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ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
Editorial Team:
Honorary Editor: Gheorghiță Geană
Editor-in-Chief: Cornelia Rada
Assistant Editor: Alexandru Teodor Ispas
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Adina-Brândușa Baciu (biomedical anthropology, medicine, psychology)
Cornelia Rada (biomedical anthropology, medicine, psychology)
Mihaela Suzana Turcu (biomedical anthropology, medicine, psychology)
Valentina Marinescu (cultural anthropology, sociology, qualitative research methods)
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Costin-Marian Crînguș
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ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
Table of Contents
Santiago BOIRA, Maria Teresa MUNOZ, Anita NUDELMAN, SEXUAL VIOLENCE AGAINST
WOMEN IN ECUADOR: AN OVERVIEW FROM THE RURAL AND INDIGENOUS
AREAS OF IMBABURA .............................................................................................................1-14
Elisabeta NIȚĂ, Diana BRADU, Mihaela Camelia POPA, THE ROLE OF PSYCHOLOGICAL
SUPPORT FOR ADOLESCENTS WITH CANCER .............................................................15-23
Flavia-Elena CIURBEA, Marco CAVANNA, Cornelia RADA, PREDICTORS OF
ADOLESCENT INVOLVEMENT IN CLIQUES AND GANGS ..........................................24-48
Thi Kim Dung LE, CHARACTERISTICS OF TRADITIONAL VIETNAMESE FAMILY AND
ITS INFLUENCE ON COMMUNICATION CULTURE IN THE FAMILY ......................49-64
Gopal Chandra MANDAL, Saheli BISWAS, Pijush Kanti ROY, Kaushik BOSE, AGE
VARIATIONS AND SEXUAL DIMORPHISM IN ADIPOSITY AND BODY COMPOSITION
AMONG TRIBAL ADOLESCENTS OF KHARAGPUR, WEST BENGAL, INDIA .........65-77
Zahouo Pascale Ghislaine KOUAME, Adou Serge Judicael ANOUA, N'Doumy Noel ABE, HIGH
RISK OF POSTPARTUM HAEMORRHAGE AT BOUAKÉ UNIVERSITY HOSPITAL
(NORTH-CENTRAL CÔTE D’IVOIRE) ................................................................................78-91
Miana DINA, Jose Manuel Rodriguez GOMEZ, Cornelia RADA, DIMENSIONS OF CRIME
INVOLVING WOMEN IN DRUG TRAFFICKING - LITERATURE REVIEW FROM
DEPENDENT BEHAVIOR TO RELAPSE ...........................................................................92-116
Yahir GONZALEZ, Diego-Oswaldo CAMACHO-VEGA, THE IMPORTANCE OF WELL-
BEING AND SATISFACTION WITH LIFE IN READING-COMPREHENSION AND
MATHEMATICAL ABILITIES IN DEAF AND HEARING INDIVIDUALS ................117-128
Raja ZAKARIA, Hakima AMOR, Abdellatif BAALI, Noureddine ELKHOUDRI, BODY IMAGE
AVOIDANCE QUESTIONNAIRE AND ASSOCIATED FACTORS: A STUDY OF A GROUP
OF MOROCCAN ADOLESCENTS .....................................................................................129-138
Mihaela LUNGU, Elena Lucreția NEACȘU, Cornelia RADA, ANXIETY, DEPRESSION,
STRESS, EMOTIONALITY AND AGGRESSIVITY - FACTORS THAT MAY INFLUENCE
IRRATIONAL ALCOHOL CONSUMPTION AND RISKY SEXUAL BEHAVIOR ....139-164
Abdellatif BAALI, Hakima AMOR, Raja ZAKARIA, Noureddine EL KHOUDRI, Nadia FATHI,
Nadia EL KADMIRI, ASSESSMENT OF THE QUALITY OF LIFE OF A GROUP OF
SUBJECTS AGED 65 AND OVER (MOROCCO) .............................................................165-178
SPECIALISTS INVOLVED IN THE REVIEW OF ARTICLES AND ABSTRACTS IN THE
PERIOD 2012-2020 .................................................................................................................179-182
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
1
SEXUAL VIOLENCE AGAINST WOMEN IN ECUADOR: AN OVERVIEW FROM THE
RURAL AND INDIGENOUS AREAS OF IMBABURA
DOI: http://doi.org/10.26758/11.1.1
Santiago BOIRA (1), Maria Teresa MUÑOZ (2), Anita NUDELMAN (3)
(1) University of Zaragoza, Faculty of Social Sciences and Labor, Spain; E-mail:
mariateresammarco@hotmail.com
(2) Medicusmundi in Aragón, Spain; E-mail: anitanudelman@gmail.com
(3) Ben Gurion University, Faculty of Medical Sciences, Israel
Adress correspondence to: Santiago Boira, Facultad de Ciencias Sociales y del Trabajo, University
of Zaragoza. C/Violante de Hungría, 23, 50009 Zaragoza, Spain. Ph.: +0034976761000; E-mail:
sboira@unizar.es
Abstract
Objectives. Sexual violence against women is a major social problem for governments and
institutions. International reports warn about its magnitude and its global nature and findings from
Latin America have also confirmed the seriousness of the issue. The objective of this article is to
address the problem of sexual violence against women in Ecuador, with emphasis on rural and
indigenous areas.
Material and methods. The official data offered by the Attorney General of the State of Ecuador is
analyzed. Likewise, the qualitative information provided by professionals in the province of
Imbabura through interviews and focus groups.
Results. Quantitative data shows a very significant increase in the number of crimes of sexual
violence against women in practically all the provinces of Ecuador in the past three years. Likewise,
from a qualitative perspective, patriarchal culture is very present as one of the causes that explain
violence. As for the manifestation of sexual violence, its most frequent form is within partner
relationships. However, cases of incest, sexual abuse and aggression against minors within the family
environment are also common.
Conclusions. Data for disaggregated and specific monitoring of sexual violence in Ecuador is limited.
In this regard, the use of qualitative methodology to complement such information is recommended.
This study identifies a serious situation both in terms of the prevalence and of the impact of sexual
violence in Ecuador.
Keywords: sexual violence, Ecuador, abuse, rural areas, violence against women.
Introduction
The impact of sexual violence is a global issue which affects millions of girls and women
(World Health Organization, 2013). The World Health Organization (WHO) defines sexual violence
as "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to
traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless
of their relationship to the victim, in any setting, including but not limited to home and work" (WHO,
2002, p. 149). Likewise, it specifies different forms and contexts where sexual violence, which may
include: "rape within marriage or dating relationships; rape by strangers; systematic rape during
armed conflict; unwanted sexual advances or sexual harassment, including demanding sex in return
for favours; sexual abuse of mentally or physically disabled people; sexual abuse of children; forced
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
2
marriage or cohabitation, including the marriage of children; denial of the right to use contraception
or to adopt other measures to protect against sexually transmitted diseases; forced abortion; violent
acts against the sexual integrity of women, including female genital mutilation and obligatory
inspections for virginity; forced prostitution and trafficking of people for the purpose of sexual
exploitation" (WHO, 2002, p. 149-150).
Taking this into account, the Integral Organic Law for the Prevention and Eradication of
Gender Violence against Women in Ecuador (2018), defines sexual violence as: "Any action that
implies the violation or restriction of the right to sexual integrity and to voluntary decisions about
their sexual and reproductive life, by means of threats, coercion, use of force or intimidation,
including rape within marriage or other related kinship relationships - whether or not there is
cohabitation - the intentional transmission of sexually transmitted infections (STIs), as well as forced
prostitution, trafficking for the purpose of sexual exploitation, sexual harassment and other similar
practices. Sexual violence also includes the involvement of children in sexual activities with an adult
or any other person who is in a position of advantage over them, either because of their age, their
greater physical or mental development, or because of a kinship, affective or trusting relationship,
which binds them to the child, due to their position of authority or power. Sexual abuse, sexual
exploitation and the use of the image of children and adolescents in pornography also constitute,
among others, forms of sexual violence. Furthermore, this type of violence includes child pregnancy".
In Latin America, various studies have been conducted to try to establish the prevalence of
the phenomenon in the region and have demonstrated the seriousness of the problem of gender and
sexual violence (Contreras, Bott, Guedes, & Dartnall, 2010; Bott, Guedes, Goodwin, & Mendoza,
2012; WHO, 2013). Contreras et al. (2010) reviewed more than 200 published and unpublished
documents on sexual violence in Latin America and the Caribbean concluding that sexual violence is
a serious problem in the region and that it is most prevalent within a couple's relationship. Moreover,
according to these authors, if sexual violence is caused by someone other than a partner, its most
frequent forms are sexual abuse of children and youth, trafficking and sexual exploitation, sexual
violence in the migration process, sexual harassment at work and sexual violence as a result of
emergencies or armed conflict. The aforementioned study also shows that this type of violence has
its origin in a social order based on gender inequality and power relations between men and women,
where there is a tendency to legitimize violence against women in intimate relationships, to blame
women, to justify men or to consider women as sexual objects.
In terms of the prevalence of the problem in Ecuador, the Demographic and Maternal and
Child Health Survey (CEPAR, 2005) noted that 31% of Ecuadorian women of reproductive age
reported that they had ever been physically, psychologically, or sexually abused. Similarly, the
National Survey on Family Relations and Gender Violence against Women indicated that 6 out of
every 10 women in Ecuador have experienced some type of gender violence. On the other hand,
25.70% have experienced some type of sexual violence and 14.5% have suffered sexual violence
from their partner (National Institute of Statistics and Censuses of Ecuador, 2011; Camacho, 2014).
In Ecuador, this problem has been contextualized from different perspectives. For example,
Friederic (2013) analyzes women's rights including their sexual and reproductive ones. Likewise,
Goicolea (2001) and Goicolea, Wulff, Öhman and Sebastian (2009) explore issues such as women's
needs or the risk of teenage pregnancy. Also, Boira, Tomas-Aragones and Rivera (2017) and Boira
and Brunke (2018) examine the professional response and the context of impunity in which many of
these crimes occur. Among the studies relevant to the context of this article are those which focus on
the differences between the rural areas and the city (Astete & García, 2012; Boira, Carbajosa, &
Méndez, 2015; Cuvi, Ferraro, & Martínez, 2001), or on violence in relation to racial diversity in areas
where mestizo, Ecuadorian and Afro-descendant communities live together (Prieto, Cuminao, Flores,
Maldonado, & Pequeño, 2005; Salgado, 2009).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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As Boira et al. (2015) point out, a markedly sexist and patriarchal culture persists in Ecuador,
with a particular incidence in the rural areas where social pressure is strongest, thus increasing the
vulnerability of women and making it difficult for them to speak out or to denounce.
This study was carried out in the province of Imbabura, located in the Andean region of
Zone 1, in the north of Ecuador. It has an area of 4599 km2 and a population of 398,244. According
to the last available census, the average age is 29. In addition, 65.7% of its inhabitants are considered
mestizo, 25.8% indigenous and 5.4% Afro-Ecuadorian, and the illiteracy rate is 10.6% (National
Institute of Statistics and Censuses of Ecuador, 2010).
The objective of this article is to provide an overview of the issue of sexual violence against
women in Ecuador, with an emphasis on rural and indigenous areas such as Imbabura. To this end,
the data offered by the Ecuadorian Attorney General's Office will be examined together with relevant
findings related to this type of violence, based on previous research carried out by the authors of this
article.
Material and methods
For the purpose of this article, a mixed quantitative and qualitative strategy has been used.
The following sections outline the central aspects of the analysis carried out in our study.
Quantitative analysis
In order to assess the data on the prevalence of sexual violence, a quantitative analysis of
has been carried out concerning the different manifestations of sexual violence in each of Ecuador's
provinces. The data was obtained from reports of the Ecuadorian Attorney General's Office (2018).
For this work, we have analyzed the total sexual crimes reported by the Prosecutor's Office, as well
as the categories of rape, sexual abuse and sexual harassment. One of the limitations of the data
presented is that when violence against women or against a member of the family unit is discussed,
not only women are included, and the motivations for such violence sometimes may be others than
gender-based violence.
Qualitative analysis
The qualitative analysis is based on the first author’s involvement in the field, as a
Prometheus Researcher for the Ecuadorian Government during the years 2014 and 2015. As a result
of his work in Ecuador, several publications were produced that addressed different aspects of gender
violence in the country, mainly in the province of Imbabura: violence in rural areas (Boira et al.,
2015), violence from the point of view of the professionals involved (Boira, et al., 2017), femicide
(Boira & Rivera, 2016), and impunity (Boira & Brunke, 2018). In recent years, and as a result of
different training processes carried out in the country, there is a growing concern about sexual
violence towards women. This article uses primary materials from the articles cited above addressing
the specific issue of sexual violence against women and girls. Specifically, it gathers the transcriptions
of the interviews and focus groups carried out in Imbabura with professionals involved in addressing
violence against women, both from the public and private spheres. From the set of research
interviews, four are incorporated for this article, in which the participants were an activist from a
women's organization, a social worker, a doctor from a judicial team and a judge. Regarding the focus
groups, information is collected from four of them. Table 1 shows their main characteristics.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Table 1
Characteristics of the Focus Groups
Group Site
Number of
participants Gender
Mean age (in
years) Ethnicity
1 Peña
Herrera 5 6 women 42.4 Mestizo
2 Ambuquí 10 2 women
8 men 36.4
Mestizo/indigen
ous/ of African
descent
3 Peña
Herrera 6 6 men 43.1 Mestizo
4 García
Moreno 10
6 women
4 men 36.7 Mestizo
Results
Contextualization of crime and violence in Ecuador
According to 2018 data, the most populated provinces of Ecuador are: first Guayas, with
25.07% of the national population, second Pichincha with 18.30% of the population and third Manabí,
where a little more than 9.03% reside. These three provinces concentrate more than half of the
country's population (52.4%), which is why when we reviewed the number of crimes which amounted
to 347,819 in 2018; these three provinces concentrated more than half of them (57%): Guayas with
29%, Pichincha with 21% and Manabí 7%. In the case of the Province of Imbabura, 9,015 crimes
were committed in 2018, representing 8.8% of the crimes in the whole country. When examining the
typologies of the major crimes, it was found that among the ten most prominent are two related to
sexual violence: psychological violence against women or nuclear family members in third place with
13% and sexual abuse in the ninth place with 3%. In the case of Imbabura, the crime of psychological
violence against women or nuclear family members is the second most frequent, with 1,225 cases,
and the category of rape, abuse, and sexual harassment is the fifth most frequent, with 515 crimes. It
is significant that the most common typology is psychological violence and this type of violence tends
to figure between the first and third places in all provinces. This fact leads us to reflect that the major
type of violence in Ecuador is a violence that does not leave a physical mark on the victim, but
certainly affects their self-esteem, reducing their ability to react, which indicates a clear relationship
of inequality between the aggressor and the victim.
Impact and prevalence of sexual violence
When observing the data of cases of sexual violence against women in the country, it is
noteworthy that of the total crimes for 2018, almost 15% are about sexual violence (51,900 of a total
of 347,819). The province where the greatest number of news items on crimes of sexual violence
collected is Guayas with 19,032, which in this case represents 18.84% of the provincial total. If we
analyze the percentage of sexual violence crimes in relation to the total crimes in each province, the
provinces of Morona Santiago (30.38%) and Manabí (26.70%) have the highest percentage. In the
case of Imbabura, the percentage is close to 20% and thus clearly above the average of Ecuador as a
whole. Figure 1 shows the percentage of sexual violence crimes related to the total of crimes in the
country.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Figure 1
Percentage of crimes of sexual violence over total crimes
Source: developed base on data from the Public Prosecutor's Office
When relating to the different types of violence against women or members of the nuclear
family, including physical, psychological, and sexual violence, it is clear that sexual violence is the
most represented type of crimes, with Guayas having the highest percentage (30.68%).
In reviewing the 2018 data on sexual harassment in Ecuador, it is necessary to bear in mind
the differentiation between harassment of minors (18 years of age) and of adults. It is important to
emphasize the fact that the breakdown of the data into harassment of minors and adults indicates that
minors are being victims of this crime in a significant way. Out of a total of 2,401 sexual harassment
crimes in 2018, Guayas and Pichincha again are the provinces with the highest number of victims of
this crime. However, if analyzed according to the percentage of the population, the provinces with
the greatest number of reports of crimes of harassment are Galapagos and Pastaza.
In the case of rape, Guayas and Pichincha are again the provinces where this crime mostly
occurs. But it is important to look at the percentage of the population that these provinces represent
and the percentage of this type of crimes in relation to it, in order to know exactly if the degree is
higher.
In 2018, in the province of Imbabura, there were 227 sexual abuse crimes and 209 rape ones,
which represent 2.5% and 3.5% of the crimes of this type that occur in the country.
As for sexual abuse against women, an increase over time of this crime can be observed and
unfortunately more so over recent years, even doubling among some populations. This may be due
to its being underreported before or perhaps because they were not aware that this was a crime, having
"normalized" it, since women tend to suffer in silence, often without making the crime visible.
