten to Injury by Family Members in Past 3 Months %
Odds Ratio
1.1
9.1 3.8 3.1 1.6
6.27*** 2.45** 2.02# 1.00
2.4 2.1 1.5 1.6
1.57 ns 1.37 ns 0.94 ns 1.00
0.9 1.8 1.5 0.3
3.61 ns 6.83* 5.73* 1.00
5.4 4.3
1.29 ns
1.5 2.4
0.62#
1.1 1.1
1.00 ns
*** p , 0.001; ** p , 0.01; * p , 0.05;
#
p , 0.10; ns, not significant.
For alcohol consumption and fighting with others, there was a clear-cut dose-response relationship with being beaten to injury—the more frequently they consumed alcohol or fought, the more likely they were to have experienced being beaten to injury by family members. Physical Abuse and Health Status/Hospitalization Students who had experienced the three physical abuse-related outcomes were generally more likely to have suffered from somatic conditions or accidents and to perceive their health status to be very bad (Table 3). Many of these comparisons were statistically significant. Those who had
Table 2. Physical Abuse Indicators by Health-Related Behaviora Corporal Punishment by Parents in Past 3 Months
Health-Related Behavior Drank alcohol in past 3 months? no rarely sometimes always Smoked cigarettes in past 3 months? no rare sometimes always Fought with others in past 3 months? no rare sometimes always a
Beaten by Parents for no Apparent Reason in Past 3 Months
Beaten to Injury by Family Members in Past 3 Months
%
Odds Ratio
%
Odds Ratio
%
Odds Ratio
4.3 5.7 6.9 7.6
1.00 1.39 ns 2.01** 2.14 ns
1.5 2.5 3.8 6.1
1.00 1.55 ns 2.70** 5.00**
0.5 2.3 2.3 4.5
1.00 3.92** 4.61*** 8.78**
4.3 10.8 7.5 9.2
1.00 2.92*** 1.73 ns 2.94**
1.7 3.2 6.5 3.4
1.00 1.79 ns 4.42*** 2.51 ns
0.7 3.2 7.5 3.4
1.00 4.96** 11.00*** 5.17*
3.3 9.4 15.1 10.0
1.00 2.62*** 4.60*** 2.88#
1.2 3.8 8.9 5.0
1.00 3.98*** 9.65*** 5.67*
0.5 2.5 5.0 7.5
1.00 5.81*** 10.04*** 17.81***
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
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Table 3. Physical Abuse Indicators by Health Status Indicesa Corporal Punishment by Parents in Past 3 Months
Illness or Hospitalization in the Past Three Months Asthma Epigastric pain Anxiety Insomnia Dizziness Headache Common cold/influenza/cough Fall Burn/cut/other accidents Stayed in hospital Self-perceived Health Status Your health status is very bad
Beaten by Parents for no Apparent Reason in Past 3 Months
Beaten to Injury by Family Members in Past 3 Months
Yes (%)
No (%)
Odds Ratio
Yes (%)
No (%)
Odds Ratio
Yes (%)
No (%)
Odds Ratio
8.7 18.6 14.3 12.4 17.4 17.4 60.2 34.8 18.6 6.2
3.6 17.5 13.8 11.5 14.0 19.2 55.0 24.2 11.4 2.7
2.25** 1.33 ns 1.51# 1.26 ns 1.54# 1.13 ns 1.35# 1.64** 1.79** 2.59*
6.1 37.9 22.7 18.2 34.8 42.4 60.6 39.4 25.8 1.6
3.8 17.1 13.7 11.4 13.8 18.6 55.1 24.4 11.4 2.9
1.79 ns 3.13*** 2.01* 1.86 ns 3.54*** 3.34*** 1.39 ns 2.41*** 3.00*** 0.60 ns
8.3 30.6 27.8 30.6 36.1 38.9 80.6 58.3 33.3 6.3
3.8 17.4 13.7 11.3 14.0 18.8 55.0 24.4 11.5 2.8
2.49 ns 2.24* 2.78** 3.50*** 3.52*** 3.04** 3.82** 4.78*** 3.89*** 2.33 ns
11.3
6.7
1.95*
13.6
6.8
2.43*
19.4
6.8
3.71**
a
All odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
received corporal punishment were significantly more likely to have been hospitalized in the past 3 months. Physical Abuse and Anxiety/Stress Abused students were more likely to be anxious and stressed, as shown by the odds ratio estimates which all exceeded one (Table 4). Most of the comparisons were significant for corporal punishment and being beaten by parents for no apparent reason. None of the comparisons were statistically significant for being beaten to injury.
