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Prevalence of child maltreatment in Albania

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Qamil Dika1, Marsida Duli1, Genc Burazeri1,2, Rudina Çumashi3, Romina Hala3, Elsona Agolli4 and Gentiana Qirjako1,3

1Faculty of Medicine, University of Medicine, Tirana, Albania (Correspondence to Genc Buzarei: This email address is being protected from spambots. You need JavaScript enabled to view it.). 2Department of International Health, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands. 3Institute of Public Health, Tirana, Albania. 4United Nations Population Fund Office in Albania.

Abstract

Background: Child maltreatment is a global issue that significantly impacts children's lives. In 2018, 32% of 15-year-olds in Albania reported experiencing physical abuse.

Aim: To assess the prevalence and sociodemographic correlates of child abuse and neglect in Albania.

Methods: This was the 2022 Health Behaviour in School-aged Children nationwide survey in Albania conducted among 1877 schoolchildren (55% girls) aged 15 years. We collected data on sociodemographic characteristics, physical abuse, emotional abuse, sexual abuse, emotional neglect, and exposure to domestic violence. We analysed the data using SPSS version 19.0 and used binary logistic regression to assess associations between child abuse, neglect and sociodemographic characteristics.

Results: Lifetime prevalence rates were 33.1% for physical abuse, 16.2% for emotional abuse, 3.7% for sexual abuse, 15.7% for emotional neglect, and 7.0% for witness to domestic violence. Children living in urban areas had higher odds of experiencing physical or emotional abuse (OR = 1.4 and 1.6, 95% CI = 1.1–1.7 and 1.2–2.2). Girls had higher odds of experiencing emotional abuse (OR = 1.8, 95% CI = 1.4–2.4) or emotional neglect (OR = 3.4, 95% CI = 2.5–4.6). Girls and children from less affluent families had lower odds of experiencing sexual abuse (OR = 0.6, 95% CI = 0.3–0.9; OR = 0.5, 95% CI = 0.3–0.8, respectively). Children whose fathers were unemployed had higher odds of witnessing domestic violence (OR = 1.9, 95% CI = 1.1–3.2).

Conclusion: Abuse and neglect are highly prevalent among Albanian children aged 15 years, raising concerns over their future wellbeing. Action is needed by professionals and caregivers and at policy level to mitigate the negative impact and promote children's protection and well-being in the country.

Keywords: child abuse, child neglect, child violence, school age children, physical abuse, emotional abuse, sexual abuse, emotional neglect, domestic violence, Albania

Citation: Dika Q, Duli M, Burazeri G, Çumashi R, Hala R, Agolli E, Qirja G. Prevalence of child maltreatment in Albania. East Mediterr Health J. 2024;30(12):821–828. https://doi.org/10.26719/2024.30.12.821.

Received: 22/04/2024; Accepted: 03/09/2024

Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Background

Child maltreatment is a global phenomenon affecting the lives of many children in all countries (1,3-6). It can result in serious negative physical, psychological, and behavioural consequences spanning a life course and may have potential inter-generational effects (3). Child maltreatment is defined as the abuse and neglect of a human being less than 16 years of age including both potential and actual harm by a birth parent, guardian or caregiver (1). Maltreatment can include many forms of abuse and neglect: physical, emotional and/or sexual abuse (1,2). Child maltreatment constitutes a major public health challenge (1,5) and has been shown to have considerable adverse effects on both physical and mental health, as well as engagement in risky behaviours throughout the human life course (7-9).

Estimations of the prevalence of global child maltreatment from self-reported data include: 23% for physical abuse (10); 13% for sexual abuse (11), and 36% for emotional abuse (12). A recent systematic review reported estimated global percentages for child maltreatment: 8% for physical abuse; 24% for sexual abuse; 7% for emotional abuse; 16% for child neglect; and 24% for exposure to domestic violence (13).

Albania, a middle-income country (GDP per capita: ≈5250 United States dollars), with a population of about 2.8 million inhabitants (14), emerged in the early 1990s as a market economy from one of the most isolated communist regimes in Europe (15,16). The transition towards a market-oriented economy was associated with negative changes in the health status and behavioural patterns of the general population (15,16).