Table 2 illustrates the evolution of the crimes of sexual abuse and rape in Ecuador between
the years 2016 and 2018, and shows a significant increase in practically all the provinces of the
country in these two forms of crime.
0%
5%
10%
15%
20%
25%
30%
35%
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Table 2
Evolution of the crimes of sexual abuse and rape in Ecuador
Sexual Abuse Rape
Year/ province 2016 2017 2018 2016 2017 2018
Azuay 262 463 659 293 338 412
Bolívar 11 46 53 49 84 62
Cañar 81 88 128 84 114 124
Carchi 27 57 67 47 49 36
Chimborazo 114 145 144 136 165 205
Cotopaxi 58 122 159 99 131 140
El Oro 252 371 390 269 317 304
Esmeraldas 135 211 286 210 212 224
Galápagos 16 15 26 12 17 20
Guayas 818 1320 2070 912 1014 1110
Imbabura 127 212 227 132 175 209
Loja 114 187 235 157 164 177
Los Ríos 167 237 297 246 268 226
Manabí 356 516 604 329 422 476
Morona Santiago 82 156 239 198 229 234
Napo 39 64 107 87 86 77
Orellana 73 98 140 80 101 99
Pastaza 42 46 117 51 47 87
Pichincha 1028 1416 2101 879 938 921
Santa Elena 59 126 145 79 88 109
Santo Domingo de los
Tsáchilas 139 295 278 195 241 225
Sucumbíos 39 73 114 111 157 167
Tungurahua 96 98 201 101 132 158
Zamora Chinchipe 66 109 124 59 48 70
TOTAL FOR ECUADOR 4201 6471 8911 4815 5538 5873
Source: Author’s compilation based on data provided by the Public Prosecutor's Office
Sexual violence in rural and indigenous areas of Imbabura
This section reviews some emerging issues related to sexual violence in the context of the
above-mentioned research and, in particular, based on the focus groups carried out. Thus, it first
addresses the role of patriarchal culture and traditional and modern values in explaining sexual
violence. Secondly, the most common manifestations of sexual violence are characterized and finally,
the consequences of violence for the victims, low reporting rates and impunity are analyzed.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Patriarchal culture, tradition and modernity
In the descriptions made by informants, sexist attitudes and machismo frequently appear in
the context of violence suffered by women. However, most of the time these attitudes and behaviors
are only seen as affecting specific individuals, and not as a cultural manifestation that permeates
institutions and constitutes a background structure which models interpersonal relationships at all
levels of the social structure.
On the other hand, in addition to the transmission of patriarchal values, some narratives
explain the violence that occurs in the communities as a result of issues such as poverty,
overcrowding, or the influence of religious values related to sexual education. To illustrate, this is
this how a teacher narrated his conversation with a young boy on the school bus:
"Just yesterday I was talking to a boy and he said, 'The girl over there is my girlfriend'; well,
what is a girlfriend to you?"My girlfriend is my female", ah interesting, and what do you do with the
female, ah I go out to take a chance [...] I see, my son: And what is a chance? This is "chancear"
[making a gesture like having sexual relations]. I didn't know this. Well, who teaches you? Who
teaches you this? My daddy... [...] Many times it is not that the father or the mother teaches him.
Unfortunately the economic situation of the homes, they are poor and they share their room with the
children [...] The father and the mother, like in a normal home, are going to have their intimacy, and
they think that the children are already asleep; but the children are not asleep" (Ambuquí
professionals Group).
Similarly, some informants see the problem of violence in relation to the loss of traditional
values and in the confrontation between the new and the old, as well as in the double standards, which
some call: "prudishness" in social relationships. This confrontation of the new and the old also
incorporates other elements, such as the value of the indigenous perspective or the influence of the
Catholic Church.
The cultural narratives of these traditions are very powerful and can make it difficult for
women who suffer violence to get out of the situation and to report the aggression. In this regard, the
role of professionals can be decisive:
"In the end, both for the priest and the psychologists the message is: stay [together], marriage
is forever! If you won't go back to your husband, your child will have low grades, you can hurt
yourself or want to kill yourself, [instead] you should make a healthy family environment. What does
the woman do then, (she) endures" (Women's activist organization).
Characterization of sexual violence
This type of violence is significantly present in rural and indigenous areas. The types of
sexual violence that appear in the informants' narratives are primarily sexual abuse and assault among
adults both within and outside the couple, and sexual abuse of minors, especially girls. A type of
harassment and abuse that occurs in the educational setting is also mentioned.
These situations tend to be hidden in the "public narrative" of community members because
they are considered taboo. However, the professionals who work in these areas also refer to cases that
allude to situations of incest and stepfather’s relationships with their stepdaughters, who are girls or
adolescents.
"Here in the parish I am the authority in charge. It is really a social problem that is difficult
to deal with, not only here in the parish, and much more difficult in the rural areas where we live [...]
Domestic violence is not only towards the wife but also towards the children, and it is not only
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
8
physical violence and beating, there are also rapes from fathers to daughters. There are very serious
cases that have really worried us a lot, and many girls have committed suicide here, according to
investigations that have been carried out in cases in which were abused by parents, uncles, cousins...”
(Group of Garcia Moreno professionals).
In another testimony, a professional from the judicial units comments:
"I have worked in rural communities, let's say with a mestizo population, an indigenous
population, an Afro population... I don't have any data on that, but the abuse has been seen from
grandparents to granddaughters, from fathers to daughters, from stepfathers to stepdaughters"
(Social worker, judicial team).
In some of these narratives about sexual abuse the idea of "complicity" of some mothers in
these situations is mentioned, in which even their social role as a mother begins to be performed by
their daughter, leading to dramatic consequences that can result in suicide.
When relating to the sexual violence suffered by many women at the hands of their partners,
a doctor from the judicial team comments:
"In that case that I was telling you about, you see, the couple has been drinking alcohol
among friends and an argument erupts and they hit each other […]. In the evening, he wants to have
sex, and she is his wife, and because they have fought and she doesn't want to and she says, 'No, we're
not going to fight, don't even look at me. And he takes her and forces her and has forced penetration
and that is already a violation" (Medical judicial team).
Another form of abuse that appears in some narratives of different groups occurs from
teachers against students in educational settings, mostly relationships between secondary school
students (mainly girls) and teachers. These issues are well-known by the community, although, the
same as regarding incest, they are covered up and do not initially emerge:
"The Rector has been told not to allow that [the relationship between students and teachers].
Here we have the example of a 15-year-old girl who got pregnant by a teacher, now they live
together" (Group of Peña Herrera professionals).
This form of inter-generational abuse is reinforced in another one of the groups:
"Yes, exactly, for example, this is what it has been like here in the Educational Unit for many
years, I remember since I was a student myself. There were relationships between teachers and
students, many of them even made it to..., they didn't get married, the student and the teacher had
their home and their family, and soon afterwards they [usually] separated as a result of their age
gap, because imagine a graduate getting married: a 40-year-old man with a 16-year-old girl" (Group
of Ambuquí professionals).
Consequences of violence for victims, lack of complaints, reporting and impunity
The consequences for girls and women who suffer this type of violence are always very
serious often leading to psychological repercussions, low school performance, premature
pregnancies, suicide and femicide. It is also necessary to consider that situations of sexual abuse
usually continue over time and the consequences can be irreversible. One informant describes the
following:
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"We have to sensitize the parents, and also students from the age of twelve or thirteen we
should sensitize them so that they are they themselves are the spokespersons who warn or report,
because [now] they remain silent out of fear so they never warn others [...] When we made a survey
we realized by these students’ performance, their low performance, they also seem to be distracted,
and while the rest are playing games they suddenly leave" (Group of professionals García Moreno).
Regarding the influence of the experience of violence and sexuality on victims’ body image,
one of the professionals explains that women who suffer continuous sexual abuse feel that their body
does not belong to them and may even feel it is alien to them.
"[When you talk to women] you shift from cultural issues to sexuality and even to the issue
of intimacy. They say, for example, that they don't undress [to have sexual relations], so that their
body doesn't belong to them. We wondered why they don't plan anything: first, because men don't
allow them to take any contraceptives and because there is a taboo on the subject of ligatures, if a
woman is going to have ligature it is because she is going to have another guy, they are going to be
betrayed and all that. ... They don't make violence visible in their bodies" (Women's activist
organization).
An issue that is often closely related to violence is early pregnancy among teenagers. There
are many young girls who become mothers at a very early age and are left alone, as in most instances
the father of their child disappears. Thus, in these cases, the bonding of the sons and daughters is
usually with the mother and not with the father. It is also common for a single mother to bring her
children into a new relationship. In other instances, these young mothers remain in relationships that
can become violent at an early stage and the presence of the children may act as a deterrent to leaving
the relationship, radically conditioning their way of life and hindering any type of decision.
The low rates of reporting and the impunity for many of these aggressions is another aspect
that transpires from the narratives of the informants. The difficulty in reporting is due to different
causes. On one hand, because it involves a complaint against family members, often questioning the
credibility of the girl's testimony or even blaming her for what happened:
"I have seen cases of mothers who beat their daughters because they don't believe the
daughters when they tell them that the father or stepfather is raping them" (Group of García Moreno
professionals).
On the other hand, another reason for not filing a complaint is that it is usually not going to
succeed due to a lack of institutional support. However, it seems that professionals are well aware of
cases of violence in the communities where they are working. One of them even asked himself: well,
we are here, what can we do? Thus, expressing his tiredness and frustration:
"I know the problems of each of the homes, even if you don't believe it, one already knows
what is happening here or what is happening there [...]. Here are all the authorities: what do we do?
It's not just about telling the truth. Sometimes you feel powerless, as a teacher, because you don't
have money and support of the other institutions, because in effect we are told: 'you have to do this,
you have to fight against this, you have to finish this'. I always disagree with this, because these are
nice words that they are telling us, and I ask, but how?" (Group of Ambuquí professionals).
Regarding the impunity in some of the narratives, the question of the 'role played by the
indigenous justice system' appears. Although it is a right recognized in the Constitution, it is possible
that it could have negative effects in addressing violence against women, provoking processes of re-
victimization or even protecting the aggressor, is noted.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
10
"The issue of indigenous justice is very sensitive because the national legal framework
grants indigenous communities the power to apply their tradition and customs and to enforce justice
[...]. I was about 10 years into my professional career there, and unfortunately I must say that in
cases of domestic violence, people are re-victimized, especially women. I was in some meetings,
especially those of the town councils where women were accused of these aggressions [...], those that
are there are all men and they are older people y they tend to advise the woman:"don't do this because
if you do it, he will punish you" or, "why did you do that? that's why he punished you", "and then
comes the matter of keeping the family (together) despite everything" (Judge).
Discussions
The problem of the lack or inconsistency of statistical series showing the true impact of
sexual violence is also an issue in other Latin American countries. Alméras and Calderón (2012)
identify this situation, emphasizing that these countries do not have a system of indicators that can be
standardized and compared over time. They also point out that the statistics do not show the real
impact of the problem due to the low rate of complaints.
On the other hand, as already noted by the WHO (2002) the available data only reflect the
cases reported, so it is to be expected that the severity of the problem may be much greater due to, as
already noted in this article, the difficulty in reporting this type of violence. In line with the WHO
report, sexual violence can be visualized as an iceberg floating in the water, where the small visible
tip represents the cases reported to the police, but below the surface a significant unquantified part of
the problem remains. In this regard, the use of qualitative methodology such as in-depth interviews
with victims and, above all, the way in which information is obtained, are very important
considerations when assessing the impact and depth of the phenomenon (Nudelman, Boira, Tsomaia,
Balica, & Tabagua, 2017).
In accordance with what has already been noted in the review by Contreras et al. (2010), the
quantitative data available for Ecuador shows a very significant increase in the number of reports of
crimes of sexual violence against women in practically all provinces in the last three years. The
specific case of Imbabura province is no exception, as the data indicates that this type of crime has
virtually doubled. For example, regarding sexual abuse, the number of crime reports has increased
from 127 in 2016 to 227 in 2018. Likewise, the data on rape has risen from 132 in 2016, to 209 in
2018.
Patriarchal culture as a cause of violence is clearly evident in the findings of this study, thus
supporting the conclusions of some of the most relevant authors who have studied this topic in the
last decades at an international level (Dobash & Dobash, 1979; Connell, 2013; Mshweshwe, 2020;
Tonsing &Tonsing, 2019). Patriarchal culture defines, in a very powerful way, the gender and sexual
roles of what it means to be a man and a woman, their modes of behavior and social mandates, as
well as what is and is not allowed for both men and women in emotional relationships and in sexual
behavior. The loss of family and community values and the incorporation of individualism due to
globalization and neoliberalism are also seen as the origin of dysfunctions within the family and of
violence. However within this perspective, traditions can always mask a patriarchal vision that opts
for permanence and asymmetry in gender relation.
The events of violence reported by the informants do not differ from those in other settings
and the most common one is sexual violence in the context of partner relationships. However, cases
of incest, as well as sexual abuse and aggression against minors in the family environment also stand
out (Boira et al., 2015). Finally, the low rate of complaints and the ambivalent role of the so-called
"indigenous justice" draw a scenario of impunity and reinforce the passivity and the silence of the
victims. Regarding the low level of complaints, Bravo (2011) emphasizes that sometimes
professionals themselves use arguments in defense of family stability that may deter reporting. He
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
11
also underlines the lack of strong evidence and of objective witnesses, the slowness of the proceedings
and the rigidity and complexity of criminal proceedings as additional causes of these situations.
Both the analysis of the reports of the Prosecutor's Office and the qualitative data from the
field work indicate the seriousness of the prevalence of sexual violence as well as its impact on
women, which are recognized as a political and social problem, affecting the Ecuadorian society. In
this regard, the State has promoted different measures such as the recent legislation on gender
violence (Integral Organic Law for the Eradication of Violence against Women, 2018); the creation
of a specialty at the Public Prosecutor's Office on the issue of gender violence and the training and
capacity building that some provinces are receiving on these issues. Nevertheless, the influence of
the patriarchal culture on violence continues to be important in Ecuador, and therefore, it is crucial
to increase the visibility of the sexual abuse experienced by women as well as the sex education they
receive (Jerves et al., 2014).
Overall, in the Latin American region there have been important advances in national
legislation in recent years. Nevertheless, there are still challenges to be faced in addressing violence
prevention against women in all its forms. Likewise, as noted by the WHO (2006), it is necessary to
continue fighting against the lack of impunity in which many of these crimes remain, shifting from
words to actions and considering the crucial responsibility that States have in this matter.
Regarding the limitations of the study, the qualitative analysis is focused on a specific region,
which makes it difficult to generalize the results to other areas of Ecuador. The objective of future
research would be to expand the analysis to other areas of the country. In addition, it will be important
to specifically analyze the roles played by the Catholic Church and by other cultural traditions in
relation to sexual violence.
Conclusions
Even though different sources of information were used, our study has shown that there still
is a lack of data on sexual violence in the Ecuadorian context and specifically of permanent and
conveniently disaggregated series over time that would allow for specific monitoring of crimes of
sexual violence against women. This is a fundamental factor, not only to assess the real impact of the
problem, but also to promote and guide public policies.
In terms of the crimes of sexual abuse and rape in Ecuador, they have increased significantly
in recent years both in Imbabura and in practically all the provinces of the country.
From a qualitative research point of view, and based on the discourses and narratives
gathered in this study, patriarchal culture is very evident as one of the critical causes that explain
violence. Regarding the characterization of sexual violence, the study concludes that among adults,
women are sexually abused and assaulted both by their partner, as well as outside the couple relation,
while minors, especially girls, are also sexually abused. Additional conclusions that can be drawn
from the qualitative analysis are the low rate of reporting by victims and the impunity in which many
of the perpetrators remain.
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1&isAllowed=y
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THE ROLE OF PSYCHOLOGICAL SUPPORT FOR ADOLESCENTS WITH CANCER
DOI: http://doi.org/10.26758/11.1.2
Elisabeta NIȚĂ (1), Diana BRADU (2), Mihaela Camelia POPA (3)
(1) PhD. Student, School of Advanced Studies of the Romanian Academy, "Constantin Rădulescu-
Motru" Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy,
Bucharest, Romania;
(2) Pilot Complex of Curative Pedagogy "Orpheus" Chișinau, Moldova; E-mail:
dianabradu1@gmail.com
(3) "Constantin Rădulescu-Motru" Institute of Philosophy and Psychology, Department of
Psychology, Romanian Academy, Bucharest, Romania; E-mail: popa_zaizon@yahoo.com
Address correspondence to: Elisabeta Niță, School of Advanced Studies of the Romanian Academy,
"Constantin Rădulescu-Motru" Institute of Philosophy and Psychology, Department of Psychology,
Romanian Academy, Calea Victoriei 125, Sector 1, 010071, Bucharest, Romania. Ph.: + 40-720-100-
692; Fax + 40-21-312-02-09; E-mail: beti_iris@yahoo.com
Abstract
Objectives. The aim of the study was to identify specific elements of stress for adolescents surviving
cancer, and the working hypothesis was that there are statistically significant correlations between
the items of the three scales used in the study.