Table 4. Physical Abuse Indicators by Anxiety/Stress Indicatorsa Corporal Punishment by Parents in Past 3 Months Yes (%) Anxiety/Stress Indicators You feel constantly under strain You are not happy on reflection Parental expectations are too high You are often anxious about school exams You feel anxious about puberty You think of yourself as worthless person a
No (%)
Odds Ratio
Beaten by Parents for no Apparent Reason in Past 3 Months Yes (%)
No (%)
Odds Ratio
Beaten to Injury by Family Members in Past 3 Months Yes (%)
No (%)
Odds Ratio
37.9 39.9 11.2 5.4 34.2 22.5
1.16 ns 1.94* 1.82***
57.6 39.4 6.1 5.6 37.9 22.7
2.31** 1.12 ns 2.27**
41.7 39.8 8.3 5.6 33.3 22.9
1.19 ns 1.55 ns 1.76 ns
47.8 49.7 26.7 19.1
1.11 ns 1.64*
66.7 49.3 33.3 19.2
2.15** 2.04**
55.6 49.5 22.2 19.5
1.24 ns 1.27 ns
17.4 10.2
2.03**
13.6 10.5
1.39 ns
11.1 10.5
1.05 ns
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
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J. TF Lau, J. LY Liu, J. CK Cheung, A. Yu, and CK Wong Table 5. Physical Abuse Indicators by Indicators of Students’ Ability to Copea Corporal Punishment by Parents in Past 3 Months Yes (%)
Coping Indicators You do not know how to maintain your health You feel you cannot overcome difficulties You feel unable to face up to your own problems You do not know how to handle your emotional problems Suicide is a way to solve problems
Beaten by Parents for no Apparent Reason in Past 3 Months
No (%)
Odds Ratio
23.4 15.0
1.79**
25.8 15.2
1.94*
30.6 15.3
2.46*
29.8 22.1
1.88***
33.3 22.2
1.83*
33.3 22.3
1.83#
10.6
2.73***
10.6
2.29#
19.4
5.49***
1.76** 1.85*
40.9 19.6 16.7 6.9
2.77*** 2.28*
36.1 19.9 16.7 7.0
4.1
27.7 19.7 10.7 6.9
Yes (%)
No (%)
4.3
Odds Ratio
Beaten to Injury by Family Members in Past 3 Months Yes (%)
No (%)
4.3
Odds Ratio
2.43* 2.20 ns
a
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
Physical Abuse and Students’ Ability to Cope Students who had experienced any of the three physical abuse-related outcomes were more likely to have difficulties in their perceived ability to cope with problems in everyday life (as reflected by their responses to statements in Table 5). Almost all the comparisons were statistically significant. Familial Relationships Abused students were more likely to agree with statements indicative of poor familial relationships (Table 6). Most of the comparisons were statistically significant. School Performance Students who had received corporal punishment were significantly more likely to rank their school performance in the bottom 10 of their class (odds ratio 5 1.52, p , .05). Being hit for no reason and being beaten to injury were not significantly associated with school performance.
Table 6. Physical Abuse Indicators by Familial Relationshipsa Corporal Punishment by Parents in Past 3 Months Yes No (%) (%) Familial Relationships Family members cannot help you when you encounter difficulties 47.8 38.0 You have a bad relationship with family members 25.5 14.1 Your parents do not have a sufficient understanding of you 62.1 56.5 a
Beaten by Parents for no Apparent Reason in Past 3 Months
Odds Ratio
Yes No (%) (%)
1.59**
50.0 38.3
1.98*** 1.49*
Yes No (%) (%)
Odds Ratio
1.59#
47.2 38.4
1.33 ns
42.4 14.1
4.15***
50.0 14.3
5.63***
75.8 56.4
2.79***
74.3 56.6
2.70*
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
Odds Ratio
Beaten to Injury by Family Members in Past 3 Months
Correlates of physical abuse in Hong Kong adolescents
555
DISCUSSION Validity and Reliability Survey interviewers followed standardized questionnaire administration procedures. Students were assured about the confidentiality of their responses. The response rate was very high (at 98%, is much better than most published papers on child abuse), which allows us to say with reasonable confidence that the results were representative of adolescent secondary school students in Kwai Tsing District of Hong Kong. Implication of Findings Our estimates of the prevalence of physical abuse were obtained from a defined secondary school population in Hong Kong and represents an improvement over previous estimates of physical abuse occurrence in the Territory, which were mainly based on case notifications to the Government’s Child Abuse Registry (Tang & Davies, 1996) or clinical samples (Lau & Davies, 1993). Studies in the West showed long term deficits in intellectual development and scholastic standing attributable to abuse (Kurtz, Gaudin, Wodarski, & Howing, 1993; Perez & Widom, 1994). In our study, the poorer self-assessed school performance of students who had received corporal punishment from their parents was an expected finding, given the importance which Chinese families place on academic achievement. However, the results did not show any significant association between the more severe forms of abuse (i.e., being hit for no reason and being beaten to injury) and academic performance. Although the literature indicates that older Chinese children are more likely to be strictly disciplined than younger ones from spanking and scolding (Ho, 1986), our results showed that once they enter adolescence, they eventually grow out of this risk of corporal punishment. However, adolescents in the middle of their teenage years (15- to 16-year-olds) were at the highest risk of being beaten to injury by family members. While corporal punishment is less frequent, the risk for abuse stays high. Many parents in Hong Kong might argue that corporal punishment is necessary to help instil a sense of filial piety in children—this is reflected in the results of a recent study on attitudes towards child abuse, which showed that a high percentage of Hong Kong adults think that corporal punishment is a parental right and an effective educational method (Lau, Liu, Cheung, & Chan, 1998). However, in our study, corporal punishment is very strongly associated with being beaten by parents for no apparent reason (odds ratio 5 13.31; p , .001) and being beaten to injury by family members (odds ratio 5 14.30; p , .001). Thus, preventing corporal punishment might help prevent more serious forms of physical abuse from occurring. Students who reported that they had experienced any of the physical abuse-related outcomes in the family setting were at a significant disadvantage for a wide range of morbidity indicators, including self-perceived bad health, anxiety and stress, various somatic illnesses (such as asthma and epigastric pain), injuries and accidents, and hospitalization. They were also more likely to take up habits which potentially put their health at risk, such as smoking, alcohol consumption, and fighting with others. Those who were poor at coping with life’s problems and had poor familial relations had higher prevalence rates of being physically abused—these students may be vulnerable to long-term psychological (and physical) distress. These findings are consistent with Western studies on the health and psycho-pathological consequences of child abuse (Wiehe, 1996; Wodarski, Kurtz, Gaudin, & Howing, 1990), and represent the first time that such a comprehensive population-based profile of adolescent physical abuse and its correlates is available in Hong Kong. Caution must be taken in interpreting the causal direction of these findings. The health or behavioral problems of children or adolescents could be a cause of abuse. Parents who are stressed, have distorted expectations or poor parenting skills might be less able to deal with their children’s
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problems and thus be more likely to resort to abuse (Azar, Robinson, Hekimian, & Twentyman, 1984; Burrell, Thompson, & Sexton, 1994; Chan, 1994; Wiehe, 1996). However, it is also plausible that abuse is a cause of these health and behavioral problems (Wiehe, 1996; Wodarski, Kurtz, Gaudin, & Howing, 1990). Another possible pathway is that abused children develop behavioral and health problems because of the abuse, and these problems in turn put them at further risk of being maltreated—in other words, causality can go in both directions. A longitudinal study design is needed to elicit the causal sequence of these events. However, all of the above causal scenarios have important social implications. As a cause, abuse puts adolescents at a higher risk of developing anxiety and health problems, health risk habits, and poor familial relationships. As an effect, abuse adds to the adverse situation of a group of maladjusted adolescents growing up with these health and familial problems. If abuse acted as both a cause and an effect, a vicious cycle of the above events would develop. Regardless of the causal direction, if our results were extrapolated to the entire adolescent population, the underlying morbidity costs associated with physical abuse (as reflected by corporal punishment, being beaten for no reason, and being beaten to injury) could be quite high. In sum, our study provided a population-based estimate of the prevalence of physical abuserelated outcomes in the family setting for adolescent secondary school students in a district of Hong Kong and showed that the abused adolescents are growing up in an environment filled with physical, psychological, and familial adversities. Acknowledgement—The authors wish to thank the Kwai Tsing District Board and the schools, headteachers, and students for their cooperation and participation in the study, Ms. Alice Mak, a Kwai Tsing District Board member who kindly liased with the District Board and the schools, and Ms. Mei-Wah Chan and Mr. Mason Lau, who provided us with valuable data processing and coordinating support.