The Health Behaviour in School-aged Children (HBSC) study is a large school-based survey conducted every 4 years in many countries in Europe and beyond in collaboration with the World Health Organization (WHO) Regional Office for Europe (18,19). HBSC survey has been carried out in many countries since mid-1980s collecting valuable information on the health behaviours, health outcomes and the social environments of children aged 11, 13 and 15 years (18,19). Albania first conducted the HBSC study in 2009-2010 (first round/wave). Subsequent rounds/waves were conducted every 4 years: in

2012–2013 (second round), in 2017-2018 (third round), and in 2022 (fourth, or last round).

The most recent HBSC survey was conducted in

2021–2022 across 44 countries including Albania (18,19). Besides other health issues and behavioural characteristics, the survey includes a series of questions on lifetime and “in the last year” self-reported child abuse and neglect among children aged 15 years (20). For our purposes, lifetime abuse is synonymous with “ever experienced abuse or neglect”, a measure of long-term abuse and “in the last year” measures continuous (short-term) or recent abuse or neglect cases.

According to HBSC for Albania in 2017–2018, prevalence of physical abuse among children aged 15 years or less was roughly 31% (30% in boys and 32% in girls) (17). Independent positive correlates of lifetime physical abuse among Albanian schoolchildren include predisposition to substance abuse, irritability, and exposure to domestic violence (17). However, multi-variable-adjusted models of socioeconomic factors such as parental employment and family income were not statistically significant (17).

Our primary objective was to assess the prevalence and sociodemographic correlates of child abuse and neglect in Albania, based on the 2022 HBSC. Based on some indications from the previous HBSC surveys conducted in Albania in 2017–2018 (17), we hypothesized a higher prevalence of child abuse among girls than boys, possibly due to cultural traditions that favour boys over girls in terms of food, healthcare, and service provision, which is embedded in some deeply patriarchal societies (15,16). We also hypothesized a higher prevalence of abuse among children residing in urban areas than their rural counterparts, possibly related to family disruption and other unsettling environmental characteristics in urban areas, which unavoidably increase the levels of domestic violence (15,16).

As previously stated, this paper reports the prevalence and sociodemographic distribution of abuse and neglect among Albanian children. To date, evidence on child abuse in Albania is scant, particularly data on sexual abuse, emotional abuse and neglect. From this perspective, this study aimed to provide practical information on how to identify children at risk for increased rates of child abuse or neglect (maltreatment) in Albania.

Methods

We used data from the 2022 HBSC survey for our study. The HBSC is an internationally standardized cross-sectional survey instrument which has been used for multiple iterations of data collection in Albania (17). We are confident in the data collected from the HSBC because it was validated by a core research team of international experts prior to deployment in 2009.

Study population

Our target study population included a nationwide representative sample of schoolchildren aged 15 years (stratified multistage cluster sampling with probability proportionate to size. According to the HBSC international protocol, the minimum required sample size for each age group (i.e. children aged 11, 13, and 15 years) was 1550 (20). The sampling frame included all schools in Albania.

All 15-year-old children attending school were eligible for inclusion in the study. We stratified our sample based on the governing prefectures of Albania, for both rural and urban areas of the country. Noteworthy, the population size is somehow equal in urban vs. rural areas of Albania. Hence, this type of stratification (urban vs. rural areas) is used in such studies conducted in Albania to ensure fair representativeness of the sample at national level (17).

Taking these factors into account, we had a nationwide sample of 1951 schoolchildren 15 years of age. Of these, 74 refused to participate in the survey and/or provided substantially incomplete or invalid information (n = 45 girls; n = 29 boys). Thus, the study sample consisted of 1877 schoolchildren aged 15 years [n = 1032 girls (55%) and n = 845 boys (45%)]. The overall response rate was: 1877/1951 = 96.2%.

Ethics clearance

This study received approval from the Scientific Committee of the National Institute of Public Health in Albania. The data collection process was confirmed by the Albanian Ministry of Education and Sport. Prior to participation, all schoolchildren were informed about the study’s aims. They were provided with sufficient detail regarding the anonymity of the survey and the aggregated nature of data analysis. All participants were assured of confidentiality throughout the research process.