Material and methods. Between January and February 2020, 45 adolescents participated (13-18
years), 26 girls and 19 boys, in a survey in which three tests were used: Child Depression Inventory -
CDI 10 items, Scale of irrationality for children and adolescents-CASI with 28 items in four subscales
(Intolerance to frustration given by rules, Global self-assessment, Absolutist requirement for justice,
Intolerance to frustration given to work) and post-traumatic developmental scale-SRGS with 15
items.
Results. Statistically significant associations were identified between certain items from the scales
used in the study and the result very highly statistically significant is given by associating item "I
realized it was better to have more trust in me" with item "I learned to defend my personal rights" ( p
<0.05, χ 2 t east). The interaction between the dependent variable "I learned to defend my personal
rights" with the independent variables "It's awful to be wrongfully blamed by the teacher" and "There
are things that bother me" through the regression model and the result was statistically significant (p
<0.05, F test).
Conclusions. The associations and the results obtained indicate the need for effective communication
with adolescents with cancer to identify psycho-emotional needs and stress management.
Keywords: cancer, depression, anxiety, adolescence, stress.
Introduction
In the treatment of anxiety, depression, fear, pain of children/adolescents with cancer,
paediatric medical traumatic stress, cognitive behavioural various therapy techniques are
applied: pre-exposure, positive reinforcement, relaxation and breathing exercises, modelling,
systematic desensitization, guided imaging. One of the most common psychiatric symptoms in the
acute phase of cancer diagnosis and treatment is anxiety. Most of this anxiety is situational and does
not meet the diagnostic criteria for a specific syndrome. Specific types of anxiety include separation
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
16
anxiety, defined as inadequate and excessive separation anxiety from home or from those to whom
the child is attached. Younger children, children who have not been away from home overnight
or children with pre-existing anxiety disorders will certainly develop symptoms of separation
anxiety (Kreitler, Weyl Ben-Arush, & Martin, 2012, p. 23).
Acute Stress Disorder (ASD) is a physiological and emotional response to an event involving
the child or to a death or injury threatening event of intense fear, horror or helplessness. Like post-
traumatic stress disorder (PTSD), ASD includes physical symptoms, memory avoidance, and
intrusive thoughts of the event that was traumatic. ASD differs from PTSD in three ways: (1) it
is limited in time (not less than 2 days, not more than 4 weeks); (2) it is acute (within 4 weeks of the
traumatic event); and (3) it involves dissociative amnesia, numbness, depersonalization, derealisation
or feeling dizzy/dizziness. In children /adolescents agitation and disorganized behaviour ASD can
manifest itself through agitation and disorganized behaviour, particularly as a response to a perceived
threat. Children and adolescents with pre-existing anxiety disorders are at higher risk for both ASD
and PTSD. Given the overlap of the symptoms, the ASD may be confused with depression, anxiety or
delirium (American Psychiatric Association, 2016, p. 280).
Delirium is a fluctuating neuropsychiatric disorder due to encephalopathy. This type of
brain disorder often reflects an electrolyte imbalance, drug toxicity or organ failure and it is a poor
prognosis sign with hospitalized patients. The symptoms of apathy, anxiety, disorientation,
hallucinations, and delusions appear to be similar in adults and in children with delirium. Wake-up
disorder-sleep, impaired attention, irritability, agitation, emotional labiality and confusion are more
commonly seen in children / adolescents , while impaired memory, depressed mood, speech disorder,
delusions and paranoia are more commonly seen in adults. Although delirium in adults is a significant
concern, literature on delirium in children is still quite limited. A study published in 2010 examined
the literature of the period 1980 - March 2009 and found data on 217 paediatric patients with delirium
defined and 136 with "probably delirium". Among children / adolescents with delirium, 7%
had cancer (Kreitler et al., 2012, p. 43).
It is difficult to determine whether a child / adolescent with cancer is depressed or
not. Common symptoms of depression, such as changes in sleep or appetite, can be attributed to
illness or treatment. Boredom and energy conservation can be confused with anhedonia. They can
experience the fatigue related to chemotherapy, may have symptoms of energy decline, lack of
interest in activities they enjoyed before illness and social withdrawal. Despite these problems, recent
studies have found that in the case of chemotherapy, it is possible to distinguish between fatigue and
depression and to be able to continue with an appropriate intervention. There is also evidence that
self-reporting measures can be used to identify children who need interventions for anxiety,
depression, post-traumatic stress, both for themselves and for their parents and siblings (Kreitler et
al., 2012, p. 49).
Structured monitoring is needed throughout the history of cancer and not just during active
treatment. A child-cantered care philosophy would guide the child to achieve a state of health and
welfare (Darcy, Enskär, & Björk, 2019, p. 2).
Paediatric cancer has many challenges for the life of the child and his family. Among the
studies investigating risk and protection factors, social support has emerged as an important
construct. However, not much is known about how family members support each other in this
particular context. This process was explored in a qualitative study in which interviews were
conducted separately with mothers, fathers and siblings. Data analysis revealed three themes: being
together-families identified the need to be together physically; finding support in communication -
the complexity of sharing emotions; working together as a team-the families described work
together. The study broadens the understanding of the interpersonal process of providing family
support when dealing with paediatric cancer, and clinicians should be sensitive to the various
communication needs related to cancer within the family (for example, the need to speak or not to
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
17
speak); to incorporate this type of knowledge into their care giving practice (Schoors, Mol,
Verhofstadt, Goubert, & Parys, 2019, p. 6).
Given the above-mentioned circumstances, this study aims to identify specific elements of
stress for adolescents surviving cancer.
Material and methods
Between January and February 2020, a survey used three tests as follows: the Child
Depression Inventory test, the short version-CDI with 10 items (Kovacs, 2012 , p. 79), the
Irrationality Scale for children and adolescents-CASI with 28 items in four subscales (Intolerance to
frustration given by rules, Global self-assessment, Absolutist requirement for justice, Intolerance to
frustration given to work) (Bernard & Cronan, 2007, p. 4), Post-traumatic development scale -SRGS
with 15 items (Park, Cohen, & Murch, 2007 , p. 5). The study also included an open-ended question
in which respondents were asked to write the words they wanted to hear and the words they did not
want to hear from adults.
The study involved 45 adolescents, 13-18 years, 26 girls and 19 boys, of whom 11 were
about one year after diagnosis, 8 about two years after diagnosis, 12 about three years after diagnosis,
14 about four years after diagnosis.
The working hypothesis was that there are statistically significant correlations between the
items of the depression scale, the irrationality scale for children and adolescents and the post-
traumatic development scale for adolescents (13-18 years old) cancer survivors.
For the statistical analysis of the results obtained from the two tests, the statistical program
Epi Info was used, a statistical software developed by the Centers for Disease Control and Prevention
(CDC) in Atlanta, Georgia (USA) and licensed as a public domain (Epi Info™ , 2019, para. 1).
The association between the response categories was analyzed using the chi-squared test, a
contingency table between the items in the scales. Linear regression was also used to
identify which variables are, in particular, significant predictors of the resulting variable and to
explain the relationship between a dependent variable and one or more independent
variables. Regression analysis has helped to put out how much the dependency variable changes with
a change in one or more independent variables.
Results
The items on the post-traumatic scale with the highest score were: "I realized that it is
good to have more confidence in myself and I learned to defend my personal rights".
From the irrationality scale for children and adolescents the items with the highest
score were: "It is awful to be wrongfully blamed by the teacher/A teacher who wrongfully blames a
student is totally bad /Teachers should be correct all the time /I need to be rested and relaxed before
I start working hard".
The subscale absolutist requirement for righteousness had a higher score, the subscales
overall assessment of oneself and intolerance to the frustration caused by the rules scored on average
and the subscale intolerance to frustration of the work scored low.
A statistically significant association was found between the item "I realized that it is good
to have more confidence in myself" from the post-traumatic development scale with "I learned to
defend my personal rights" (p = 0.0001, chi-squared = 23.06, df = 4) (table 1).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
18
Table 1
Association of items from the post-traumatic development scale
Items/Answer variants Disagreement To some extent
agree
Strongly agree
n % n % n %
I learned to defend myself
personal rightsa
3 6.67 7 15.56 35 77.7
I realized it was
good to have more confidence in
myself a
3 6.67 7 15.56 35 77.7
Note. N = 45 participants aged between 13 and 18 years areflect the number and percentage of participants for each response variant
A statistically significant association was found between the item "It is awful to be
wrongfully blamed by the teacher" on the irrationality scale for children and adolescents with
the item "Teachers should be correct at all times" (p=0.0179, chi-squared=24.40, df=12) (table 2).
Table 2
Associating items from the irrationality scale for children and adolescents
Items/Answer
variants
Strongly
against
Against Uncertain I agree Strongly agree
n % n % n % n % n %
It is awful
to be blamed
unjustly by the
teacher a
2 4.44 2 4.44 1 2.22 22 48.9 18 40
Teachers should be
correct all the time 0 0 2 4.44 5 11.11 2. 3 51.11 1 5 33.34
Note. N = 45 participants aged between 13 and 18 years a reflect the number and percentage of participants for each response variant
A statistically significant association was identified between the item "I'm not sure if things
go well" inventory of depression Child Depression Inventory with the item "There are things that
bother me" (p = 0.0076, chi-squared = 13.89, df = 4) (table 3).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
19
Table 3
Associating items from the depression inventory
Items / Answer variants Always Often Occasionally
n % n % n %
There are things that bother me a 27 60 5 28.89 5 11.11
I'm not sure if things go well a 22 48.89 22 48.89 1 2.22
Note: N = 45 participants aged between 13 and 18 years a reflect the number and percentage of participants for each response variant
Also the regression model has been analyzed the interaction between the dependent
variable "I learned to defend my personal rights" with the independent variable "It is awful to be
wrongfully blamed by the teacher" (table 4) and "There are things that bother me" (table 5), and the
result obtained was statistically significant (p <0.05, F-test).
The connection between the variables independently of it and the dependent
variable was synthesized by the equations of the straight lines of regression as follows: For any value
of the variables "It is awful to be wrongfully blamed by the teacher" and "There are things that bother
me" a value of the variable can be predicted "I learned to defend my personal rights"; thus for the
average level of the variable "It is awful to be wrongfully blamed by the teacher" of 9.5345 the value
of 3.0611 was obtained. For the variable "I learned to defend my personal rights", and for
the average level of the variable "There are things that bother me" about 4.1782; the value of 0.787
was obtained for the variable "I learned to defend my personal rights".
Table 4
Linear regression- I learned to defend my personal rights
effect Estimated
coefficients
SE 95% CI p
LL UL
Fixed effects
Intercept
0. 668
0. 347
0. 032
1. 368
0. 06
Random
effects
It is awful to
be
wrongfully
blamed by
the teacher
0. 251
0. 081
0. 087
0. 414
0. 03
Note. N = 45, SE = standard deviation of the coefficient distribution, CI = confidence interval, LL =
lower limit, UL = upper limit
The correlation coefficient indicated that 18% of the variability "I learned to defend my
personal rights" can be explained by the variable "It is awful to be wrongfully blamed by
the teacher" and that 9% of the variability "I learned to defend my personal rights" can be explained
through the variable "There are things that bother me" (table 5).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
20
Table 5
Linear regression- I learned to defend my personal rights
effect Estimated
coefficients
SE 95% CI p
LL UL
Fixed effects
Intercept
1. 839
0. 105
1. 626
2 . 052
0.00
Random
effects
There are
things that
bother me
-0. 252
0. 123
-0. 50
-0. 000
0.04
Note. N = 45, SE = standard deviation of the coefficient distribution, CI = confidence interval, LL =
lower limit, UL = upper limit
Looking at the words that teenagers diagnosed with cancer want to hear from adults, the
following stood out: you will succeed /I support you / I am with you / I am proud of you / I love you/
thank you/I will be with you/you are right/ well done. Also the words respondents do not want to hear
from adults were: it is not possible/ You will not succeed / does it still hurt? are you sick?/ wait / that's
it / nothing is going well / it could be even worse / you don't know anything / you're not good at
anything / you have no ambition / that it will be fine when things are getting worse and worse.
Discussions
Childhood cancer is a disease that has an impact on the lives of the whole family. Supporting
families to cope with these stressful experiences should be a priority during treatment. However,
psychological support is sometimes inadequate in hospitals. Families also reported that the support
they receive decreases when the child/adolescent completes treatment, a time when family members
have few resources to cope with new stressors, adjusting to normal life (Marusak, 2018, para. 4). The
fact that patients in the study identified a correlation between self-confidence and personal rights
denotes the fact that in the efforts to cure cancer psychological support as standard of care for the
whole family, both during and after the treatment, should be supported.
Also the correlation obtained in the study between self-confidence and various things that
bother highlighted/ emphasized an uncovered need for psychological support among families of
children/adolescents treated for cancer. For example, parents of children/adolescents with cancer face
existential, physical, psychological and social struggles. They describe an unstable situation after
diagnosis and have focused on protecting the child during treatment. After completing the curative
treatment, they face challenges in daily life, as it was before the diagnosis, namely to deal with their
own emotional scars and fears related to child cancer (Carlsson, Kukkola, Ljungman, Hove´n, & von
Essen, 2019, p. 6).
Moreover, the existence of family dynamics and the natural difference in authority between
children and caregivers can complicate the treatment decision-making process. Clinicians need to
continually assess the extent to which children are given their own "voice" in the family system, the
degree to which children are aware and want to support their caregiver's preferences, and any
discrepancies in the amount and type of information provided to both parties since all the factors can
significantly influence the outcome of the decision level (Abrams, Muriel, & Wiener, 2016, p. 9).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
21
The present study was done before the Covid-19 pandemic and highlights elements of
stress, another study during the emergency of the Covid-19 pandemic on a diverse population of
Romania indicates statistically significant associations between terrified, destroyed emotions and the
statement "I have thoughts which I try to avoid", between happy emotion and utterance sometimes "I
try to keep myself busy just to keep thoughts from taking over my
mind", between satisfied emotion and utterance "I often do various things to distract myself from the
thought", both studies in fact highlighting landmarks for psychologists and not only for efficiency in
the psycho-emotional analysis of patients in crisis situations in the intervention stage (Sîrbu, Niță, &
Șchiopu, 2020, p. 16).
Soothing approaches, individual and group therapy and how to communicate about the
medical activities in which they are involved are important for managing stress in adolescents (Yildizi
& Oğuz, 2020, p.81) and living with cancer and the possibility of recurrence requires well-being and
psychological resilience to cope with treatment, the effects of disease and uncertainty about the future
(Booth, et al., 2018, p. 6).
The individual, family and social vulnerability of adolescents, as well as the individual and
family coping skills, are factors related to the mental health of adolescents in times of
crisis. Adolescents are often vulnerable, require increased care from caregivers, adaptations to the
health system, future research on adolescent psychiatric disorders during pandemics, as such a global
situation could be prolonged or repeated (Guessoum et al., 2020, p. 291).
A 2019 study identified three important topics related to the disease experience of
adolescents with cancer, namely: "Loss of what I know-that makes me different", "Communication
and exchange of information-the need to know" and "The importance of friends, colleagues and
relationships" (Drew, Kable & Van der Riet, 2019, p. 492). The results of the 2019 study and those
in this article highlight that accessing this information will allow health care providers to provide
more appropriate care when these adolescents feel most vulnerable.
Adolescents with cancer experience a continuous and dynamic process of growth and
maturity between the intrapersonal, interpersonal and environmental dimensions, and the goal of their
health care is to achieve internal integration, positive changes in their environment, a harmonious and
balanced existence with the outside world (Eunji & Sharron, 2020, p. 172).
There is a clear need for further research on rehabilitation interventions and care models for
children / adolescents with cancer. Incorporating rehabilitation into paediatric cancer care requires an
interdisciplinary effort and depends on greater involvement of all health care providers and healthcare
professionals, as well as familiarity with the tools and resources that can be used to improve the
quality of life in this population (Tanner et al., 2020, p. 14).
Conclusions
Participants in the current research greatly appreciated that the injustice and blame on
the part of teachers is particularly disturbing, which indicates that adolescents with cancer have a
great need for understanding, adequate communication to avoid stigma and psychological
suffering. For them lack of self-confidence, the different things that disturb and the vulnerable
situations have indicated the need for support for adaptive operation, and to reduce the effects of
chronic stress self-effectiveness and psychological well-being can be developed through specific
actions and personalized care. The statistically significant associations in the present study and the
results obtained at the three scales used in the survey provide benchmarks for effective
communication with adolescents with cancer, possibly also for identifying psycho-emotional needs
and stress management.
The results of this study highlighted some important elements of psychological
interventions for adolescents with cancer that lead to lower levels of psychological well-being, mood,
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
22
liveliness, self-esteem and motor and physical functioning, such as increased anxiety and problematic
behaviours.