REFERENCES Azar, S., Robinson, D., Hekimian, E., & Twentyman, C. (1984). Unrealistic expectations and problem-solving ability in maltreating and comparison mothers. Journal of Consulting and Clinical Psychology, 52, 687– 691. Basharov, D. J. (1981). Toward better research on child abuse and neglect: Making definitional issues an explicit methodological concern. Child Abuse & Neglect, 5, 383–390. Bertolli, J., Morgenstern, H., & Sorenson, S. B. (1995). Estimating the occurrence of child maltreatment and risk-factor effects: Benefits of a mixed-design strategy in epidemiologic research. Child Abuse & Neglect, 19, 1007–1016. Burrell, B., Thompson, B., & Sexton, D. (1994). Predicting child abuse potential across family types. Child Abuse & Neglect, 18, 1039 –1049. Chan, Y. C. (1994). Parenting stress and social support of mothers who physically abuse their children in Hong Kong. Child Abuse & Neglect, 18, 261–269. Fleiss, J. (1981). Statistical methods for rates and proportions. New York: Wiley. Ho, D. Y. F. (1986). Chinese patterns of socialization: A critical review. In M. H. Bond (Ed.), The psychology of the Chinese people (pp. 1–37). London: Oxford University Press. Hong Kong Government. (1996). 1996 population by-census: Basic tables for district board districts. Hong Kong: Government Printer. Hong Kong Government. (1997). Hong Kong 1997: A review of 1996. Hong Kong: Government Printer. Hosmer, D., & Lemeshow, S. (1989). Applied logistic regression. New York: Wiley. Kurtz, P., Gaudin, J., Wodarski, J., & Howing, P. (1993). Maltreatment and the school-aged child: School performance consequences. Child Abuse & Neglect, 17, 581–589. Lau, I. K. C., & Davies, D. P. (1993). Nonaccidental injury to children in Hong Kong: A 3-year hospital experience. Child Abuse & Neglect, 17, 423– 428. Lau, J. T. F., Liu, J. L. Y., Cheung, J. C. K., & Chan, M. W. (1998). Knowledge, attitudes, and perceptions of child abuse: A population-based survey of Hong Kong adults. Center for Clinical Trials and Epidemiological Research, Faculty of Medicine, The Chinese University of Hong Kong. Lieh-Mak, F., Chung, S. Y., & Liu, Y. W. (1983). Characteristics of child battering in Hong Kong: A controlled study. British Journal of Psychiatry, 142, 89 –94. MacMillan, H. L., Fleming, J. E., Trocme, N., Boyle, M. H., Wong, M., Racine, Y. A., Beardslee, W. R., & Offord, D. R. (1997). Prevalence of child physical and sexual abuse in the community: Results from the Ontario health supplement. Journal of the American Medical Association, 278, 131–135. Ong, S. G., Liu, J., Wong, C. M., Lam, T. H., Tam, A. Y. C., Daniel, L., & Hedley, A. J. (1991). Studies on the respiratory
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health of primary school children in urban communities of Hong Kong. The Science of the Total Environment, 106, 121–135. Perez, C., & Widom, C. (1994). Childhood victimization and long-term intellectual and academic outcomes. Child Abuse & Neglect, 18, 617– 633. Peters, J., Hedley, A. J., Wong, C. M., Lam, T. H., Ong, S. G., Liu, J., & Spiegelhalter, D. J. (1996). Effects of an ambient air pollution intervention and environmental tobacco smoke on children’s respiratory health in Hong Kong. International Journal of Epidemiology, 25, 821– 828. Tang, C. S. K. (1996). Adolescent abuse in Hong Kong Chinese families. Child Abuse & Neglect, 20, 873– 878. Tang, C. S. K., & Davis, C. (1996). Child abuse in Hong Kong revisited after 15 years: Characteristics of victims and abusers. Child Abuse & Neglect, 20, 1213–1218. Wiehe, V. R. (1996) Working with child abuse and neglect. Thousand Oaks, CA: Sage Publications. Wodarski, J. S., Kurtz, P. D., Gaudin, J. M., & Howing, P. T. (1990). Maltreatment and the school-age child: Major academic, socioemotional, and adaptive outcomes. Social Work, 35, 506 –513.