Data collection

We asked all participating schoolchildren to fill the most recent version of the HSBC (2022). Although the complete version of the HBSC survey contains a variety of questions aimed at health-related behavioural characteristics (nutritional patterns, physical exercise, smoking and alcohol consumption), health outcomes (self-perceived health, health complaints) and the social environment of schoolchildren, this report highlights response to only the sociodemographic and abuse/neglect related questions.

The selected indices include 5 major types of child maltreatment: physical abuse, emotional abuse, sexual abuse, emotional neglect and exposure to domestic violence (13,20). We provide a brief description of each below:

Physical abuse: children were asked whether a parent or other adult in the household had ever hit, beaten, kicked or physically tried to hurt them in any way.

Emotional abuse: children were asked whether a parent or other adult in the household had ever sworn at them, insulted them, humiliated them, threatened them or made children felt unwanted.

Sexual abuse: children were asked whether someone at least 5 years older and/or an adult had attempted or had sexual intercourse with them.

Emotional neglect: children were asked whether there were times when there was no adult living with them who made children felt loved.

Witnessed violence: children were asked whether they had seen or heard one of their parents/carers being slapped, kicked, punched, beaten or deliberately hurt by a partner or ex-partner in their homes. Data on the frequency of domestic violence in the home was unavailable.

We categorized responses for each of the 10 questions (5 questions for “lifetime” indices and other 5 for “last year preceding the survey” indices) as follows:
(i) never;
(ii) once or twice; and
(iii) many times. In the analysis, we sorted all abuse and neglect indices:
(i) no (consisting of “never”) and (ii) yes (including “once or twice” and “many times”). We also included selected socio-demographic characteristics: gender (boys vs. girls), place of residence (urban areas vs. rural areas), mother’s and father’s current employment status (“yes” vs. “no”) and family affluence (wealth) scores (“less affluent” vs. “more affluent” families).

Statistical analysis

During data cleaning, we discovered 47 children failed to report on lifetime emotional neglect and 127 children failed to report on last year's physical abuse (Table 1). Therefore, our final sample response rate ranged from 93.8% (for lifetime emotional neglect) to 89.7% (for lifetime physical abuse).

We used binary logistic regression to analyse associations of abuse and neglect with our collected independent sociodemographic characteristics of schoolchildren (gender, residence, parental employment and family affluence score). We initially ran crude (unadjusted) models (Table 2). We then calculated odds ratios (ORs), 95% confidence intervals and P values for each of the 10 abuse and neglect indices. We entered all sociodemographic variables simultaneously into the logistic regression models (Table 3) and calculated multivariable-adjusted ORs, 95% CIs and P values. We used a Hosmer-Lemeshow (21) test to evaluate goodness of fit criteria for all our multivariable adjusted models. For all statistical tests, we considered P ≤ 0.05 to be statistically significant. We used SPSS version 19.0 for all our data cleaning and analysis.

Results

Table 1 presents the socio-demographic characteristics of survey participants and their lifetime (upper panel) and last one year (lower panel) distributions of child maltreatment (n = 1 877). Overall, the prevalence of physical abuse was 33.1% (n = 601; lifetime) and 11.1%

(n = 195; last year preceding the survey). Emotional abuse was 16.2% (n = 294; lifetime) and 10.1% (n = 177; last year preceding the survey). Except when it was associated with family affluence, emotional abuse showed a similar sociodemographic pattern to physical abuse, but with a more pronounced difference by gender (lifetime: 19.4% in girls vs. 12.2% in boys).

We found sexual abuse prevalence to be 3.7% (n = 69; lifetime) and 3.2% (n = 56; last year preceding the survey), respectively. It was about 2 times (lifetime) and almost 4 times (last year preceding the survey) more prevalent among boys than girls (42/831 vs. 27/1 009 and 42/790 vs. 14/973, respectively), and 2 times higher among children of more affluent families than those from less wealthy families (45/936 vs. 20/854 for lifetime, and 36/907 vs. 17/818 for last year preceding the survey).