Acknowledgements
This study is part of the doctoral research project entitled "The impact of pediatric neoplastic
disease on family life", coordinated by PhD. Camelia Mihaela Popa, at the School of Advanced
Studies of the Romanian Academy, "Constantin Rădulescu-Motru" Institute of Philosophy and
Psychology, Department of Psychology, Romanian Academy, Bucharest, Romania.
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PREDICTORS OF ADOLESCENT INVOLVEMENT IN CLIQUES AND GANGS
DOI: http://doi.org/10.26758/11.1.3
Flavia-Elena CIURBEA (1), Marco CAVANNA (2), Cornelia RADA (3)
All authors of article have contributed equally.
(1) PhD. Student, School of Advanced Studies of the Romanian Academy, "Constantin Rădulescu-
Motru" Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy,
Bucharest, Romania;
(2) University of Padua, School of Psychology, Department of Developmental Psychology and
Socialization, Italy; E-mail: gcavannamarco@gmail.com
(3) "Francisc I. Rainer" Anthropology Institute of the Romanian Academy, Romania; E-mail:
coreneliarada@yahoo.com
Address correspondence to: Flavia-Elena Ciurbea, School of Advanced Studies of the Romanian
Academy, "Constantin Rădulescu-Motru" Institute of Philosophy and Psychology, Department of
Psychology, Romanian Academy, Bucharest, Romania, 13 September Avenue, No.13, 5th District,
Bucharest, 050711, Romania. Ph.: +40-746-692-576; E-mail: ciurbeaflavia@gmail.com
Abstract
Objectives. The gangs came to the attention of the authorities because of the criminal nature of some
of them. To understand which are the appropriate measures to prevent and reduce gang delinquency,
this paper aimed at identifying the predictors of adolescents' belonging to such groups.
Material and methods. Relevant articles published between 2010 and 2020, were searched in three
access platforms to the scientific literature. The papers based on the quantitative analysis of the data,
which evaluated the predictors of the involvement of adolescents aged 14-21 in gangs, were
preserved.
Results. Resulting in 33 significant articles, with samples between 75-26232 participants, 11 studies
had a longitudinal design, the rest being cross-sectional. Most studies were conducted in the USA,
and the rest in European, American, African, and Asian countries. Three categories of predictors were
distinguished: familial factors (e.g. deficient parenting, domestic violence), personal factors (e.g.
trauma history, low level of self-control), social and economic factors (e.g. criminogenic
neighborhood, material and financial instability). The most common predictor was the criminogenic
neighborhood, identified by 16 studies. There were also highlighted gender differences regarding
gang membership, adolescent boys being more likely to be gang members.
Conclusions. This systematic review highlighted that the main factors that can compete to adolescent
gang involvement are: criminogenic social environment, low level of self-control, dysfunctional
family-educational environment, and low socioeconomic level. As research has shown that many of
these can be risk factors for violence, it is necessary to develop coping strategies and heal traumas to
prevent the formation and maintenance of the antisocial identity of adolescent gangs.
Keywords: gang, clique, adolescents, violence.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Introduction
For adolescents, entering this period of development brings with it changes, from which
social relations are no exception. Adolescence corresponds to a period of biological, mental, and
social vulnerability (Selosse, 1978, pp. 503-511, as cited in Săucan, Liiceanu, & Micle, 2009, p.11). Even if they continue to have friends in the form of a dyad, it can be noticed the importance that
adolescents give to the type of community called clique, respectively to the larger ensemble, specific
to adolescence - the gang - whose purpose is to gives its members identity, image or a certain
reputation (Papalia, Olds, & Feldman, 1978/2010, p. 411). "Sitting between two chairs, between his
family of origin, from which he separates, and the one he has not yet founded, between the school
that, most of the time, no longer interests him, and the labor market, which receives him reluctantly,
the adolescent often takes advantage of the freedom that adults give him and their vaguely worried
tolerance" (Cusson, 2002, as cited in Săucan, Liiceanu, & Micle, 2009, p.11).
The "gang" concept refers to a phenomenon that initially appeared in North American cities
in the twentieth century, and its meaning differs slightly from one country to another (Smith & Egan,
2014). According to the National Gang Intelligence Center (2015), "street gangs are criminal
organizations that formed on the street and operate in neighborhoods throughout the United States"
(p. 11). In Europe, however, "an annoying group of young people" may correspond to the term "gang"
with the characteristic of sustainability, street orientation, and an identity shaped including by
involvement in illegal activities (Klein, Weerman, & Thornberry, 2006, p. 418). A particular type of
gang is the prison gang, which is formed in the criminal system, but which continues to act outside
the prisons (National Gang Intelligence Center, 2015). The clique, on the other hand, is a concept
which designates "a small group of people who spend their time together and do not welcome other
people into that group" (Cambridge Dictionary, n.d.).
Gangs are generally formed according to age and neighborhood criteria (Cristea, 2011, p.
101). Within the gang, adolescents undertake common activities (walks in nature, hangs out in the
city, 18th birthday parties, meals served in fast-food restaurants, gossip etc.), reaching in some cases
to the manifestation of some antisocial behaviors (sometimes with a criminal character) who are
approved by the group of friends who constitutes the gang, such as smoking, alcohol and drug use,
truancy etc. (Dobrescu, 2016, pp. 108-109; Papalia et al., 1978/2010, pp. 411-412; Baciu, 2019). In
the literature, the gang can also be found under the name of the "band" (bandă, in the Romanian
language), the latter being used more frequently in the context of delinquency (Papalia et al.,
1978/2010; Heywood, 2001/2017; Cristea, 2011). In other words, when the criminal characteristics
are added to the general characteristics of a gang, the group can be seen as a band. The bands are
organized hierarchically and do not tolerate deviations from group norms (Rodríguez et al., 2016).
Zimbardo (2009) presented the initiation process into a band, providing examples from his own
experience as an adolescent: theft, beatings between children, and intimidation were forms of
compliance with the rules of the band and a way of subordination to its leader (p. 11).
Cliques, usually hostile, are formed as a result of the subdivision of a larger group, this
separation being a consequence of the divergences between the members of the initial group
(Maisonneuve, 1996). Similar to gangs, cliques may involve a certain level of delinquency, but the
average delinquency tends to be lower among clique members, as opposed to gang members (Klein
et al., 2006).
From the perspective of social psychology, the cliques and gangs formed by adolescents
represent primary and belonging groups, which exert a considerable influence on the members who
identify with the group (Duduciuc, Ivan, & Chelcea, 2013, pp. 124-126). According to the same
authors, the group of affiliation can be simultaneously the reference group of the person. In this case,
adolescents compare themselves with the members of the cliques and gangs they belong to and
behave like them. In their turn, the reference groups can be positive or negative, depending on the
acceptance or rejection of their norms and values by society, this delimitation being a significant
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
26
condition in the study of delinquent subcultures.
Although the benefits of belonging to groups such as cliques and gangs are undeniable,
adolescents having the opportunity to experience new ways of relating, which contribute to the
development of self and self-image (Cristea, 2011, p. 101), the risks posed by such adolescent groups
have been highlighted. For example, gang membership has been recorded in the group of risk factors
for youth violence (World Health Organization - WHO, 2020). Another representative danger is the
war between the gangs, which falls into the category of collective violence (WHO, n.d.).
In developing countries, such as Barbados and Colombia has been recorded an upward
trajectory of gang violence and criminal acts (WHO, 2019a, 2019b). However, the activity of street
gangs has also been noticed in cities of developed countries, such as London, where gang members
are responsible for half of the incidents involving firearms and for 22% of all serious acts of violence
(HM Government, 2011, p. 3). In the United States of America (USA), the trends recorded in the
period 1996-2012 in relation to gang problems reflect their predominant occurrence in large cities,
the following in descending order of incidence being suburban areas, small towns, the lowest rate
being registered for rural areas (National Gang Center, n.d.). Also in the USA, according to data
obtained from victims in a nationwide study, approximately 6% of violent crimes recorded between
1998 and 2003 were committed by members of some gangs (Harrell, 2005). Also, according to
estimates of law enforcement structures, there are around 30,000 gangs in the USA, totaling about
850,000 members (Mora, 2020). Looking towards Central America, the information available at the
El Salvador country-level indicates that of the 262 municipalities, in more than 247 of them exist
gang members exercising control (Human Rights Watch, 2019).
Illegal activities of the gangs have also been recorded in the European Union. The year 2019
marked an increase in violence caused by them in Copenhagen, the Danish authorities suspecting a
link between local and Swedish gangs (Overseas Security Advisory Council, 2020). Delinquent
behaviors have also been reported in youth gangs in countries such as Greece, France, Italy, and
Romania (Smith & Egan, 2014). In 2009, 222 violent gangs were identified in France, amounting to
2500 ordinary members, to which was adding an approximately equal number of affiliated members
(Pillet, 2009, as cited in Smith & Egan, 2014). According to the same source, between 2008 and 2009,
there were 366 gang confrontations on the territory of France, resulting in six deaths, and another 143
people were seriously injured. In Romania, according to data provided by the police, 140
neighborhood groups and gangs were detected in 2005 only at the level of Bucharest municipality,
89 of them having a criminal history (National Anty-drug Agency, 2006). Regarding existing data at
the level of Greece, in a study conducted in Crete with 305 pupils, 10.9% of them reported being part
of a youth gang, and the majority (74.3%) had knowledge of such groups (Riga, 2012, as cited in
Smith & Egan, 2014). On the territory of Italy operate the so-called "baby gang", which are groups
made up mainly of adolescents, which are formed on ethnic criteria and which exhibit a dynamic
specific to small organized crime, the phenomenon being significantly increasing in the peninsula
(Commissione parlamentare per l'infanzia e l'adolescenza, 2000) [Parliamentary Commission for
Children and Adolescents].
The phenomenon of juvenile delinquency began to be officially recognized in Romania in
1646, when Vasile Lupu initiated the first code of laws, called the "Romanian Book of Teaching"
(Colectivul pentru Vechiul Drept Romînesc al Academiei R.P.R., 1961 [Collective for the Old
Romanian Law of the Academy R.P.R.]. Both the first code of laws and the "Îndreptarea Legii" ["Law
Guide"] from 1652 of Matei Basarab (Colectivul de Drept Vechi Romînesc, 1962 [Collective of Old
Romanian Law], differentiated the criminal liability of the person according to his age and his ability
to discern. With the advent of the "Condica Criminaliscească" ["Criminal Codex"] of Şuțu and
Sturdza, in 1826, as well as the Ghica-Ştirbei Code, called "Condica Criminală" ["Criminal Codex"]
(1852), the age limit for criminal liability changed from seven to eight years, eliminating the
distinction between boys and girls previously established (Dvoracek & Stihan, 1984, as cited in
Lefterache, 2011). The minority was legislated in the Criminal Code of 1865, and the Criminal Code
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
27
of 1936 replaced understanding and moral development with the criterion of discernment (Brezeanu,
1998).
In Romania, starting from 1646, until 1969, the minimum age of criminal liability varied,
and with the entry into force of the Criminal Code from 1969, it stabilized at 14 years (Lefterache,
2011; Petruț, 2014). National legislation considers convicted persons between the ages of 14 and 21
to be young, and if the educational measure of deprivation of liberty is required, they are interned in
educational or detention centers, where adolescents are included in recovery programs, depending on
the particularities of each person's age and personality (Petruț, 2014; Parlamentul României, 2013)
[Parliament of Romania].
Starting from the problems raised by the antisocial behaviors carried out by adolescents in
group, this meta-analysis aims to investigate the characteristics of adolescents who adhere to social
structures such as cliques and gangs, to provide a broad understanding of their prejudicial
manifestations.
Purpose and objectives of the study
The aim of this meta-analysis was to highlight the factors that announce the involvement of
adolescents in cliques and gangs. The results of the study could contribute to the development of
prevention and combat directions for juvenile delinquency, taking into account both the needs of
adolescents in general and the needs of cliques and gangs in particular.
To achieve the intended purpose, the following objectives have been outlined: identification
of some factors that predict the involvement of adolescents in cliques and gangs; development of
recommendations to support the process of preventing and combating delinquency in adolescent
groups such as cliques and gangs.
Starting from these objectives, the following research questions have been formulated: what
are the most common factors in the literature that predict the membership of adolescents in groups
such as cliques and gangs? Can these predictors be considered risk factors for the delinquency of
adolescent gangs? Are there gender differences regarding adolescent involvement in cliques and
gangs?
Material and methods
Data sources
The strategy for identifying the literature relevant to the research involved searching for
papers related to adolescents and their membership in cliques and gangs in the following platforms
providing access to scientific literature: Web of Science, PubMed, and Oxford Journals. The
following keywords were used to obtain scientific publications of interest: adolescent, clică, and
gașcă. These have been translated into English by the following terms: adolescent, clique, and gang.
Three combinations were made using the three terms, these word combinations being used in
advanced search, as follows: "adolescent AND clique", "adolescent AND gang", "clique AND gang".
In the search performed on the Web of Science, as this is allowed, an asterisk was inserted after each
searched word, this symbol having the role of identifying articles including by the derivatives of the
words entered (e.g. cliques, gangs, gangster, adolescence etc.).
In order to refine the search process, the settings provided by the three platforms were used.
Research article and data article, written in English and published between 2010 and 2020, was
chosen. Studies published over the past 10 years have been chosen out of a desire to capture current
predictors, so that the recommendations address the needs of contemporary society. It was also taken
into account that the year of publication of a work does not always coincide with the year in which
the data were collected, thus there is the possibility of extending the results beyond the threshold
represented by 2010. Following the implementation of this strategy, 2281 search results were
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
28
obtained.
Inclusion criteria
The total search results were subsequently subjected to the selection procedure.
The criteria established for the inclusion of studies in the meta-analysis were the following:
participants were between 14 and 21 years of age at the time of the research, or at least the average
age of the participants was between 14 and 21 years; studies were based on quantitative analysis of
the data; studies referred to the factors that predicted the involvement of adolescents in cliques and
gangs.
Exclusion criteria
All the resulting items have been archived, this action being performed through the free
bibliography management program – Zotero (Corporation for Digital Scholarship, n.d.). This
program facilitated the alphabetical listing of the papers, their separate filing, and the identification
of duplicate items. The program also allowed viewing information (title, authors, publication name,
volume, pages etc.) about each selected record, as well as reading the abstract for each paper, without
having to open it in a separate file. It was also possible to keep track of both the original number of
papers and the one left after the application of the exclusion criteria by automatically generating the
number of records from each collection of titles (file). In this way, Zotero allowed the efficient
management of the time for the process of systematic review of the literature.
The first analysis involved the identification of duplicate records and their union. As a result
of this process, 217 items were excluded. For the remaining papers, the following sorting was based
on the exclusion according to the title, with the removal of those articles whose titles explicitly
indicated the absence of any link with the subject of the research (e.g. laboratory animal experiments;
studies on epilepsy, dysmenorrhea, heterosexuality, autism; studies with samples consisting of adults
or children; ganglion studies etc.), respectively clinical studies (e.g. studies involving patients with
bipolar disorder and mania or involving adolescent patients with HIV), literature or history studies,
theoretical studies, articles based on literature review and those involving therapeutic interventions
(e.g. research with adolescents with autism, studies involving group treatments etc.). At this stage,
1844 articles were excluded. The next phase involved studying the abstracts of the remaining articles,
117 articles being deleted for reasons such as: it was found that the subject was that of leaving the
gangs, the article was based on the content analysis (of films, rap songs etc.), the articles referred to
the effects of involvement in the gang, respectively to the effectiveness of psychological
interventions, the characteristics of the sample did not meet the criteria for inclusion in the meta-
analysis, the articles did not have a psychological component, or it was found that the approach of
the articles did not focus on cliques or gangs (e.g. some studies validating some psychological
assessment tools). Also at this stage were deleted articles based on the literature review that were not
removed at the previous stage and those based on qualitative analysis of the data. For the remaining
103 studies, the full-text analysis was used. Figure 1 exposes the entire article review process.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
29
Figure 1
Diagram of the systematic review process
2281 articles extracted
from databases 217 duplicates
removed
2064 unique articles 1844 articles
excluded after the
analysis of the title
220 abstracts
analyzed
117 articles excluded, relating
to issues different from those
pursued (consequences of
joining, effectiveness of
therapeutic interventions,
different age of the sample etc.)
103 articles
analyzed in
extended version
70 articles excluded
8 did not provide information
about the age of participants
19 did not have average age
between 14-21 years
3 exceeded the range 14-21
years and did not specify the
average age
8 articles could not be
accessed for free
27 did not analyze predictors
of the involvement of
adolescents in cliques and
gangs
3 were qualitative studies
2 were theoretical studies
33 articles were included
in the analysis of the
predictors of adolescents'
adherence to gangs
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
30
Data analysis and extraction
In the analysis of the 33 articles, the following indicators were followed: sample size,
participants' ages or their average age, gender of participants included in the study, place where the
research was conducted, type of research (cross-sectional or longitudinal research), and results
regarding predictors of participants' involvement in clique or gang type groups. In addition to these
main indicators, information related to the particularities of the samples was also noted, such as:
people in detention, homeless people, people belonging to a certain subculture, the percentage of
affiliated participants versus the percentage of unaffiliated in the case of comparative studies, the
time interval in which data were collected in the context of longitudinal research that provided this
information.