RE´SUME´ Objectifs: Cette e´tude s’est penche´e sur des re´sultats de mauvais traitements physiques dans des familles d’adolescents vivant a` Hong Kong, et avait pour objectif d’en e´valuer les divers facteurs ainsi que la pre´valence. Me´thode: On a enqueˆte´ aupre`s d’un e´chantillon ale´atoire de 3 355 e´tudiants au niveau secondaire dans le district Kwai Tsing de Hong Kong. Le taux de re´ponse fut de 98%. Re´sultats: Le taux des punitions corporelles, le fait d’avoir e´te´ battu par ses parents pour aucune raison et d’en avoir subi des blessures dans les trois derniers mois et la combinaison de n’importe quelle des trois situations ci-haut e´taient comme suit: 4.9% (95% IC, 4,2% a` 5,6%), 2% (95% IC, 1,5% a` 2,5%), 1.1% (95 IC, 98% a` 1,2%) et 6.6% (95%, IC 5,7% a` 7,5%) respectivement. Les e´tudiants qui avaient connu des re´sultats ci-haut suite a` la maltraitance e´taient fort de´savantage´s vis-a`-vis d’une vaste gamme d’indicateurs de morbidite´ y compris la perception d’eˆtre en mauvaise sante´, l’angoisse, le stress, les conditons somatiques telles que l’asthme et la douleur e´pigastrique, les blessures, les accidents et l’hospitalisation. Ils e´taient plus aptes a` avoir de mauvaises relations familiales et des faibles capacite´s de faire face aux exigences de la vie et d’adopter des habitudes malsaines telles que la cigarette, l’alcool et les bagarres. Conclusions: Les e´valuations de la pre´valence des mauvais traitements physiques dans la famille dans une population d’e´tudiants a` Hong Kong de´montrent qu’il y a une baisse dans les taux de maltraitance compare´s a` des taux ante´rieurs qui s’appuyaient sur des signalements et des e´chantillons cliniques. Les re´sultats de´montrent aussi que les adolescents abuse´s grandissent dans un milieu rempli d’adversite´ physique, psychologique et familiale.
RESUMEN Objetivo: Los objetivos fueron estimar la prevalencia y correlatos del maltrato fı´sico en familias de adolescentes de Hong Kong. Me´todo: Se utilizo´ un disen˜o transversal. Se encuesto´ a una muestra seleccionada al azar de 3.355 estudiantes de secundaria en el Distrito Kwai Tsing de Hong Kong. El porcentaje de respuesta fue del 98%. Resultados: Las tasas de prevalencia de (a) castigo fı´sico, (b) ser golpeado por los padres sin razo´n aparente, (c) ser golpeado hasta padecer lesiones por familiares en los u´ltimos tres meses, y (d) cualquiera de las tres anteriores, fueron del 4.9% (95% IC, 4.2% a 5.6%). 2.0% (95% IC, 5.7% a 7.5%) respectivamente. Los estudiantes que habı´an experiementado estas situaciones de maltrato fı´sico se encontraban en desventaja en un amplio espectro de indicadores de morbilidad, incluyendo una percepcio´n de la propia salud como negativa, ansiedad y estre´s, enfermedades soma´ticas (tales como asthma y dolores abdominales), lesiones y accidentes, y hospitalizacio´n. Eran ma´s propensos a tener unas pobres relaciones familiares y pobres habilidades de enfrentamiento a los problemas, y a mantener ha´bitos que potencialmente ponı´an su salud en riesgo, tales como fumar, consumir alcohol e implicarse en peleas. Conclusiones: Nuestras estimaciones de la prevalencia del maltrato fı´sico intrafamiliar en una poblacio´n de estudiantes de Hong Kong supone un avance respecto a las estimaciones que habı´a previamente sobre la ocurrencia del maltrato fı´sico en este contexto, que se basaban principalmente en casos notificados y muestras clı´nicas. Los resultados muestran tambie´n que los adolescentes maltratados esta´n creciendo en un entorno lleno de adversidades fı´sicas, psicolo´gicas y familiares.
Pergamon
PII S0145-2134(99)00029-0
PREVALENCE AND CORRELATES OF PHYSICAL ABUSE IN HONG KONG CHINESE ADOLESCENTS: A POPULATION-BASED APPROACH JOSEPH TF LAU, JOSEPH LY LIU,
AND
JACKY CK CHEUNG
Center for Clinical Trials and Epidemiological Research, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
AARON YU Department of Pediatrics, Pamela Youde Nethersole Eastern Hospital, Hong Kong Island, Hong Kong
CK WONG Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
ABSTRACT Objective: The objectives were to estimate the prevalence and correlates of physical abuse-related outcomes in the family setting in Hong Kong’s adolescent population. Method: A cross-sectional study design was used. A randomly selected sample of 3,355 secondary school students in Kwai Tsing District of Hong Kong was surveyed. The response rate was 98%. Results: The prevalence rates of corporal punishment, being beaten by parents for no apparent reason, being beaten to injury by family members in the past 3 months and any one of the above three were 4.9% (95% CI, 4.2% to 5.6%), 2.0% (95% CI, 1.5% to 2.5%), 1.1% (95% CI, .98% to 1.2%) and 6.6% (95% CI, 5.7% to 7.5%), respectively. Students who had experienced the above physical abuse-related outcomes were at a significant disadvantage for a wide range of morbidity indicators, including self-perceived bad health, anxiety and stress, somatic illnesses (such as asthma and epigastric pain), injuries and accidents, and hospitalization. They were more likely to have poor familial relations and coping skills, and to take up habits which potentially put their health at risk, such as smoking, alcohol consumption, and fighting with others. Conclusions: Our prevalence estimates of physical abuse in the family setting for a student population in Hong Kong is an improvement over previous local estimates of physical abuse occurrence, which were mainly based on case notifications and clinical samples. The results also show that the abused adolescents are growing up in an environment filled with physical, psychological, and familial adversities. © 1999 Elsevier Science Ltd Key Words—Physical abuse, Adolescents, Prevalence, Risk factors, Hong Kong.