The prevalence of emotional neglect was 15.7% (n = 287; lifetime) and 10.3% (n = 182; last year preceding the survey). It was about 3 times more prevalent among girls than boys (223/1 010 vs. 64/820 for lifetime, and 137/976 vs. 45/789 for last year preceding the survey), and a bit higher among children whose fathers were unemployed and/or those from less affluent families than for fathers who were employed or ranked as more affluent.

The prevalence of witnessing violence in the family was 7.0% (n = 128; lifetime) and 3.9% (n = 69; last year preceding the survey). It was significantly more prevalent among children with unemployed than with employed fathers. It was only slightly more prevalent among children whose mothers were unemployed and among children from less affluent families than employed mothers and children from better-off families (Table 1).

In our crude (unadjusted) binary logistic regression models (Table 2), we only found a positive association between lifetime indices of maltreatment and urban residence but did not find evidence of any other association between physical abuse and socio-demographics (OR = 1.4, 95% CI=1.1–1.7).

We found a positive association between emotional abuse and female gender (lifetime: OR=1.7, 95% CI = 1.3–2.3; last year preceding the survey: OR = 1.8, 95% CI = 1.3–2.5) and urban residence (lifetime: OR=1.7, 95% CI=1.2–2.2; last year preceding the survey: OR=1.5, 95% CI = 1.1–2.2).

Sexual abuse indices were negatively associated with female gender (lifetime: OR=0.5, 95% CI=0.3–0.9; last year preceding the survey: OR=0.3, 95% CI = 0.1–0.5) and less affluent families (lifetime: OR = 0.5, 95% CI = 0.3–0.8; last year preceding the survey: OR = 0.5, 95% CI = 0.3–0.9). Significantly, we observed that emotional neglect indices were positively associated to female gender (lifetime:

OR = 3.4, 95% CI = 2.5–4.5; last year preceding the survey: OR = 2.7, 95% CI = 1.9–3.8). We also observed that lifetime values for witnessing domestic violence was positively associated with father’s unemployment (OR = 1.9, 95% CI = 1.1–3.1), a finding that was even stronger for witnessing family violence during last year preceding the survey (OR = 2.6, 95% CI = 1.4–4.8), and positively associated with mother’s unemployment (OR = 1.9, 95% CI = 1.1–3.1) (Table 2).

In our multivariable-adjusted binary logistic regression models (Table 3), associations of sociodemographic factors with all abuse and neglect indices remained unaltered, except for the association between witnessing of family violence during last year preceding the survey and mother’s unemployment, which was not statistically significant (OR = 1.66, 95% CI = 0.98–2.81).

Thirty-six percent (n = 216) of the children who reported lifetime physical abuse also reported lifetime emotional abuse, compared with only six percent (n = 77) of those who did not report lifetime physical abuse (P

Discussion

In this study of child maltreatment, we found a high prevalence of self-reported abuse and neglect among children aged 15 years in Albania. One in 3 schoolchildren reported lifetime physical abuse, whereas 1 in 6 children reported emotional abuse and/or emotional neglect. Abuse and neglect indices were strongly associated to each other. Urban residence was independently associated with both physical and emotional abuse. Female gender was positively associated with emotional abuse, particularly emotional neglect.

We found that paternal unemployment was associated with increased risk of exposure to domestic violence. Remarkably, male gender and family affluence were independently associated with sexual abuse. The odds of a male reporting sexual abuse were about 80% higher than for female children. More affluent male children were more likely to report lifetime sexual abuse than less affluent male children. The 2022 results on self-reported prevalence of lifetime physical abuse (33%) were nearly identical to the 2017–2018 HBSC results (32%). We found a slightly higher prevalence of physical abuse among male than female children. We did not find evidence of a significant association between physical abuse and gender of schoolchildren and there was no significant association between physical abuse and parental employment status or family income (17).

A meta-analysis of the global evidence on child maltreatment among 250 167 participants reported a prevalence of 23% for physical abuse, without gender differences (10). However, there were significant geographical differences in child maltreatment. The prevalence of physical abuse among school children ranged from 14% in Australia to 23% in Europe and nearly 55% in South America (10).