This analysis aimed to identify predictors of adolescents' membership in cliques and gangs,
being selected only those factors that could explain the adherence of people in this age group to such
groups. In cases where it was not clear whether some variables are predictors or consequences that
arise as a result of the involvement of adolescents in cliques or gangs, their inclusion in Table 1 was
waived.
Results
Description of studies
Following the inclusion and exclusion criteria, 33 articles were found that addressed
predictors of adolescent involvement in gangs. None of the remaining articles addressed the concept
of "clique". These were largely excluded based on the age range of the participants, with the average
age of the adolescents being under 14 years. In the case of cross-sectional studies that did not provide
information on age, it was mentioned that the participants were enrolled in gymnasium studies (e.g.
Closson & Watanabe, 2016).
Of the 33 studies that analyzed predictors of adolescents' adherence to gangs, 11 were
conducted according to a longitudinal plan, and the rest were cross-sectional. Of the total studies, 23
were conducted in the USA, five studies were conducted in the United Kingdom (UK), one study was
conducted in Georgia, another in Trinidad and Tobago, one study in Asia, one in Africa, and for one
of the studies no location was mentioned. Of the 23 studies conducted in the USA, one study operated
on data obtained from both the USA and Canada. No studies have been identified to target the
involvement of adolescents in Romania in gangs.
In the cross-sectional studies, the youngest participants were 13 years old, and the oldest had
an average of 21.32 years old. For the longitudinal ones, the minimum age at wave 1 was 10 years,
and the highest at the last wave was 27 years. The highest percentage of participants was represented
by male, and among selected publications were included researches involving individuals belonging
to only one of the two genders (three studies focused exclusively on boys and four studies involving
only female persons). In most researches, a balanced relationship between boys and girls has been
maintained. The sample size ranged from 75 to 26232 participants. The information is presented in
detail in Table 1, after the conclusions of the article.
Familial predictors
Nine studies identified the following familial predictors of adolescent gang involvement:
• deficient parenting (low parental monitoring; low level of parental communication; parents
who favor antisocial behavior; and authoritarian, neglectful, and permissive parenting
styles);
• involvement of some family members in gangs;
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
31
• witness to family violence;
• with parents in military service (including military parents deployed in combat zones) in the
case of female.
Figure 2 illustrates the graphical representation of these predictors.
Figure 2
Diagram of family factors that predict adolescent gang involvement
Personal predictors
Personal predictors of adolescent involvement in gangs were analyzed in 30 studies. The data
obtained were grouped into seven subcategories:
• trauma history;
• personal values;
• low self-control;
• indicators of some psychological disorders;
• consumption or intention to consume alcohol or drugs;
• cognitive predictors;
• affective predictors.
A detailed description of these secondary categories of personal predictors can be consulted
Familial predictors
Low
monitoring
Parents who
favor antisocial
behavior
Low level of
communication
Negligence Permissiveness
Deficient
parenting
Involvement of
some family
members in
gangs
Witness to
family
violence
Parents in
military service
(in the case of
girls)
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
32
in Figure 3.
The low activity alleles of the monoamine oxidase A gene predicted involvement in gangs, but only
for boys (Beaver, DeLisi, Vaughn, & Barnes, 2010). High self-esteem and grandiose-manipulative
traits were predictors of becoming a high-level member in the gang, but only after the age of 17
(Dmitrieva, Gibson, Steinberg, Piquero, & Fagan, 2014).
Figure 3
Diagram of personal factors that predict adolescent gang involvement
Personal predictors
Moral
disengagemen
t
Low
responsibility
The value
attached to
social status
Dominant
social
orientation
Anti-authority
attitudes
Behavioral
school
disengagement Personal values
Low self-control
➢ delinquency
➢ impulsivity
Indicators of some
psychological disorders
➢ conduct problems
➢ antisocial tendencies
➢ depressive/anxiety
symptoms
Affective predictors
Low
self-
esteem
Reduced
empathy
Reduced
guilt
Consumption or
intention to
consume alcohol
or drugs
High level of
rationalisation
Perception of
racial
discrimination
Rumination
s
Cognitive predictors
Peer
victimization Physical
abuse
Sexual
abuse Physical
neglect
Trauma
history
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
33
Social and economic predictors
Criminogenic neighborhood, cultural factors, school climate, and instability of material and
financial resources are the four categories of social and economic factors that predicted the
involvement of adolescents in gangs. These subcategories were built on the results of 17 studies.
Figure 4 provides a detailed picture of how the four predictor classes are formed.
Figure 4
Diagram of social and economic factors that predict adolescent gang involvement
Social and economic predictors
Criminogenic
neighborhood
School climate
➢ poor connection
between student
and teacher
➢ limited exposure to
prosocial
behaviours in
school
Cultural factors
➢ belonging to an
ethnic minority
➢ low level of
acculturation
Instability of
material and
financial resources
Exposure to
community
violence
Deviant peers
and friends
Antisocial
neighborhood
Perceived
availability of
hand guns
Committing a
murder in the
neighborhood
Neighborhood
drug availability
Social
disorganization in
the neighborhood
Living with a
gang member
Low income
per family
member
Living with a
family member who
receives social
assistance
Housing
instability
Lack of
shelter
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
34
Discussions
This paper presents a comparative analysis of the concepts "clique" and "gang", as both were
considered important for the period of adolescence (Papalia et al., 1978/2010). The systematic
analysis of the literature published over the last 10 years highlighted, however, that clique-type groups
were not the subject of numerous research, unlike gangs, whose members were more frequently
included in analyses on adolescents. This may be due to the specifics of the cliques, which may be
characteristic of preadolescence or early adolescence. As for the gang, this is a model of organization
specific to the developmental period of adolescence (Papalia et al., 1978/2010; Dobrescu, 2016).
The systematic review of scientific articles has highlighted predictors of adolescent
involvement in gangs. The value of the paper is given by the diversity of data obtained both through
cross-sectional studies and through repeated measurements in the context of longitudinal research.
The 11 longitudinal studies are intended to support a potential causal link between certain factors and
adolescent gang involvement. According to the Institute for Work & Health (2015), longitudinal
studies are more likely to suggest a cause-and-effect relationship compared to cross-sectional studies,
as data collection is not limited to a single point in time, allowing the sequential division of a
particular event. In this way, a longitudinal design could explain the adolescent gang involvement
according to the course of their development, from preadolescence to mid-adolescence, respectively
from mid-adolescence to the end of this age period.
The most often analyzed predictor was the criminogenic neighborhood, supported by the
results of 16 studies. The following predictor in order of frequency of occurrence in processed studies
was low self-control, this factor being a significant predictor in 14 articles, followed by trauma
history, significantly in 13 studies. Deficient parenting, as a subcategory of familial predictors and
affective predictors, as a subcategory of personal predictors, predicted gang involvement in five
studies each. Consumption or intention to consume alcohol or drugs, as well as personal values,
predicted involvement in the gang in four studies each. The indicators of some psychological
disorders, subcategory represented by depressive symptoms, conduct problems, and antisocial
attitudes, were the subject of three articles. Other subcategories of predictors among the familial (the
affiliation of a family member to gangs, witnessing family violence), personal (personal values,
cognitive predictors), and social and economic ones (instability of material and financial resources,
school climate) significantly predicted the involvement of adolescents in gangs in two studies each.
However, differences between samples prevent generalizations. As some results were obtained
following the investigation of a population in a detention center (e.g. Wood, Alleyne, Mozona, &
James, 2014; Dmitrieva et al., 2014), those cannot be extended to the general population. In addition,
the research undertaken by Wood et al. (2014) followed the involvement of participants in the activity
of prison gangs, which may explain those unique predictors, which were not highlighted in any of the
other studies. In another study, a particular subculture called Jugallos was addressed, which,
according to Petering, Rhoades, Winetrobe, Dent, and Rice (2017), was the subject of a contradictory
discussion in the context of considering it to be a gang. It is also important to take cultural differences
into account, as the authors analyzed data from samples from different continents (America, Europe,
Asia, and Africa). However, in terms of the low level of emotional regulation, the data obtained
indicate that it is a predictor of involvement in gangs in both the USA (Lenzi, Sharkey, Wroblewski,
Furlong, & Santinello, 2018) and in Georgia (Voisin, King, Diclemente, & Carry, 2014), respectively
in South Africa (Mfidi, Thupayagale-Tshweneagae, & Akpor, 2018). This result may suggest that the
regulation of emotions is not a factor dependent on a particular culture when considering its role in
the adhesion of adolescents to gangs.
Although not included in this systematic review, it is worth mentioning an article from
another platform for access to academic literature (different from those used in this paper), with data
from 52,714 adolescents between 12 and 16 years old who lived in 1997 in the USA, which
highlighted that the low level of intelligence quotient is an important predictor of adolescent
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
35
participation in gang activities (Seals Jr. & Stern, 2013). Also, completing the category of family
predictors, the Child Walfare League of America recalls among the risk factors of gang involvement
parents' criminal history, belonging to a gang being a response of the child to the traumatic experience
represented by the incarceration of the parent (North Carolina Division of Social Services & Family
and Children’s Resource Program, 2002).
Regarding gender differences, some authors did not find significant differences between
girls and boys, while other authors found that people belonging to the male gender are more likely to
be affiliated with gangs (Voisin & Neilands, 2010; McDaniel, 2012; Vasquez, Osman, & Wood,
2012). Moreover, Beaver et al. (2010) demonstrated that only boys carrying alleles with low
monoamine oxidase A gene activity were at increased risk of joining such groups. In the research
conducted by Reed, Bell, and Edwards (2014), the military service of parents turned out to be a
significant predictor of gang membership only in the case of female participants.
Predictors resulting from this systematic analysis of literature can be considered risk factors
for the actions with attributes of some offenses, committed by adolescent gangs. Mfidi et al. (2018)
showed that adolescents' inability to emotional self-regulation predicted gang formation, which the
authors described as destructive groups. Comparative studies between adolescents involved in gangs
and those not involved in such groups have also shown that gang members were more likely to have
committed violent acts or exhibited other risky behaviors, such as drug use (Weitzel, Hopper, &
Herridge, 2020; Petering, 2016). Referring to the high levels of delinquency as a predictor of
adolescent involvement in gangs, the risk for antisocial actions committed with the gang is obvious
(Barnes, Beaver, & Miller, 2010; Lachman, Roman, & Cahill, 2012; McDaniel, 2012; Wood et al.,
2014; Ang, Huan, Chan, Cheong, & Leaw, 2015; Hennigan, Kolnick, Vindel, & Maxson, 2015;
Hautala, Sittner Hartshorn, & Whitbeck, 2016).
The results of the cross-sectional research conducted by Faus, de Moraes, Reichenheim, da
Matta Souza, and Taquette (2019) in Rio de Janeiro, with 699 participants, showed that traumatic
childhood experiences, especially emotional, sexual abuse, and physical neglect, increase the chances
for violence among adolescents. Based on the analysis of archival data, physical neglect in childhood
has been proved to be a predictor of violent behavior for male adolescents (12-19 years) in the custody
of a USA detention center (McGuigan, Luchette, & Atterholt, 2018).
It is noted that there is a need to intervene on the predictors that determine adolescents to get
involved in gang activities, to reduce the risks that these factors entail in such a collective. This
finding is based on the results of the experiment undertaken by Dimant (2019) with 185 participants
in Germany, which showed that social proximity increases the likelihood of transmission and taking
over of antisocial behavior, the contagion being much more significant than in the case of prosocial
behavior. Thus, if there are adolescents in the gang who exhibit violent behaviors, there is a risk that
other members to become violent. Cristea (2011) explained that the gang formation mechanism is
based, in addition to the age index, on neighborhood criteria. Most of the studies analyzed in this
paper showed that the criminogenic neighborhood predicted adolescent gang involvement. Therefore,
concentrating the findings of Cristea (2011) and Dimant (2019) in a macroscopic analysis, the
following reasoning can be configured: if the gang members live near neighbors who commit
undesirable actions, it could increase the risk that some of them take over this behavioral model,
which can later become an element of the value system of the gang.
Criss, Smith, Morris, Liu, and Hubbard (2017) found after a research conducted on a sample
of 206 adolescents from America (10-18 years) that violence and the threat posed by neighborhood
were associated with antisocial behavior. The same research revealed, however, that the emotional
regulation and prosocial behaviors of peers have reduced the link between violence in the
neighborhood and the antisocial behavior of adolescents, and the high quality of the relationship
between parents and adolescents has been shown to be a protective factor against danger and violence
in the neighborhood.
Other authors have stated that reducing the level of aggression could be a way to prevent
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
36
violent crime (Li, bt Roslan, binti Ahman, binti Omar, & Zhang, 2019). The study undertaken by
them with 60 participants between 18 and 19 years in China showed that the levels obtained on all
subscales of aggression decreased significantly for participants in the group involved in interpersonal
group psychotherapy. Further research is needed to indicate whether group psychotherapeutic
intervention on adolescent gangs leads to reducing levels of aggression of the members and whether
this is a prophylactic measure in preventing and spreading violence by adolescents through gangs.
Conclusions
The systematic review of the literature highlighted predictors of adolescent gang
involvement, which belong to the following categories: familial predictors, personal predictors, and
social and economic predictors. The most common predictor was a social environment factor
(criminogenic neighborhood). Personal predictors (low level of self-control and history of trauma)
were the next important factors in joining gangs. Less frequent in the investigated articles were shown
to be the familial predictors.
It was found that there were gender differences between adolescents regarding joining gangs.
The results of comparative research between girls and boys indicated a higher probability of males
being affiliated with such groups.
It is important to mention that following the search procedure described in the methodology
section, no scientific articles regarding the gangs of adolescents in Romania have been identified.
This needs to be taken into account by the policies for the prevention of juvenile delinquency at
national level, being recommended to undertake research on the phenomenon of involvement of
Romanian adolescents in gang activities. The results of such studies can provide useful information
to guide efforts to prevent the increase in crime rates across the country. The merits of forensic science
need recognition in the context of preventing, investigating, and combating crime, and at the same
time, there are still some reservations of forensics in this direction (Gheorghiță, 2016), so that the
research of adolescent gangs could contribute to the completion of the body of knowledge, according
to existing requests from the ever-changing society.
Most of the individual predictors identified in this paper can be considered risk factors for
antisocial actions perpetuated through adolescent gangs. The criminogenic neighborhood may
encourage adolescents to take up the antisocial behavior model within the gang. There is also the
possibility that the abuse suffered in childhood to be reproduced by gang members at the age of
adolescence. The low level of self-control may be a favoring factor in this picture of the perenniality
of violence and other risky behaviors.
The "broken windows" theory proposes a solution to reduce the negative impact of the
criminogenic neighborhood, namely lowering the level of physical disorder (Wilson & Kelling,
1982), however, it was found that this measure is not effective in all cities (Zimbardo, 2009).
Therefore, organizing support groups for adolescents and their carers, promoting both the quality of
the parent-child relationship and socially desirable behaviors, could be a more appropriate protective
measure against the spread of antisocial behavior from the neighborhood through gangs. Learning
and integrating effective coping mechanisms, with emphasis on emotional and behavioral self-
control, could also help reduce gang involvement in acts of violence. The implementation of personal
development programs in the form of psycho-educational groups could prove useful in this regard.
Finally, involving adolescent gangs in group psychotherapy programs can be a way to prevent and
reduce juvenile delinquency. The psychotherapeutic intervention could give gang members remedial
experiences so that the gang becomes a support group for each of its members and not a tool through
which traumatic events of childhood to spread in society.
In exposing measures to prevent and combat juvenile delinquency, it is worth remembering
the Tri-Agency Resource Gang Enforcement Team program, implemented since 1992 in Orange
County, California, and whose strategy was based on differentiated sanctions, depending on age, the
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
37
degree of violence, and the level of recidivism presented by gang members who committed crimes.
This program, which aimed to form multidisciplinary teams made up of gang investigators, a
probation officer, and two officials from the district attorney's office, led to a 47% drop in gang crime
over seven years (Kent, Donaldson, Wyrick, & Smith, 2000; National Gang Center, n.d.). Kent et al.
(2000) recommended that policymakers and researchers replicate this program in different
jurisdictions, both to test its effectiveness and to improve it. Therefore, adapting this program to
Romania's particularities, implementing the program at the country level, and evaluating the results,
could prove useful in the effort to prevent and reduce the negative consequences of adolescent gangs.
Other programs that have had an effect in reducing risky gang-related behaviors or in
preventing adolescents from joining groups of this type were presented by Howell (2010), who
divided them into two categories: a primary prevention program (Gang Resistance Education And
Training) and secondary prevention programs (Preventive Treatment Program; Aggression
Replacement Trening; CeaseFire–Chicago; The OJJDP Comprehensive Gang Prevention,
Intervention, and Suppression Model; Striving Together to Achieve Rewarding Tomorrows; Boys &
Girls Clubs Gang Prevention Through Targeted Outreach; Boys & Girls Clubs Gang Intervention
Through Targeted Outreach; The Broader Urban Involvement and Leadership Development
Detention Program; Movimiento Ascendencia etc.). These programs can serve as a starting point in
outlining efficacious directions for reducing delinquency among adolescents, including in Europe,
through the collaboration of European and American researchers in The Eurogang Project (n.d.).