INTRODUCTION PREVIOUS STUDIES HAVE shown that in Hong Kong, child abuse tends to occur at a later age in childhood than in the West (Lieh-Mak, Chung, & Liu, 1983). In Chinese societies, infants are
Received for publication May 27, 1998; final revision received May 27, 1998; accepted October 15, 1998. Requests for reprints should be sent to Dr. Joseph Tak-fai Lau, Center for Clinical Trials and Epidemiological Research, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong. 549
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J. TF Lau, J. LY Liu, J. CK Cheung, A. Yu, and CK Wong
treated with attention and loving care, but this gives way to strict discipline (and thus the risk of abuse) after the age of 4 or 5 to ensure filial piety (Tang & Davis, 1996). The extent to which abuse continues in adolescence has not been a widely explored issue, in both Asian and Western contexts. One exception is a study of the experience of 375 university students in Hong Kong by Tang (1996), which estimated the prevalence of respondents who had experienced minor and severe physical violence from parents in the past year. However, Tang’s figures were based on a selected sample of university students, which could not be generalized to a larger community. According to a Medline search, a population-based estimate of the prevalence of physical abuse in Hong Kong children had not previously been published. The small number of published community-based studies on the prevalence and correlates of child abuse is explained by methodological and logistical difficulties in carrying out such studies (Basharov, 1981; Bertolli, Morgenstern, & Sorenson, 1995; MacMillan, Fleming, Trocme, Boyle, Wong, Racine, Beardslee, & Offord, 1997). MATERIALS AND METHODS Background to Study Kwai Tsing, one of Hong Kong’s 18 geographical districts and located in the Northwest New Territories, is the territory’s most important manufacturing and commercial shipping district, with a residential population of 471,000 (Hong Kong Government, 1996). Previous epidemiological studies have been carried out in Kwai Tsing; they focused on somatic conditions in its preadolescent children (Ong, Liu, Wong, Lam, Tam, Daniel, & Hedley, 1991; Peters, Hedley, Wong, Lam, Ong, Liu, & Spiegelhalter, 1996). A general population-based health needs assessment study of adolescent secondary school students in Kwai Tsing carried out by the authors included questions about respondents’ experience with corporal punishment and indicators of being physically abused by parents and family members in the past 3 months. The results are reported here. Study Population and Data Collection Methods The study consisted of a cross-sectional survey of students from 12 randomly selected secondary schools in Kwai Tsing District, using self-administered structured questionnaires. Secondary schools in Hong Kong cover the equivalent of grades seven through 12 in junior-high and high schools in America. Hong Kong has a compulsory 9-year education policy, which means that all children are required by law to attain a junior high-school level education. Eighty-five percent of students who complete junior high school continue their education in high school (Hong Kong Government, 1997). The questionnaires were completed in class in the presence of a trained survey administrator, who was available to answer in a standard manner queries from students concerning the interpretation and meaning of questionnaire items. Students were encouraged to be honest in their responses and were assured that absolute confidentiality would be maintained. The students were asked whether they had: 1. Received corporal punishment from their parents in the past 3 months; 2. Been beaten by their parents for no apparent reason in the past 3 months; 3. Been beaten to injury by family members in the past 3 months. In addition, questions were asked about the students’ sociodemographic background (e.g., sex and age, type of living quarters, and father’s occupation and educational attainment), health-related behaviors (cigarette smoking, alcohol consumption, and fighting with others in the past 3 months), health status (whether respondents had experienced various illnesses in the past 3 months, whether they had stayed in the hospital in the past 3 months, and whether they agreed with the statement
Correlates of physical abuse in Hong Kong adolescents
551
“Your health status is very bad”), anxiety and stress, ability to cope with everyday problems, and familial relationships. For the last three types of questions, students were presented with statements indicative of stress, coping ability (e.g., “suicide is a way to solve problems”) or familial relations and asked whether these statements accurately depicted their situation or state of mind. The broad-ranging scope of this inquiry provided us with an opportunity to assess in detail the prevalences and correlates of physical abuse-related outcomes in Kwai Tsing adolescents. The study sample consisted of 3,355 13- to 19-year-old students. The response rate was 98%. Data Analysis Initially, the prevalence rates of physically abused students in sociodemographic and other subgroups were compared using chi-square tests and odds ratio estimates. The odds ratio is defined as the ratio of the odds of experiencing an outcome (e.g., corporal punishment) when exposed to a factor of interest (e.g., students having a father with primary level education or less) to the odds of experiencing the outcome when not exposed (in this example, having a father with better education). An odds ratio of greater than one indicates that a higher proportion of students with poorly educated fathers are inflicted with corporal punishment. An odds ratio of one indicates that there is no difference between the two educational subgroups. An odds ratio of less than one indicates that a lower proportion of students with poorly educated fathers have experienced corporal punishment than students with better educated ones. Logistic regression was used to standardize odds ratio estimates for potentially important confounding effects, such as age and sex (see Fleiss, 1981 for a discussion of the odds ratio and Hosmer and Lemeshow, 1989 for a detailed treatment of the logistic regression model). All analyses were carried out using SPSS for Windows Version 7.5. RESULTS Physical Abuse and Sociodemographic Factors The study sample had slightly more boys than girls (51.5% vs. 48.5%) and had an age distribution as follows: 32.8% were 14 years old or below, 24.5% were 15, 18.9% 16, and 23.7% 17 or above. The prevalence rates of corporal punishment, being beaten by parents for no apparent reason and being beaten to injury in the past 3 months were 4.9% (95% CI, 4.2% to 5.6%), 2.0% (95% CI, 1.5% to 2.5%) and 1.1% (95% CI, .98% to 1.2%), respectively (Table 1). The prevalence of students who had experienced any of the three physical abuse-related outcomes was 6.6% (95% CI, 5.7% to 7.5%). Corporal punishment was found to be significantly associated with age—the younger the respondents the more likely they had received corporal punishment from their parents (Table 1). A similar pattern was observed between age and being beaten by parents for no apparent reason, but the association was not statistically significant. Fifteen- and 16-year-olds were significantly more likely to have been beaten to injury by family members than students aged 17 and above. Girls were marginally significantly (p , .10) more likely than boys to have been beaten by parents for no apparent reason. Socioeconomic factors (father’s educational attainment, father’s occupation, birth place, and type of living quarters) were found not to be associated with any of the three physical abuse-related outcomes (results not shown). Physical Abuse and Health-Related Behavior Generally speaking, students who consumed alcohol, smoked cigarettes, and got into fights were significantly more likely to have experienced all three physical abuse-related outcomes (Table 2).