A recent systematic review reported a lower

prevalence of child physical abuse (≈8%) than in our study (33%; 13). The prevalence of emotional abuse was also lower (≈7% vs. ≈16%; 13), whereas the prevalence of sexual abuse (≈24%) was higher than in our study (3.7%; 13). Exposure to domestic violence was estimated at (≈24%; 13), higher than the 7% found in our study. Only the prevalence of neglect was comparable (16%).

Our findings, based on self-reported surveys, provide higher estimates of child maltreatment than official statistics, a trend seen globally (6). In the United Kingdom, self-reported data on child maltreatment showed rates 7–17 times higher than official statistics (22). Similarly, in 6 developed countries, including the USA and Canada, only 1 in 30 cases of child maltreatment was officially recognized (23).

We observed a higher prevalence of sexual abuse among males than females, which may seem counterintuitive and differs from some international literature (5,6). Sexual abuse was also higher among children from more affluent families. Female participants and children from less affluent families may have underreported due to stigma. Adolescent males may have included paid sexual encounters with older partners, which may partly explain this difference. Further research is needed to explore this finding.

Our finding of greater abuse and neglect among urban children may be linked to Albania's rapid urbanization, which is associated with family disruption and other unsettling factors that contribute to domestic violence (15,16).

Study limitations

Potential limitations of our study include selection bias, information bias and survey design. A large, probabilistic nationwide sample with a high response rate was used, but it did not include out-of-school children (17). Information bias may exist despite using a validated international instrument (20). Misunderstanding of questions, reluctance to disclose, and absence of recent pretesting of the instrument (since 2009) may compromise validity. Additionally, no data on abuse-related outcomes, such as infections or behavioural issues, were collected, and the cross-sectional design limits causal interpretations.

Conclusions

Our findings indicate a high prevalence of abuse and neglect among children aged 15 years in Albania, which should raise concern among health professionals and policymakers. Awareness of the negative impact of abuse is crucial for promoting children's well-being in the country.

Acknowledgment

This study was conducted by the Faculty of Medicine, University of Medicine, Tirana, Albania.

Funding: This study was funded by the United Nations Population Fund Office in Albania, the United Nations Children’s Fund Office in Albania, and the Swiss Development and Cooperation Agency through the project “Schools for Health”. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Competing interests: None declared.

Prévalence de la maltraitance des enfants en Albanie

Résumé

Contexte : La maltraitance des enfants constitue un problème mondial, ayant un impact significatif sur leur vie. En 2018, 32 % des jeunes albanais âgés de 15 ans ont déclaré avoir été victimes de sévices physiques.

Objectif : Évaluer la prévalence et les corrélats sociodémographiques associés à la maltraitance et à la négligence envers les enfants en Albanie.

Méthodes : Il s'agissait de l'enquête nationale 2022 sur le comportement des enfants d'âge scolaire en matière de santé menée en Albanie auprès de 1877 écoliers (55 % de filles) âgés de 15 ans. Nous avons recueilli des données sur les caractéristiques sociodémographiques, les sévices physiques, psychologiques, l'abus sexuel, la négligence émotionnelle et l'exposition à la violence domestique. Nous avons analysé les données à l'aide du logiciel SPSS version 19.0 et utilisé la régression logistique binaire pour évaluer les associations entre la maltraitance, la négligence des enfants et les caractéristiques sociodémographiques.

Résultats : Les taux de prévalence au cours de la vie étaient de 33,1 % pour les sévices physiques, de 16,2 % pour la violence psychologique, de 3,7 % pour l'abus sexuel, de 15,7 % pour la négligence émotionnelle et de 7,0 % pour l'exposition à la violence domestique. Les enfants vivant dans des zones urbaines avaient un risque accru de subir des sévices physiques ou psychologiques (odds ratio = 1,4 et 1,6 ; IC à 95 % = 1,1−1,7 et 1,2−2,2). Les filles étaient plus susceptibles de subir de la violence psychologique (odds ratio = 1,8 ; IC à 95 % = 1,4−2,4) ou de la négligence émotionnelle (odds ratio = 3,4 ; IC à 95 % = 2,5−4,6). Les filles et les enfants issus de familles moins aisées étaient moins susceptibles de subir des abus sexuels (odds ratio = 0,6 ; IC à 95 % = 0,3−0,9 ; odds ratio = 0,5 ; IC à 95 % = 0,3−0,8, respectivement). Les enfants dont les pères étaient sans emploi avaient une probabilité plus élevée d'être témoins de violences domestiques (odds ratio = 1,9, IC à 95 % = 1,1−3,2).