As the present analysis shows, gangs are an important objective of intervention to prevent
and combat juvenile delinquency. In order to diminish the negative impact of the factors that predict
the joining of adolescents in gangs (neighborhood with criminogenic potential, low level of self-
control, and family with dysfunctional emotional-educational climate), it is recommended that the
intervention to be led by multidisciplinary teams (psychologists, social workers, teachers, police
officers etc.) and to be carried out at community, family, and individual level. In this complex
prophylactic approach, the support of institutions such as the school, the police, and the General
Directorate for Social Assistance and Child Protection is necessary. Non-governmental organizations
can also play a significant role in the joint effort to reduce risky actions undertaken by members of
adolescent gangs.
Table 1
Description of studies included in the meta-analysis
Authors and year
of publication
Sample size Gender Place of study Type of study
Wechsberg et al.
(2015)
237 female North Carolina Cross-sectional
Predictors of gang involvement: history of sexual abuse; history of physical abuse; low social
support; low emotional support; witness to gun battles; the occurrence of a murder in the
neighborhood.
Weitzel et al.
(2020)
2443 50.8% male UK Cross-sectional
Predictors of gang involvement: lack of shelter; staying in temporary housing.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
38
Authors and year
of publication
Sample size Gender Place of study Type of study
Lachman et al.
(2012)
200 55% male Montgomery
County &
Washington, DC
Cross-sectional
Predictors of gang involvement: instrumental purposes (e.g. joining the group in order to obtain
protection).
Mendez, Mozley,
and Kerig (2020)
817 25.93% female Western USA Cross-sectional
Predictors of gang involvement: trauma exposure (callous-unemotionality being an explanatory
factor).
Cepeda, Valdez,
and Nowotny
(2014)
75 male West Side, San
Antonio, Texas
Cross-sectional
Predictor of gang involvement: physical neglect.
van Dommelen-
Gonzalez,
Deardorff, Herd,
and Minnis
(2015)
162 44.87 female
affiliated
57.14 female
unaffiliated
San Francisco Cross-sectional
Predictors of gang involvement: age (those affiliates were older than those unaffiliated); to live
with a family member who receives social assistance; affiliation of some family members to gangs;
having close deviant friends (truants, who spent a night in custody etc.).
Kubik, Docherty,
and Boxer (2019)
611 52% female USA Longitudinal
Predictors of gang involvement: childhood maltreatment; childhood neglect.
Ang et al. (2015) 1027 58.2% male Singapore Cross-sectional
Predictors of gang involvement: proactive aggression; delinquent behavior; behavioral
disengagement from school.
Reed et al.
(2014)
9952 2782 female Washington Cross-sectional
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
39
Authors and year
of publication
Sample size Gender Place of study Type of study
Predictors of gang involvement: having military parents (in the case of girls); having parents
deployed in combat zones (in the case of girls).
Katz and Fox
(2010)
2206 59.6% female Trinidad &
Tobago
Cross-sectional
Predictors of gang involvement: perceived availability of hand guns; high level of residential
mobility; parents who favor antisocial behaviour; early initiation into antisocial behaviours;
intention to use drugs; antisocial peers; peers who use drugs.
Gilman, Hill,
Hawkins,
Howell, and
Kosterman
(2014)
808 51% male Seattle Longitudinal
1985-1993
Predictors of gang involvement: living with a gang member; antisocial neighborhood; influences
of antisocial peers in the previous year.
Voisin and
Neilands (2010)
563 38.89% male Midwestern Cross-sectional
Predictors of gang involvement: lower levels of student-teacher connection; male gender; risky
rules imposed by colleagues.
Lenzi et al.
(2018)
11753 59.6% male California Cross-sectional
Predictors of gang involvement: low levels of behavioral self-control; low levels of emotional
regulation; low levels of empathy; limiting access to social support (within the school); limiting
exposure to prosocial behaviors (within the school).
Ventura Miller,
Barnes, and
Hartley (2011)
1633 66% male –
belonging to the
gang
South Texas Cross-sectional
Predictors of gang involvement: low level of grades obtained at school; drug availability in the
neighborhood; low levels of acculturation; low levels of school satisfaction; perceiving a higher
degree of marginalization based on ethnicity.
Beaver et al.
(2010)
2196 52.59% female USA Longitudinal
1994-2002
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
40
Authors and year
of publication
Sample size Gender Place of study Type of study
Predictors of gang involvement: low activity alleles of the monoamine oxidase A gene (only
carrier men are at increased risk of joining the gang).
Lenzi et al.
(2014)
26232 53.4% female California Cross-sectional
Predictors of gang involvement: associating with deviant peers; perceiving the school as an
unsafe environment; type of school (special, vocational, alternative vs. comprehensive).
Petering (2016) 505 27.72% female Los Angeles Cross-sectional
- homeless
population
Predictors of gang involvement: childhood sexual abuse; witness to family violence; childhood
physical abuse; witness to interpersonal violence.
Wood et al.
(2014)
188 male UK Cross-sectional
Predictors of gang involvement: the value attached to social status; levels of dominant social
orientation; anti-authority attitudes; moral disengagement; threat levels (before incarceration);
individual delinquency levels (before incarceration); levels of involvement in group crime (before
incarceration); group support on streets; longer current punishments.
Barnes et al.
(2010)
Wave 1 - 20745
adolescents,
17700 carers
Wave 2 - 14738
Wave 3 - 15197
50.51% female USA Longitudinal
Predictors of gang involvement: low levels of self-control; greater involvement in delinquency;
more victimization experiences.
Ha, Kim,
Christopher,
Caruthers, and
Dishion (2016)
998 52.7% male Northwestern USA Longitudinal
Predictor of gang involvement: maltreatment.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
41
Authors and year
of publication
Sample size Gender Place of study Type of study
Gilman, Howell,
Hipwell, and
Stepp (2016)
2450 female Pittsburgh Longitudinal
2003-2011
Predictors of gang involvement: peer victimization.
Mfidi et al.
(2018)
347 169 male Eastern Cape,
South Africa
Cross-sectional
Predictors of gang involvement: improper handling of emotions (anger – the most common
emotion experienced).
Smith, Gomez
Auyong, and
Ferguson (2018)
15445 50.6% male Avon, UK Longitudinal
1991-2019
Predictors of gang involvement: delinquent peers; social disorganization in the neighbourhood
(graffiti, presence of stray dogs on the streets, vandalized objects etc.); drug use.
Dmitrieva et al.
(2014)
1354 male - in
detention
Maricopa &
Philadelphia
Longitudinal
Predictors to be a low-level gang member: low temperance; low perspective; low responsibility;
low self-esteem (in early adolescence).
Predictors to be a gang leader: low temperance; low self-esteem (after 19 years); high self-esteem
(after 17 years); grandiose-manipulative traits (after 17 years).
Hautala et al.
(2016)
646 50.5% female
USA & Canada Longitudinal
2002-2011
- Indigenous
population
Predictors of gang involvement: low income for each family member; low parental monitoring;
low links with school (increased risk only for gang initiation); early conduct problems in primary
school; risk factors at peer level (increased risk only for initiation); early negative events increase
the risk for initiation into the gang; early perception of racial discrimination; anger (risk for
initiation); depressive symptoms; hyperactivity / Impulsivity; substance use; high level of
delinquency before involvement in the gang.
Frisby-Osman,
and Wood (2020)
91 64.8% male England Cross-sectional
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
42
Authors and year
of publication
Sample size Gender Place of study Type of study
Predictors of gang involvement: high levels of conduct problems; moral disengagement;
ruminations; symptoms of anxiety; symptoms of depression; higher levels of exposure to violence
(being a victim of violent attacks).
McDaniel (2012) 4131 51.49% female - Cross-sectional
Predictors of gang involvement: belonging to an ethnic minority; male gender; depressive state;
reporting suicidal ideation; alcohol or drug use; delinquency; experiencing peer victimization.
Petering et al.
(2017)
495 71.30% male Los Angeles Cross-sectional
-Jugallos
Predictors of gang involvement: childhood sexual abuse; physical childhood abuse; exposure to
community violence; witnessing family violence.
Vasquez et al.
(2012)
310 185 male London Cross-sectional
Predictors of gang involvement: ruminal thinking about aversive events; male gender.
Vuk (2016) 5935 48% male USA Cross-sectional
Predictors of gang involvement: low self-esteem; authoritarian parents; negligent parents;
permissive parents; delinquent peers; low levels of self-control; increased levels of rationalization;
low levels of guilt.
Hennigan et al.
(2015)
391 67% male Los Angeles Longitudinal
Predictors of gang involvement: antisocial tendencies; impulsive risk-taking; neutralization of
guilt; parental monitoring; influence of the family gang; negative influence of friends; delinquency
of friends; critical life events in the last six months; self-reported delinquency.
Shelley and
Peterson (2018)
1730 55% female USA Longitudinal
2006-2012
Predictors of gang involvement: being a bully; being a victim of bullying; beying a bully-victim.
Voisin et al.
(2014)
188 female Atlanta Georgia Cross-sectional
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
43
Authors and year
of publication
Sample size Gender Place of study Type of study
Predictors of gang involvement: low self-esteem; emotional dysregulation; trauma history,
deviant colleagues; low parental monitoring; low level of parental communication; housing
instability; poor quality of the neighborhood.
Acknowledgements
This study is part of the doctoral research project entitled "Adolescents and Youth in
Educational and Detention Centers: Personality Dimensions and Psychological Factors", PhD.
Student Flavia-Elena Ciurbea, coordinated by PhD. Cornelia Rada, at the School of Advanced Studies
of the Romanian Academy, "Constantin Rădulescu-Motru" Institute of Philosophy and Psychology,
Department of Psychology, Romanian Academy, Bucharest, Romania.
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49
CHARACTERISTICS OF TRADITIONAL VIETNAMESE FAMILY AND ITS INFLUENCE
ON COMMUNICATION CULTURE IN THE FAMILY
DOI: http://doi.org/10.26758/11.1.4
Thi Kim Dung LE
Faculty of Sociology and Social work, Hue University of Sciences, Vietnam;
PhD student at Faculty of Sociology and Social work, Bucharest University, Romania
Address correspondence to: Thi Kim Dung Le, Faculty of Sociology and Social work, Hue University
of Sciences, 77 Nguyen Hue Street, Hue city, Vietnam; Ph.: +84987424920; E-mail:
kimdungkls@gmail.com
Abstract
Objectives. Understanding the family's communication culture means understanding the ethnic
communication culture, therefore, research on communication culture in the family has an important
and practical meaning. The article aims to study generalize the basic characteristics of Vietnamese
traditional families, thereby understanding the communication culture in the family, which is the basis
for understanding the traditional communication culture of Vietnamese people.
Material and methods. This research is done based on the synthesis and analysis of documents
related to family and communication in family to make comparisons and make appropriate
judgments. 58 scientific value and reliable documents are searched on online databases, websites,
indexes and printed documents, typed files in the computer, and then classified by topic groups for
analysis. The documents mentioned or cited in the article are fully shown in the list of references.
Results. The traditional Vietnamese family has the characteristics of the traditional Asian family; this
family model that has dominated all the values and standards of the family, which has a profound
effect on the communication culture in the family. It is a type of communication that follows
hierarchical order and pattern from top to bottom, emphasis on factors of location, age, gender and
communication space.
Conclusions. Communication culture in the traditional Vietnamese family bears the imprint of wet
rice civilization as well as Confucian and Buddhist ideology creating a polite, flexible communication
style and cultural behavior, order and discipline in the family; however, its limitation is hesitation,
inhibits personal criticism; there are stricter stereotypes against some family members. Currently,
some of the traditional Vietnamese family’s foundations have been changed but the communication
culture in the family still needs to be preserved to preserve the communication culture of the nation.
Keywords: communication, culture, communication culture, communication in the family,
traditional Vietnamese family.
Introduction
Communication is a daily activity of people from birth to death. The family is the first
environment in which people perform communication, through communication between members,
the family performs the socialization function, helping each individual shape personality and integrate
into life society. Therefore, communication becomes a regular and essential activity for exchanging
information and transmitting culture from generation to generation, from individual to individual.
Understanding how people communicate means understanding the cultural identity of a certain
nation. Understanding the communication culture of a nation represents understanding the origin and
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
50
root culture of that nation. Therefore, communication and communication culture are interesting
topics, attracting the research interests of many authors in the world as well as in Vietnam.
Communication topic has been studied in many studies from the 50s and 60s of 20th century to clarify
the meaning of communication concept (Stevens, 1950; Schachter, 1951; Hoben, 1954; Ayer, 1955;
Alex, 1959; Barnlund, 1962; Cartier & Hanvood, 1953; Miller, 1966; Andersen & Guerrero, 1997;
Ting-Toomey, 2018), then the concepts of communication was analyzed quite fully in the study of
Dance (1970) and Luhmann (1992). However, it must be admitted this is too broad a concept and
researchers often delve into smaller or specific aspects of communication, for example research on
family communication.
Research on family communication is also a topic of interest to many authors and mainly
focuses on interpersonal communication in the family (Robinson & Levy, 1986; Beebe, Bebee, &
Redmond, 2000; Guerrero, Andersen, & Afifi, 2007; Trenholm, 2008; DeVito, 2019). Studies of
interpersonal communication in the family focus on the models and theoretical frameworks that
characterize the communication occurring in the family, the role of family communication and the
influence of the family communication environment to the ability to communicate of individuals
(Moore & Moschis, 1981; Barnes & Olson, 1985; Moschis, Prahasto, & Mitchell, 1986; Carlson &
Grossbart, 1988; Fitzpatrick & Ritchie, 1994; Forehand et al., 1997; Koesten & Anderson, 2004;
Punyanunt-Carter, 2008; Schrodt et al., 2009). Through these studies, the issues of subjects, roles and
tools of measuring family communication are also addressed and clarified. The studies have shown
that family communication can be described as a combination of family members to balance and
control information and relationship goals. Family communication takes place in a home
environment. "The family communication environment is a set of norms governing the trade off
between information and relational objectives of communication" (Fitzpatrick & Ritchie, 1994, p.
524).
In Vietnam, family communication culture haved shown in many studies (Bùi, 1990, 1993,
1994; Đỗ, 1990; Nguyễn, 1993; Ngô, 2006; Phạm, 2012; Trương & Trần, 2012; Khuất, 2014; Lê,
2015; Nguyễn, 2015; Bùi, 2018; Nguyễn, 2018). Meanwhile, traditional family culture is mentioned
in many general studies on Vietnamese culture by some great scholars such as Trần (2001), Trần
(1996, 1997, 1998, 2016), Trần (2005), Huỳnh (2012), Đào (2014). The studies of culture
communication and communication in Vietnamese families have focused on cultural aspects
traditional Vietnamese communication on the use of vocation, communication skills, attitudes in
communication and the position between the speaker and the listener in communication. Thus, a
general study on traditional communication culture in Vietnamese families is almost not mentioned,
this became an inspiration for this research. The study aims to condense the basic characteristics in
the traditional communication culture of the Vietnamese families, from which each individual, family
has a sense of promoting good values, improving outdated elements, concomitant sharing a typical
communication culture of Vietnamese families around the world.
Material and methods
This article explores the basic characteristics of the traditional Vietnamese family, then learn
the communication culture in the traditional family, so the mainly materials of research based on
secondary sources. In order to identify, locate and create a secondary database for the research topic,
researcher conducted a search of publications by keywords (communication, culture, communication
culture, communication in the family, traditional Vietnamese family) in professional journals. There
are a total of 58 well-searches online databases and indexes, focusing mainly on "Google scholar",
"Research gate", "Jstor" with many other trusted websites and libraries (such as libraries of
universities, website of Ministry of culture - sport and tourism, local website etc.) and printed
documents, typed files in the computer to collect the most appropriate secondary source. After the
documents were collected, the researcher divided into groups of topics to analyzed and cited. The
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
51
documents on the same topic are also compared and collated to have a basis for making appropriate
and relevant judgments, ensure the science and reliability of the research.
Results
Traditional Vietnamese family characteristics
Family is a concept that is approached under many different angles. From a sociological
perspective, Giddens (2006) introduced the concept of "a family is a group of persons directly linked
by kin connections, the adult members of which assume responsibility for caring for children" (p.