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J. TF Lau, J. LY Liu, J. CK Cheung, A. Yu, and CK Wong Table 1. Physical Abuse Indicators by Demographic Factors
Overall Prevalence Socio-demographic Factors Age group 14 years or below 15 years 16 years 17 years or above Sex Male Female
Corporal Punishment by Parents in Past 3 Months
Beaten by Parents for no Apparent Reason in Past 3 Months
%
%
Odds Ratio
4.9
Odds Ratio
2.0
Beaten to Injury by Family Members in Past 3 Months %
Odds Ratio
1.1
9.1 3.8 3.1 1.6
6.27*** 2.45** 2.02# 1.00
2.4 2.1 1.5 1.6
1.57 ns 1.37 ns 0.94 ns 1.00
0.9 1.8 1.5 0.3
3.61 ns 6.83* 5.73* 1.00
5.4 4.3
1.29 ns
1.5 2.4
0.62#
1.1 1.1
1.00 ns
*** p , 0.001; ** p , 0.01; * p , 0.05;
#
p , 0.10; ns, not significant.
For alcohol consumption and fighting with others, there was a clear-cut dose-response relationship with being beaten to injury—the more frequently they consumed alcohol or fought, the more likely they were to have experienced being beaten to injury by family members. Physical Abuse and Health Status/Hospitalization Students who had experienced the three physical abuse-related outcomes were generally more likely to have suffered from somatic conditions or accidents and to perceive their health status to be very bad (Table 3). Many of these comparisons were statistically significant. Those who had
Table 2. Physical Abuse Indicators by Health-Related Behaviora Corporal Punishment by Parents in Past 3 Months
Health-Related Behavior Drank alcohol in past 3 months? no rarely sometimes always Smoked cigarettes in past 3 months? no rare sometimes always Fought with others in past 3 months? no rare sometimes always a
Beaten by Parents for no Apparent Reason in Past 3 Months
Beaten to Injury by Family Members in Past 3 Months
%
Odds Ratio
%
Odds Ratio
%
Odds Ratio
4.3 5.7 6.9 7.6
1.00 1.39 ns 2.01** 2.14 ns
1.5 2.5 3.8 6.1
1.00 1.55 ns 2.70** 5.00**
0.5 2.3 2.3 4.5
1.00 3.92** 4.61*** 8.78**
4.3 10.8 7.5 9.2
1.00 2.92*** 1.73 ns 2.94**
1.7 3.2 6.5 3.4
1.00 1.79 ns 4.42*** 2.51 ns
0.7 3.2 7.5 3.4
1.00 4.96** 11.00*** 5.17*
3.3 9.4 15.1 10.0
1.00 2.62*** 4.60*** 2.88#
1.2 3.8 8.9 5.0
1.00 3.98*** 9.65*** 5.67*
0.5 2.5 5.0 7.5
1.00 5.81*** 10.04*** 17.81***
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
Correlates of physical abuse in Hong Kong adolescents
553
Table 3. Physical Abuse Indicators by Health Status Indicesa Corporal Punishment by Parents in Past 3 Months
Illness or Hospitalization in the Past Three Months Asthma Epigastric pain Anxiety Insomnia Dizziness Headache Common cold/influenza/cough Fall Burn/cut/other accidents Stayed in hospital Self-perceived Health Status Your health status is very bad
Beaten by Parents for no Apparent Reason in Past 3 Months
Beaten to Injury by Family Members in Past 3 Months
Yes (%)
No (%)
Odds Ratio
Yes (%)
No (%)
Odds Ratio
Yes (%)
No (%)
Odds Ratio
8.7 18.6 14.3 12.4 17.4 17.4 60.2 34.8 18.6 6.2
3.6 17.5 13.8 11.5 14.0 19.2 55.0 24.2 11.4 2.7
2.25** 1.33 ns 1.51# 1.26 ns 1.54# 1.13 ns 1.35# 1.64** 1.79** 2.59*
6.1 37.9 22.7 18.2 34.8 42.4 60.6 39.4 25.8 1.6
3.8 17.1 13.7 11.4 13.8 18.6 55.1 24.4 11.4 2.9
1.79 ns 3.13*** 2.01* 1.86 ns 3.54*** 3.34*** 1.39 ns 2.41*** 3.00*** 0.60 ns
8.3 30.6 27.8 30.6 36.1 38.9 80.6 58.3 33.3 6.3
3.8 17.4 13.7 11.3 14.0 18.8 55.0 24.4 11.5 2.8
2.49 ns 2.24* 2.78** 3.50*** 3.52*** 3.04** 3.82** 4.78*** 3.89*** 2.33 ns
11.3
6.7
1.95*
13.6
6.8
2.43*
19.4
6.8
3.71**
a
All odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
received corporal punishment were significantly more likely to have been hospitalized in the past 3 months. Physical Abuse and Anxiety/Stress Abused students were more likely to be anxious and stressed, as shown by the odds ratio estimates which all exceeded one (Table 4). Most of the comparisons were significant for corporal punishment and being beaten by parents for no apparent reason. None of the comparisons were statistically significant for being beaten to injury.