Conclusion : La maltraitance et la négligence sont très répandues chez les enfants albanais âgés de 15 ans, ce qui soulève des préoccupations concernant leur bien-être futur. Des mesures doivent être prises par les professionnels et les aidants, ainsi qu'au niveau des politiques, pour atténuer les effets négatifs et promouvoir la protection et le bien-être des enfants dans le pays.

انتشار إساءة معاملة الأطفال في ألبانيا

كاميل ديكا، مارسيدا دولي، جينك بورازيري، رودينا تشوماشي، رومينا هالا، إلسونا أجولي، جنتيانا كيراكو

الخلاصة

الخلفية: إساءة معاملة الأطفال مشكلة عالمية لها أثر بالغ على حياتهم، وفي عام 2018، أبلغ 32% من الأطفال البالغين 15 عامًا في ألبانيا عن تعرضهم للاعتداء البدني.

الأهداف: هدفت هذه الدراسة الى تقييم مدى انتشار إساءة معاملة الأطفال وإهمالهم في ألبانيا والارتباطات الاجتماعية السكانية بهما.

طرق البحث: أُجريَ في عام 2022 استقصاء السلوك الصحي للأطفال في سن الدراسة على الصعيد الوطني في ألبانيا، وشمل 1877 مشاركًا من تلاميذ المدارس الذين تبلغ أعمارهم 15 سنة (55% منهم فتيات). وخلال هذا الاستقصاء جمعنا بيانات عن الخصائص الاجتماعية السكانية، والاعتداء البدني، والإيذاء العاطفي، والاعتداء الجنسي، والإهمال العاطفي، والتعرض للعنف الأسري. وقد حلَّلنا البيانات بالإصدار 19.0 من برمجية SPSS، واستخدمنا الانحدار اللوجستي الثنائي لتقييم الارتباط بين إساءة معاملة الأطفال وإهمالهم والخصائص الاجتماعية السكانية.

النتائج: بلغت معدلات الانتشار مدى الحياة 33.1% للاعتداء البدني، و16.2% للإيذاء العاطفي، و3.7% للاعتداء الجنسي، و15.7% للإهمال العاطفي، وكان 7% شهداء على حالات عنف أسري. وكان احتمال التعرض للاعتداء البدني أو الإيذاء العاطفي أكبر لدى الأطفال الذين يعيشون في مناطق حضرية (نسبة الأرجحية = 1.4 و1.6، بينما كان فاصل الثقة 95% = 1.1–1.7، و1.2–2.2). وكان احتمال تعرُّض الفتيات للإيذاء العاطفي (نسبة الأرجحية = 1.8، فاصل الثقة 95% = 1.4–2.4) أو الإهمال العاطفي (نسبة الأرجحية = 3.4، فاصل الثقة 95% = 2.5–4.6) أعلى. أمَّا الاعتداء الجنسي فقد كانت احتمالية التعرض له أعلى بين الفتيان والأطفال من الأُسر الثرية (نسبة الأرجحية = 0.6، فاصل الثقة 95% = 0.3–0.9؛ نسبة الأرجحية = 0.5، فاصل الثقة 95% = 0.3–0.8، على التوالي). وكان احتمال التعرض للعنف الأسري أكبر بين الأطفال الذين كان آباؤهم عاطلين عن العمل (نسبة الأرجحية = 1.9، فاصل الثقة 95% = 1.1–3.2).

الاستنتاجات: تنتشر الإساءة والإهمال انتشارًا كبيرًا بين الأطفال الألبانيين في عمر 15 عامًا، وهو ما يثير المخاوف والقلق بشأن عافيتهم في المستقبل. ويجب اتخاذ الإجراءات اللازمة من جانب المهنيين والقائمين على الرعاية، وعلى مستوى السياسات، للتخفيف من الأثر السلبي للمشكلة وتعزيز حماية الأطفال وعافيتهم في البلد.

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