206). According to Psychological Dictionary, author Vũ (2008) introduces the concept "the family is
the community of people living together under one roof, forming the smallest unit of society (also
known as social cells) bound together by marriage and blood"; "the family is a miniature society
consisting of one or more different generations living and working together in an organized,
principled or unwritten way. Peace is ensured by warmth, a sense of security and love". From a legal
perspective, "a family is a set of people bound together by marriage, blood relations or nurturing
relations, giving rise to obligations and rights between them" (Quốc hội Việt Nam, 2000). From a
cultural perspective, "family is a form of blood-relationship community - the earliest kind of human
gathering and association; forming specific cultural forms that the ancient Vietnamese called "gia
phong". "Gia phong" was understood as the lifestyle, habits, customs and manners of family members
to organize the family, educate people, especially spiritually. Each family in different regions has its
own nuances of family-style, which have its own characteristics of family organization, relationships
and behavioral standards, and educational methods (Ngô, 2006, p. 26). From the above connotations,
family is an overall widespread with biological, economic, social and cultural characteristics.
Therefore, when caring about the family in terms of culture and family, it cannot be separated from
its social and economic characteristics (Ngô, 2006, p. 27).
In general, the Vietnamese traditional family has many similarities with the common
characteristics of traditional families Asian but also has unique characteristics. The traditional
Vietnamese family has the characteristics of the traditional Asian family, always retaining the
traditional nuances even when the society has reached a high level of industrial civilization, this is
different from families in Western societies (Đỗ, 1990, p. 9). It is a family type characterized by an
agricultural economy growing wet rice - Asian production method and village organization as a base
(Lê, 2015, p. 20). However, the traditional concept also has many meanings, and in each different
approach, one can only share a few of them. In the most common sense, the traditional family is the
rural family, so the characteristic of Asian agrarian society is an important foundation for maintaining
the long-standing and almost immutable family type on many sides. However, there also exists
another way of understanding the concept of the traditional family, that is the type of family where
the characteristic values of the spirit, morality, culture and religion are always appreciated and
become a framework that defines standards and behaviors in the family. In this sense, the concept of
traditional family in Vietnam is often used almost identical with the concept of "Confucian family".
Thus, "people look for attributes of the traditional family in the influences of Confucian ideology that
encompass a long history in Asian societies from China, Japan, Korea and whole of Vietnam" (Đỗ,
1990, p. 9). Reality has proven that, the search for the true social logic of the East Asian family with
Confucian logic is a mistake. Although in China, Japan or Vietnam, the traditional family is all
influenced by Confucianism, equally stable and strict in nature, the differences can still be found
basic.
The traditional Chinese family carries the institution of "tu thân, tề gia, trị quốc, bình thiên
hạ" (means that a gentleman must first train himself well, then arrange a good family, then rule the
country and reassure the people) is the basic morality of gentleman to set the model of a family-like
organization with the dominant position from village to country. Accordingly, the name of a family
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52
line has taken as the name of the village is popular. Yanfen cited by Đỗ (1990) mentioned "traditional
Chinese family is a large collection of many members living, it includes not only direct descendants
but also relatives, creating a family of three or four generations call tam đại đồng đường, tứ đại đồng
đường" (a three-generation family, a four-generation family also living under one roof), not just the
present nuclear family (p. 10). Meanwhile, Kurimolo Kazuo cited by Đỗ (1990) argued the traditional
Japanese IE family is seen as a social-economic institution rather than a community of bloodline (p.
10). Consequently, Confucian morality was originally directed towards political purposes in China,
here it was directed towards economic goals (Đỗ, 1990, p. 10). Although it is also influenced by
Confucian ideology, the traditional Vietnamese family does not have the characteristics of a socio-
political institution, which is a huge difference from the Chinese family. The Vietnamese family is
dependent and dominated by the village, the village unit is the foundation of the monarchy of
Vietnam, not the family unit.
In Vietnam, the characteristics of the economy create the cultural characteristics of the
family and community. 80% of Vietnamese people in the traditional society choose and associate
with the economic sector mainly in agriculture, the agricultural life in rural areas is linked to families
with villages. The pace of life of each individual and family revolves around symbols of banyan tree,
river wharf, communal courtyard, bamboo rampart - community and autonomy of traditional
Vietnamese village also formed from there. Although the agricultural life is worrisome and busy with
crops, the village's festival activities are still the focal point attracting the participation of everyone
in a relaxed and connected mind. That is also the basic root that shapes cultural values in the spiritual
life of the people. In that context, community and autonomy are two aspects that seem to be
contradictory but exist in parallel in all Vietnamese villages. Banyan tree, river wharf, communal
courtyard are symbols of community. It creates the morality of family and society in Vietnam,
upholding the spirit of solidarity, mutual reciprocity on the common order, on the interests of the
family and collectively, on covenants, on sacrifice, on peace and taking family as the most important.
The bamboo rampart is a symbol of autonomy, so many conventions and conventions that frame the
individual and family in the village's customary are such that "custom rules the law". Autonomy
encourages a spirit of hard work, independence and self-reliance, and it is fundamental to maintaining
a self-sufficient agricultural economy that has existed for centuries. Each traditional Vietnamese
family is considered as an agricultural production unit, due to its inclination to self-sufficiency, and
agricultural production activities that help each family satisfy the living needs of its members.
The traditional families in Vietnam take the form of a semi-nuclearized family as the basis
(Đỗ, 1990), so in terms of structure it can be divided into two main types of families: small family
(one or one generation) and large family (extended family of three generations or more). The big
family also follows the model of a three-generation family, a four-generation family also living under
one roof, when the children are mature and married, parents often live with the family of their eldest
son, other members of the family will live separately. In some families, due to economic conditions,
there are still many couples, kids and grandchildren living in the same house with their parents, but
basically still parents living with the eldest son. This is not required by law, but it is by default in all
Vietnamese villages. The most profoundly unifying element of traditional extended family is ancestor
worship, followed by sharing other big family events (wedding, birth, new house) and economic
aspects (supporting workers in the crop). Ancestor worship is performed in the family of the eldest
son, an event with ritual worshiping can take place within the family or the whole lineages. From the
characteristics of the lineages in Vietnam, it is appropriate to propose the concept of the lineage is
understood as the kind of family extending according to the blood relation, the strength of a lineage
is often expressed in aspects such as the success of the descendants and solidarity in the spirit of
emotional attachment as well as mutual assistance. Each family has a genealogy, which is a treasure,
although it does not have much meaning about the organization of life, but genealogy is the basis for
establishing and maintaining order and hierarchy in the lineages. Genealogy has a special meaning in
confirming whether a marriage relationship is allowed or not, because according to customary, in the
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lineages, marriage is strictly prohibited within a fifth generation relationship. The customary of
relationships and behavior in the family, lineages are the implicit verbal defaults that didn’t be
expressed in writing. Although this customary is different in each locality or ethnic group (in
Vietnam), basically all Vietnamese people know, understand and obey under the influence of the
lineages.
The delineation of the position and hierarchy in the Vietnamese family is influenced by the
characteristics of the wet rice agricultural economy (Đỗ, 1990) and Confucianism, with the ideology
of promoting the role of men "nhất nam viết hữu, thập nữ viết vô" (having 1 son in a family means
having kid, but even having 10 girls is still considered to have no kid) and there are many strict
requirements for women such as "công dung ngôn hạnh", "tam tòng tứ đức". "Công dung ngôn hạnh"
mentions four basic women's standards: "công" means to be good at housework, good at taking care
of family; "dung" is formal beauty, appearance: loveliness, discreet, graceful; "ngôn" is a courteous,
discreet, small, easy-to-hear speech associated with a well-mannered gesture that shows modesty;
"hạnh" referring to morality, kindness, faithfulness and devotion, rich in love, keeping full family-
style. "Tam tòng tứ đức" means when a woman is at home, she has to listen to her father, until she
gets married must listen to her husband, and when her husband dies, must listen to her son. In the
family, to promote the role of men and to be strict with women so the upper and lower relationships
are clear: father - kid; older brother - younger brother; husband - wife. These relationships are adjusted
by the morality of "tam cương" (talk about three main relationships in society: king - citizen, father -
kid, wife – husband) and "ngũ thường" (refers to five ethics that a person should have and should
have: personality, polite, righteousness, intellect, reputation). The husband is the mainstay and is
usually the one who holds the name of all assets in the family, the wife has a lower status but has a
huge role in money management, revenue and expenditure - the woman is considered the person who
holds the hand of the key box, and manages the money in the family. Therefore, even though it is
patriarchal family, the wife is truly the ruler (Đỗ, 1990). This is explained that in Vietnamese villages,
besides Confucianism, there is another religion that is popular and has a great influence on the
spiritual life of the people, which is Buddhism. Buddhism has been regarded as the religion of women
and children for centuries, so it is the Buddhist teachings that soften Confucian notions of woman
(Đỗ, 1990, p. 10).
The above is the basis for looking for a specific sociological approach to analyzing
traditional Asian families in general and traditional Vietnamese families in particular. One thing has
to admit that, all values and standards of the family are governed by that traditional family pattern.
Therefore, in order to understand the traditional communication culture in a Vietnamese family, first
of all, it is necessary to understand the characteristics of Vietnamese traditional families.
Understanding this is also the basis for determining the changes of the traditional communication
culture in the current Vietnamese family and the decisive factors for that change.
Communication culture in traditional Vietnamese family
Culture is a multifaceted concept, so there are many different definitions of culture.
Parsonian cited by Lamont & Small (2008) mentions culture as unitary and internally coherent set of
attributes that characterizes a social group (p. 79). On the other hand, Ortner (1984) refers culture as
what people produce and act on their environment. Fiske (2002) considers culture as "a set of customs,
capacities, ideas, values, rules, institutions; cultural products created by society and passed down
from generation to generation". It can be seen that the common point reflected in the connotation of
most concepts of culture is the symbolic culture of the community. People create culture and on their
side culture carries the mark of people in it.
The concept of communication is clarified in many respects in studies from the mid-20th
century, that communication is related to: interaction/ relationship; reduction of uncertainty; process;
transfer; linking; commonality; channel/ means; replicating memories; response/ change; stimuli;
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
54
intentional; time/ situation; power. As such, the definitions of communication reflect all levels of
fields from all meaningful behavior and purpose of people in conscious interaction (Dance, 1970).
Thereby, it can be understood that communication is a process of transmitting information in a
conscious way of people through symbols and words. Communication is an important activity that
creates cultural values. In the family, communication plays an extremely important role, is a
fundamental activity in family relationships, creating the culture of the family. Talking about culture
refers to the symbols of a certain community, so the traditional culture of communication in a
Vietnamese family is typical values of Vietnamese families in the context of Vietnamese community
and society. On the basis of the wet rice agricultural economy, the Vietnamese people are intimately
attached to nature and the universe, living in a peaceful, flexible, emotional, discreet, delicate, all
forming principles and how to communicate and behave in Vietnam (Trần, 2001).
Communication follows hierarchy
Traditional communication culture in families is formed and maintained in the context of
traditional Vietnamese families, and becomes an important part of family culture. The family is not
only a specific social group, but also a biological - cultural entity, a social - cultural institution. Family
from the beginning is a cultural existence, a cultural entity in close relation with biological factors
and gender (Lê, 2015). Therefore, the communication culture in the family is shaped and standardized
from the common standards of the family culture. In the traditional Vietnamese family, there are three
values and standards that are appreciated, creating the family culture, including: "gia đạo", "gia
phong" and "gia lễ". "Gia đạo" is the moral standards that the family values, among those standards,
filial is the highest value (filial piety to parents, ancestors). "Gia lễ" are customs in a family that are
expressed through the way of eating, behaving, and walking that have been passed down through
generations become a tradition and descendants must follow as a ritual hierarchy. "Lễ", according to
Asian, not only means autonomy but also means human. In a word, then "all the treatment of the
Asian people are in one word Lễ" (Phạm, 2012). Many Vietnamese families in the past, thanks to
their ability to maintain cultural behaviors, have created an order and discipline for everyone to
follow. "Gia đạo", "gia phong" and "gia lễ" are the root of the family, keeping the people of Vietnam,
the family and Vietnamese society a strong vitality and purity with their roots. "Gia đạo", "gia phong"
and "gia lễ" are three important standards that govern and regulate family relationships and govern
the behavior of family members not only towards the survivors but also towards the ancestors have
passed away. All elements of family communication are referenced in the common standard of that
family culture. Accordingly, the speaker, the listener, the communication content, the way of
communication, the way of responding and the context of communication are all placed in the
common cultural framework of the family. This cultural framework forms the principle of highly
hierarchical communication and obey the hierarchy.
Principle of highly hierarchical communication guides the communicator in his or her role
and position with the communicator and the context of communication. In terms of hierarchy in
family communication, communicators must be aware of who they are in that communication
relationship to have an appropriate way of communicating (vocative, attitudes, gestures). In the
traditional communication of the Vietnamese family, the speaker usually targets the listener with two
attitudes: polite or impolite expressed in four types of vocative nuances: (1) formal; (2) neutralization;
(3) friendly, flippant; (4) buggery, contemptuous (Nguyễn, 1993). In a normal conversation, the
speaker who in a high position (great grandparent, grandparents, parents, uncles, aunts) talking to
their children or grandchildren can display one of three nuances of the address: (1) normal; (2)
neutralization; (3) friendly, flippant. However, if the speaker in low position (kid, grandchildren) who
talks to their great grandparent, grandparents, parents, aunts and uncles, they are only allowed to use
the expression (1) formal. The principles of family vocation are often strict and very respectful, both
according to the order of bloodline, and according to the age order, but the order of blood is still the
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
55
decisive factor. Therefore, in the groups of vocative nouns, kinship nouns are used more often to
ensure the exact position and hierarchy of the family members when communicating. If in English
only "I" and "you" refer to the speaker and the listener, in Vietnamese, there are 3 ways of addressing
people at lower position when talking to people at higher position, including: "con" (kid), "cháu"
(grandchildren) and "em" (younger sister/ younger brother), the people at higher position depending
on their position to responded. Specifically, speaker call "con" when talking to "bố" (father) and "mẹ"
(mother); call "cháu"’ when talking to "cụ" (great grandparent), "ông" (grandfather), "bà"
(grandmother), "cô" (father's sister), "bác" (father's brother, mother's brother); "chú" (uncle); "dì"
(mother's sister); "cậu" (mother's brother), "thím" (uncle's wife), "mợ" (wife of mother's brother),
"dượng" (aunt's husband); call "em" (younger brother/ younger sister) when talk to "anh" (older
brother) or "chị" (older sister). All vocative nouns that do not correspond exactly have their own
meanings with different psychosocial colors: grandparents call their grandchildren is "con", parents
call their children is "em" to show their intimacy affection between family members or an older
person vocative to the younger being "mày" (you), "tao" (I) to expresses plain, intimate or maybe
angry. Conversely, when a person in lower position vocative "tao" and call "mày" to a person in a
high position, it will be attributed to chaotic and filial behavior. In different communication situations,
a given word can reveal many different expressions, even opposites. For example, the vocation "ông"
represents the normal relationship between a grandfather to his grandchild (or any elderly man when
communicating with a young subject but does not have any blood relationship), but there are also
cases where younger people vocative "ông" to an elderly, when a young man is in a quarrel with an
older person, he says: "ông" (I) challenged "mày" (you) do that. In addition to the right vocative, there
still exists the phenomenon of "vocation for replacement", which means that the vocation of the
person who claims is not showing his position but in the position of others. For example, a kid calls
his parents is grandparents when that kid also has a child. The way of vocation "grandparents" in this
case mean that the parents call to replace their children. In Confucian culture, there is always the
thought that men despise women, so they often use words for men first, words for women put behind
in a phrase used by both sexes, such as "ông bà" (grandfather grandmother), "anh chị" (brother sister),
"chú dì" (uncle aunt). The choice of forms of vocation clearly shows the position and power in the
family as well as the attitude of the characters in communication. Therefore, the home network is a
sustainable structure in which vocation have important role for showing attitudes, feelings. All forms
of vocation in society are influenced by the choice of the form of vocation in the home network (Bùi,
2018).
The vocative communication mechanism is understood as a structured system of the vocative
communication elements operating under a certain organization, including: vocative communication
units (vocative words, structures and vocative pattern), speaker - the person called and the principles
of vocative communication (Nguyễn, 1993). In the Vietnamese family, when the communication
takes place, the speaker - the listener who wants to perform a proper vocative communication must
determine how he and the object communicates in the relationship, especially save pay attention to
factors of age, gender, position, and intimacy level. In terms of age, the older person must be called
with respect, the position of the person of lower position shows respect for the person of high position,
if the relationship is a close one, the vocation is also more intimate. This principle forms an implicit
rule, when naming children, it is certain to avoid the same name as the superiors in the family. In
terms of gender, Vietnamese language is very rich with the system of anonymous words to call in
communication such as: "nàng", "thiếp", "người", "ngài", "mình", "ta" to use instead the name of
husband - wife in the family ("nàng": the husband calls his wife, "thiếp": the wife calls herself;
"chàng", "ngài", "người": wife calls her husband; "ta": used for both husband and wife when talking
to the other; "mình": wife or husband calls the other). In addition to the above factors of age, gender,
status, participants must pay attention to specific communication situations in terms of space, time,
and purpose.