Table 4. Physical Abuse Indicators by Anxiety/Stress Indicatorsa Corporal Punishment by Parents in Past 3 Months Yes (%) Anxiety/Stress Indicators You feel constantly under strain You are not happy on reflection Parental expectations are too high You are often anxious about school exams You feel anxious about puberty You think of yourself as worthless person a
No (%)
Odds Ratio
Beaten by Parents for no Apparent Reason in Past 3 Months Yes (%)
No (%)
Odds Ratio
Beaten to Injury by Family Members in Past 3 Months Yes (%)
No (%)
Odds Ratio
37.9 39.9 11.2 5.4 34.2 22.5
1.16 ns 1.94* 1.82***
57.6 39.4 6.1 5.6 37.9 22.7
2.31** 1.12 ns 2.27**
41.7 39.8 8.3 5.6 33.3 22.9
1.19 ns 1.55 ns 1.76 ns
47.8 49.7 26.7 19.1
1.11 ns 1.64*
66.7 49.3 33.3 19.2
2.15** 2.04**
55.6 49.5 22.2 19.5
1.24 ns 1.27 ns
17.4 10.2
2.03**
13.6 10.5
1.39 ns
11.1 10.5
1.05 ns
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
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J. TF Lau, J. LY Liu, J. CK Cheung, A. Yu, and CK Wong Table 5. Physical Abuse Indicators by Indicators of Students’ Ability to Copea Corporal Punishment by Parents in Past 3 Months Yes (%)
Coping Indicators You do not know how to maintain your health You feel you cannot overcome difficulties You feel unable to face up to your own problems You do not know how to handle your emotional problems Suicide is a way to solve problems
Beaten by Parents for no Apparent Reason in Past 3 Months
No (%)
Odds Ratio
23.4 15.0
1.79**
25.8 15.2
1.94*
30.6 15.3
2.46*
29.8 22.1
1.88***
33.3 22.2
1.83*
33.3 22.3
1.83#
10.6
2.73***
10.6
2.29#
19.4
5.49***
1.76** 1.85*
40.9 19.6 16.7 6.9
2.77*** 2.28*
36.1 19.9 16.7 7.0
4.1
27.7 19.7 10.7 6.9
Yes (%)
No (%)
4.3
Odds Ratio
Beaten to Injury by Family Members in Past 3 Months Yes (%)
No (%)
4.3
Odds Ratio
2.43* 2.20 ns
a
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
Physical Abuse and Students’ Ability to Cope Students who had experienced any of the three physical abuse-related outcomes were more likely to have difficulties in their perceived ability to cope with problems in everyday life (as reflected by their responses to statements in Table 5). Almost all the comparisons were statistically significant. Familial Relationships Abused students were more likely to agree with statements indicative of poor familial relationships (Table 6). Most of the comparisons were statistically significant. School Performance Students who had received corporal punishment were significantly more likely to rank their school performance in the bottom 10 of their class (odds ratio 5 1.52, p , .05). Being hit for no reason and being beaten to injury were not significantly associated with school performance.
Table 6. Physical Abuse Indicators by Familial Relationshipsa Corporal Punishment by Parents in Past 3 Months Yes No (%) (%) Familial Relationships Family members cannot help you when you encounter difficulties 47.8 38.0 You have a bad relationship with family members 25.5 14.1 Your parents do not have a sufficient understanding of you 62.1 56.5 a
Beaten by Parents for no Apparent Reason in Past 3 Months
Odds Ratio
Yes No (%) (%)
1.59**
50.0 38.3
1.98*** 1.49*
Yes No (%) (%)
Odds Ratio
1.59#
47.2 38.4
1.33 ns
42.4 14.1
4.15***
50.0 14.3
5.63***
75.8 56.4
2.79***
74.3 56.6
2.70*
Odds ratios adjusted for sex and age using logistic regression. *** p , 0.001; ** p , 0.01; * p , 0.05; # p , 0.10; ns, not significant.
Odds Ratio
Beaten to Injury by Family Members in Past 3 Months
Correlates of physical abuse in Hong Kong adolescents
555
DISCUSSION Validity and Reliability Survey interviewers followed standardized questionnaire administration procedures. Students were assured about the confidentiality of their responses. The response rate was very high (at 98%, is much better than most published papers on child abuse), which allows us to say with reasonable confidence that the results were representative of adolescent secondary school students in Kwai Tsing District of Hong Kong. Implication of Findings Our estimates of the prevalence of physical abuse were obtained from a defined secondary school population in Hong Kong and represents an improvement over previous estimates of physical abuse occurrence in the Territory, which were mainly based on case notifications to the Government’s Child Abuse Registry (Tang & Davies, 1996) or clinical samples (Lau & Davies, 1993). Studies in the West showed long term deficits in intellectual development and scholastic standing attributable to abuse (Kurtz, Gaudin, Wodarski, & Howing, 1993; Perez & Widom, 1994). In our study, the poorer self-assessed school performance of students who had received corporal punishment from their parents was an expected finding, given the importance which Chinese families place on academic achievement. However, the results did not show any significant association between the more severe forms of abuse (i.e., being hit for no reason and being beaten to injury) and academic performance. Although the literature indicates that older Chinese children are more likely to be strictly disciplined than younger ones from spanking and scolding (Ho, 1986), our results showed that once they enter adolescence, they eventually grow out of this risk of corporal punishment. However, adolescents in the middle of their teenage years (15- to 16-year-olds) were at the highest risk of being beaten to injury by family members. While corporal punishment is less frequent, the risk for abuse stays high. Many parents in Hong Kong might argue that corporal punishment is necessary to help instil a sense of filial piety in children—this is reflected in the results of a recent study on attitudes towards child abuse, which showed that a high percentage of Hong Kong adults think that corporal punishment is a parental right and an effective educational method (Lau, Liu, Cheung, & Chan, 1998). However, in our study, corporal punishment is very strongly associated with being beaten by parents for no apparent reason (odds ratio 5 13.31; p , .001) and being beaten to injury by family members (odds ratio 5 14.30; p , .001). Thus, preventing corporal punishment might help prevent more serious forms of physical abuse from occurring. Students who reported that they had experienced any of the physical abuse-related outcomes in the family setting were at a significant disadvantage for a wide range of morbidity indicators, including self-perceived bad health, anxiety and stress, various somatic illnesses (such as asthma and epigastric pain), injuries and accidents, and hospitalization. They were also more likely to take up habits which potentially put their health at risk, such as smoking, alcohol consumption, and fighting with others. Those who were poor at coping with life’s problems and had poor familial relations had higher prevalence rates of being physically abused—these students may be vulnerable to long-term psychological (and physical) distress. These findings are consistent with Western studies on the health and psycho-pathological consequences of child abuse (Wiehe, 1996; Wodarski, Kurtz, Gaudin, & Howing, 1990), and represent the first time that such a comprehensive population-based profile of adolescent physical abuse and its correlates is available in Hong Kong. Caution must be taken in interpreting the causal direction of these findings. The health or behavioral problems of children or adolescents could be a cause of abuse. Parents who are stressed, have distorted expectations or poor parenting skills might be less able to deal with their children’s
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J. TF Lau, J. LY Liu, J. CK Cheung, A. Yu, and CK Wong
problems and thus be more likely to resort to abuse (Azar, Robinson, Hekimian, & Twentyman, 1984; Burrell, Thompson, & Sexton, 1994; Chan, 1994; Wiehe, 1996). However, it is also plausible that abuse is a cause of these health and behavioral problems (Wiehe, 1996; Wodarski, Kurtz, Gaudin, & Howing, 1990). Another possible pathway is that abused children develop behavioral and health problems because of the abuse, and these problems in turn put them at further risk of being maltreated—in other words, causality can go in both directions. A longitudinal study design is needed to elicit the causal sequence of these events. However, all of the above causal scenarios have important social implications. As a cause, abuse puts adolescents at a higher risk of developing anxiety and health problems, health risk habits, and poor familial relationships. As an effect, abuse adds to the adverse situation of a group of maladjusted adolescents growing up with these health and familial problems. If abuse acted as both a cause and an effect, a vicious cycle of the above events would develop. Regardless of the causal direction, if our results were extrapolated to the entire adolescent population, the underlying morbidity costs associated with physical abuse (as reflected by corporal punishment, being beaten for no reason, and being beaten to injury) could be quite high. In sum, our study provided a population-based estimate of the prevalence of physical abuserelated outcomes in the family setting for adolescent secondary school students in a district of Hong Kong and showed that the abused adolescents are growing up in an environment filled with physical, psychological, and familial adversities. Acknowledgement—The authors wish to thank the Kwai Tsing District Board and the schools, headteachers, and students for their cooperation and participation in the study, Ms. Alice Mak, a Kwai Tsing District Board member who kindly liased with the District Board and the schools, and Ms. Mei-Wah Chan and Mr. Mason Lau, who provided us with valuable data processing and coordinating support.
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RE´SUME´ Objectifs: Cette e´tude s’est penche´e sur des re´sultats de mauvais traitements physiques dans des familles d’adolescents vivant a` Hong Kong, et avait pour objectif d’en e´valuer les divers facteurs ainsi que la pre´valence. Me´thode: On a enqueˆte´ aupre`s d’un e´chantillon ale´atoire de 3 355 e´tudiants au niveau secondaire dans le district Kwai Tsing de Hong Kong. Le taux de re´ponse fut de 98%. Re´sultats: Le taux des punitions corporelles, le fait d’avoir e´te´ battu par ses parents pour aucune raison et d’en avoir subi des blessures dans les trois derniers mois et la combinaison de n’importe quelle des trois situations ci-haut e´taient comme suit: 4.9% (95% IC, 4,2% a` 5,6%), 2% (95% IC, 1,5% a` 2,5%), 1.1% (95 IC, 98% a` 1,2%) et 6.6% (95%, IC 5,7% a` 7,5%) respectivement. Les e´tudiants qui avaient connu des re´sultats ci-haut suite a` la maltraitance e´taient fort de´savantage´s vis-a`-vis d’une vaste gamme d’indicateurs de morbidite´ y compris la perception d’eˆtre en mauvaise sante´, l’angoisse, le stress, les conditons somatiques telles que l’asthme et la douleur e´pigastrique, les blessures, les accidents et l’hospitalisation. Ils e´taient plus aptes a` avoir de mauvaises relations familiales et des faibles capacite´s de faire face aux exigences de la vie et d’adopter des habitudes malsaines telles que la cigarette, l’alcool et les bagarres. Conclusions: Les e´valuations de la pre´valence des mauvais traitements physiques dans la famille dans une population d’e´tudiants a` Hong Kong de´montrent qu’il y a une baisse dans les taux de maltraitance compare´s a` des taux ante´rieurs qui s’appuyaient sur des signalements et des e´chantillons cliniques. Les re´sultats de´montrent aussi que les adolescents abuse´s grandissent dans un milieu rempli d’adversite´ physique, psychologique et familiale.
RESUMEN Objetivo: Los objetivos fueron estimar la prevalencia y correlatos del maltrato fı´sico en familias de adolescentes de Hong Kong. Me´todo: Se utilizo´ un disen˜o transversal. Se encuesto´ a una muestra seleccionada al azar de 3.355 estudiantes de secundaria en el Distrito Kwai Tsing de Hong Kong. El porcentaje de respuesta fue del 98%. Resultados: Las tasas de prevalencia de (a) castigo fı´sico, (b) ser golpeado por los padres sin razo´n aparente, (c) ser golpeado hasta padecer lesiones por familiares en los u´ltimos tres meses, y (d) cualquiera de las tres anteriores, fueron del 4.9% (95% IC, 4.2% a 5.6%). 2.0% (95% IC, 5.7% a 7.5%) respectivamente. Los estudiantes que habı´an experiementado estas situaciones de maltrato fı´sico se encontraban en desventaja en un amplio espectro de indicadores de morbilidad, incluyendo una percepcio´n de la propia salud como negativa, ansiedad y estre´s, enfermedades soma´ticas (tales como asthma y dolores abdominales), lesiones y accidentes, y hospitalizacio´n. Eran ma´s propensos a tener unas pobres relaciones familiares y pobres habilidades de enfrentamiento a los problemas, y a mantener ha´bitos que potencialmente ponı´an su salud en riesgo, tales como fumar, consumir alcohol e implicarse en peleas. Conclusiones: Nuestras estimaciones de la prevalencia del maltrato fı´sico intrafamiliar en una poblacio´n de estudiantes de Hong Kong supone un avance respecto a las estimaciones que habı´a previamente sobre la ocurrencia del maltrato fı´sico en este contexto, que se basaban principalmente en casos notificados y muestras clı´nicas. Los resultados muestran tambie´n que los adolescentes maltratados esta´n creciendo en un entorno lleno de adversidades fı´sicas, psicolo´gicas y familiares.