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Paying attention to communication space demonstrates the characteristic that values
communication context. The traditional Vietnamese family communication space is usually the space
during a meal or after a meal when all family members enjoy tea and chat. Communication space is
sometimes extended in the workplace (in the garden, in the field, for example, people weeding,
transplanting rice, digging peanuts, etc. and talking together). Communication contexts can show a
state of close, intimate connection, but can also be formal, serious, and even heavy. Conversations
around the tray are often associated with problems or daily activities of the family, so the main theme
is temperate and intimate. One of the unique culinary cultural traits of Vietnamese people is the sense
of community shown right on the tray: food is share and everyone eats together, including a bowl of
sauce. That has a lot to do with the way Vietnamese people eat and communicate when they eat.
People of high position, the elderly take the food first and then the people of low position, children
must invite the adults before eating. Therefore, in the Vietnamese food culture, there is a saying "be
careful of possible faux pas", this regulates the behavior of family members when eating together.
Everyone has just eaten but must also listen and observe to ensure dignity and show respect for the
superior, the elderly. Children in the family are also taught how to eat slowly and especially when
chewing, they don't talk. The context of family communication is sometimes extended in family
meetings, which often have different emotional nuances depending on the content and purpose of the
meeting. If it is a family meeting about rejoicing (getting married, building a house, reaping crops),
the emotional state is usually comfortable and happy. However, if it is a meeting that involves dealing
with unusual incidents in the lineages, for example descendants in the offending family line (theft,
unmarried daughter pregnant) then the atmosphere is heavy. Most family meetings involve the
elderly, so when young people want to consult and exchange information, they must be allowed and
use honorifics with the people have higher position when speaking.
Communication context in traditional Vietnamese families is often associated with
communication time. Communication time is usually while the family is eating and working, but
perhaps the main time is still the evening when everyone is drinking tea and talking. Because this is
the time when most of the family's day-to-day tasks have been settled, everyone is in an
accommodating and relaxed mood while enjoying tea and chatting. Stories on the teapot or tray are
often related to family, how to organize life, assign tasks for tomorrow, ask questions, remind
children's education, but can also be stories about village communities. Later, when economic
conditions as well as technology developed, family members drank tea, watched television and
discussed together. There, although technology has begun to take part in family life, almost every
family member shares activities together with content on television: watching news, watching
movies, listening to music and entertainment together. Although there are intermediaries involved,
the communication of family members is still guaranteed.
Thus, all factors of age, gender, role, context, time or family communication purpose create
a multi-dimensional space, helping to realize communication and vocative behavior in
communication of Vietnamese family. Understand that multidimensional space in vocation and
family communication is to grasp the key of the traditional communication and help each family
member perform appropriate and effective communication behavior.
Communication emphasizes top-down pattern
Communication follows the principles of promoting hierarchies, so sharing and
communicating information is usually one-way from top to bottom. Listening, receiving and
responding to information in communications of low position people often must comply with
standards in eye contact, attitudes expressed through verbal and nonverbal language. Therefore, in
traditional Vietnamese family, parents attach great importance to teaching their kids "think today,
speak tomorrow", "courtesy costs nothing", "the cobbler should stick to his last", "words must be
weighed, not counted" it emphasizes that the speaker must be very careful before saying anything.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
57
When people are angry, do not say anything, because "word is silver but silence is gold". Even people
at higher position like grandparents, parents must also pay attention to this to act as an example for
younger people. On the contrary, those at lower position and younger people have to be more cautious
when speaking so as not to make messy mistakes with those above, violating the family hierarchy.
Vietnamese people say "cha mẹ đặt đâu con ngồi đó", it’s mean kids must follow all parental,
arrangements cover all the implications of parents' influence on their kids in the family, including
life-long greatness such as (marriage) to daily routine (communication). That affirms parents' right
to make decisions over all their kid's problems. Accordingly, imposing communication has also
become common in many families, parents say what their kids must obey. Because, in traditional
Vietnamese society, kids obey their parents is one of the criteria to show a good, filial and polite son.
Gradually it shapes the habit of one-way communication, that is, kids, people at low position only
receive information from adults and obey, less critical and objectionable. Judging from the point of
view of the kids and people at low position is often seen as disobeying their parents - one thing to
avoid in the family. The limitation from this communication feature is that the formation of
generations is only obedient without their own opinion, so personal development is also inhibited.
In addition, the delicate, circular communication style that makes all family members, big
or small, when expressing their opinions, is often less likely to open up directly to issues like in the
West. Delicate and caring communication style is the product of a respectful lifestyle and a way of
thinking that values relationships. This method of communication contributes to maintaining
affection, harmony, joy, avoiding family conflicts and quarrels, but its disadvantage is its lack of
assertiveness and frankness. Vietnamese people love harmony, so they always try to maintain
solidarity and happiness in the family; each family member must be educated and trained to have
appropriate communication. The ability to communicate, namely the kid's ability to speak and
behave, is the appearances of their parents, parents pay much attention to this, so they often teach
their kids how to communicate in a proper manner. The teaching content is not only the way of
speaking, how to convey it, but also the tone of the communication.
Hierarchical communication is also reflected in the ritual in a very polite and rich way of
speaking, the people at lower position always have to use honorifics when talking to the people at
high position and the elderly. Right vocation shows the full educational environment that is received
from children to adults and shows how that individual is in dealing with human beings. It requires
the speaker and the listener to attach to different honorifics, and to state the subject and the predicate
in which. Depending on the position of each person in the communication relationship, honorifics are
also used with different degrees.
Through communication to teach communication
Admittedly, people begin to communicate from birth with early behaviors such as: eye
contact, physical contact, conversation between adult and child. This has been made clear through
the psychiatrist Bowlby's theory of attachment, who affirms that "attachment is a long-term
psychological relationship between people" and that attachment begins at a young age newborn baby
(Bowlby, 1969). The theory of attachment states that infants enjoy human company and that most
infants respond equally to any caregiver when the child before the age of 6 months (McLeod, 2017).
In the Vietnamese family, in addition to the usual ways of communication such as
conversation, body caressing, eye contact, the adults in the family have a special way of
communicating with the child, which is "lullaby". Lullaby is performed with the purpose of helping
the child to fall asleep easily, feel secure and warm when sleeping, but from this activity it creates a
unique way of communication, that is how adults show love for children, and also a way of educating
the child from birth. From there, forming a precious treasure of lullabies for which grandmother and
mother are the main transmitters to the child, sometimes the men also perform this work. Through
lullabies, adults comfort the child to go to sleep, but more importantly transmit the teachings, basic
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
58
values, good manners, speech, in human morality. From that way of communication, the child will
know filial piety with ancestral root, the merits of parents, the peaceful affection between brothers,
and the behavior of words and voices to be human. The process of socialization of a child starts from
those everyday actions, each child in the family is raised with a treasure of proverbs, singing
performed through lullabies about how to be human. From the way family functions, it can be stated
that the socialization function of the traditional Vietnamese family not only focuses on teaching
children, directing them towards scientific knowledge, but first of all, towards human morality. That
process continues every day, as the child grows up, the lullabies are replaced by moral and benevolent
stories, to teach the child how to live and behave humanly, then the discussions about daily life. Every
story, event has an educational implication in it. When a child is well educated there will be good
manners and communication, because personal honour is tied to the ability to communicate, good
words spoken leave marks, forming a reputation; bad words spread to many people's ears, creating
disreputable. In addition, the respect of family dignity makes parents in traditional Vietnamese
families aware of teaching their children to behave in an ethical manner, because in the community
"bad news has wings". Children must be cultivated so as not to affect the honour of their parents,
ancestors, because "the apple never falls far from the tree".
Thus, Vietnamese people attach special importance to communication and love to
communicate; although they like to communicate, Vietnamese people have the opposite, almost,
timid characteristic and be careful in communication. The coexistence of these two opposing
personalities (like to communicate and shy) stems from two basic characteristics of Vietnamese
villages: community and autonomy. Put this in the context of family communication, everyone in the
family communicates very openly, but outside the family, it is quite timid, meeting strangers is even
more quiet. Children, people lower position when communicating with adults must be cautious and
cautious. These two seemingly contradictory personalities do not contradict each other, they are two
sides of the same nature, a manifestation of the flexible behavior of the Vietnamese people.
Discussions
This research explores the basic characteristics of the traditional Vietnamese family pattern
and the characteristics of the communication culture dominated by this family pattern. In synthesis,
there are linked and analyzed relevant documents to discover those features. There are two main
issues to clarify in this study, which are also more extensive and complete than previous studies on
traditional Vietnamese family and family communication culture.
As in previous studies as Trần (2001), Trần (1996, 1997, 1998, 2016), Trần (2005), Huỳnh
(2012), Đào (2014), the family pattern is shaped by the specific economic conditions and cultural and
social contexts of the country. This is clearly reflected in the characteristics of Asian production
methods - with the core base of the wet rice agricultural economy. However, on that common
background, each Asian country also has its own ethnic characteristic and the Vietnamese family
depends on and is dominated by villages. Village units are the foundation of the monarchy of
Vietnam, not the family unit. Vietnamese village is the place where the community and autonomy is
most clearly shown and in that particular context, the family culture, including the communication
culture, has a clear mark. It should also be added that the community and autonomy in the village as
well as the expression in the family are not two opposing and mutually exclusive states, on the
contrary, these two characteristics are complementary to create high cohesion but still have
differences and encourage autonomy and independence.
In addition to the economic context, ideology is also an important factor affecting the
lifestyle and culture of the Vietnamese people and the Vietnamese family. Specifically, it is the
Buddhist and Confucian ideology that creates strict rules, expressing hierarchy (Confucianism) but
also very humane (Buddhism), thereby creating the model of family and obey the defence is in a
family order, but also very soft and harmonious (Đỗ, 1990). Therefore, Vietnamese family’s notion
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
59
is only influenced by Confucianism creates harshness for some family members is not really
satisfactory, because before Confucian introduction, Vietnam was an independent country, a culture
with its own basic characteristics.
Communication culture in traditional Vietnamese family through this study shows the
following: all elements of family communication are referenced in the common standards of family
culture, forming principles communicate highly and hierarchically, communication emphasizes the
principle of top-down stereotypes. It can be seen that the principle of communication upholding and
obeying the hierarchy requires that participants to always pay attention to the hierarchy of
communication relationships, but it seems very natural and is not basically a mode of communication
that limits the communication level or ability of family members. This is actually easy to understand
and explain, because what comes from the family and community culture, all members of that cultural
context practice cultural norms freely natural and voluntary. Therefore, Vietnamese people have a
way of transmitting the family culture, including a specific communication culture: through
communication to teach communication.
Research results also show that although communication emphasizes top-down stereotypes
according to the hierarchy is maintained in the social relations of the Vietnamese people (Nguyễn &
Cao, 2012), Vietnamese people also seek to soften it through opening and leading communication in
a subtle, circular manner to increase the communicator's encouragement to participate in
communication. According to the Confucian influence, the moral concept of "tam cương, ngũ
thường" has quite profoundly influenced three core relationships in society: king - people, father -
child, wife - husband. Setting in the family context shows the clear shaping the father - child, wife-
husband relationship through behavior and communication, in which the husband, the father has the
biggest role and position in the family, has strongest influence on the remaining members. But it is
also important to see that this father - child relationship has expanded further into a parent-child
relationship. Therefore, in general, parents have a profound influence on their children, even on the
communication aspect that creates the imposed communication from top to bottom. This
communication limits the power and the capacity to criticize from low - position people (children) to
high - position people (parents) in the family, it tends to the principle of listening and passive
reception of the low - position people (children). To soften this principle, Vietnamese people build a
habit of delicate and thoughtful communication, which is also a product of a dignified lifestyle and a
way of thinking that values relationships. This way of communication contributes to maintaining
affection, harmony, joy, and avoiding conflicts and quarrels in the family. Therefore, despite focusing
on the way of communicating that is highly hierarchical and imposed from above, Vietnamese people
still maintain a respectful, flexible communication style that has created a cultural behavior, creating
a background order, discipline for everyone to follow.
Conclusions
Traditional culture of communication in the Vietnamese family was formed, preserved and
developed for a long time, bearing the imprint of wet rice civilization as well as Confucian and
Buddhist ideology. The respectful but flexible way of communication has created a cultural behavior,
creating an order and discipline for everyone to follow. However, the limitation of this
communication style is the lack of assertiveness, inhibiting personal criticism; the overestimation of
the reputation and dignity of the family creates stricter stereotypes against some family members,
especially towards people at low position, women and children. In that context, every family member
must learn how to communicate through daily communication, whether verbal or non-verbal, self-
improvement to form a way of communication, behave in accordance with standards. Since then, the
family fully performs their socialization functions, becoming the cradle to nurture, store and transfer
traditional cultural values from generation to generation. It can be seen that, although the term
"traditional Vietnamese family" is used according to a time convention, the reality still shows that
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
60
the characteristics of the traditional Vietnamese family are still preserved in many modern
Vietnamese families through values including respect for affection, living in love (Lê, 2015, para.15).
However, in the context of modern society some basic conditions of traditional society have
been changed, leading to many other changes in communication, behavior and culture in the family.
Traditional wet rice agriculture was gradually replaced by other economic activities, the influence of
Confucian thought was increasingly narrowed down at the same time with the expansion of
Buddhism's influence. Besides that, the trend of opening up integration, international exchange in
culture was also focused. The profound influence of science and technology, particularly the
penetration and influence of the Internet, are creating significant disturbances in the traditional
communication culture of the Vietnamese family. In the context Vietnam ranks 6th in Asia, 4th out of
10th in Southeast Asia and 17th out of 20 countries with the most Internet users in the world (Trần,
Trần, Nguyễn, Nguyễn, & Trần, 2017), using the Internet too much affects the quality and
effectiveness of communication in the family. In fact, there is a paradox that the more connected
users on social media, the more lonely they feel (Turkle, 2017), that fact requires a comprehensive
and comprehensive study on the influence of the Internet on communication in the Vietnamese family
to help families to be more fully aware of this issue, thereby having solutions to use the Internet and
communicate effectively, in accordance with national cultural traditions.
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65
AGE VARIATIONS AND SEXUAL DIMORPHISM IN ADIPOSITY AND BODY
COMPOSITION AMONG TRIBAL ADOLESCENTS OF KHARAGPUR, WEST BENGAL,
INDIA
DOI: http://doi.org/10.26758/11.1.5
Gopal Chandra MANDAL (1), Saheli BISWAS (2), Pijush Kanti ROY (2), Kaushik BOSE (2)
(1) Bangabasi College, Kolkata, India;
(2) Vidyasagar University, Paschim Midnapore, West Bengal, India
Address correspondence to: Gopal Chandra Mandal, Department of Anthropology, Bangabasi
College, 19, Rajkumar Chakraborty Sarani, Kolkata-700009, India, Ph.: 91-9433773205; E-mail:
golmal_anth@rediffmail.com
Abstract
Objectives. Although tribals constitute around 8.6% of the total population of India, detailed
information on their body composition is scanty. Thus, our objective was to evaluate age variations
and sexual dimorphism in adiposity and body composition among rural tribal adolescents of
Kharagpur, West Bengal, India.
Material and methods. This cross-sectional study was conducted among 788 tribal adolescent boys
and girls, aged 10-17 years of Kharagpur, West Midnapore, West Bengal, India. Height (kg), weight
(cm) and skinfolds were measured following standard method. The Body Mass Index (BMI) was
derived. Body composition measures including Percent Body Fat (PBF), Fat Mass (FM), Fat Free
Mass (FFM), Fat Mass Index (FMI) and Fat Free mass Index (FFMI) were computed using standard
equations.
Results. All the variables showed a significant age trend in both sexes. Age-combined significant sex
differences existed in mean BMI and all body composition measures. Girls had significantly higher
mean values of fat measures (PBF, FM and FMI) whereas boys had significantly higher mean values
of non-fat measures (FFM and FFMI). In both sexes, age had significant correlations with BMI and
the five body composition measures. Similarly, all body composition indicators were significantly
correlated with BMI in both sexes.
Conclusions. There were significant age and sex variations in body composition measures. Girls had
significantly more fat mass whereas boys had more lean body mass. All body composition measures
increased significantly with increasing age as well as BMI. Attainment of puberty could be a
mediating factor causing these age variations and sexual dimorphism.
Keywords: India, tribal adolescents, age variations, sexual dimorphism, body composition.
Introduction
The adiposity of an individual can be assessed by body composition. Eveleth and Tanner
(1990) commented that, the age, sex, genetic component, environmental conditions affect the
differential accumulation of body fat which is considered as a good indicator of the health and
nutritional status of a community. Skinfold thickness is an important measure of fatness (Roche,
Sievogel, Chumlea, & Webb, 1981). Body mass index (BMI) has been found to be associated with
body composition (Garrow & Webster, 1985) and nutritional status. It also has a high correlation with
body fatness (Rolland-Cachera, 1993). The influence of body fat distribution on health, first
suggested by Vague in 1956, is a topic of current interest. Several criteria are used for selecting
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
66
probable measures for nutritional studies. Skinfold thickness measures subcutaneous or “low-risk”
fat and is thus better for measuring body composition, while BMI is good for assessing the
relationship between internal fat and risk factors (Rolland-Cachera, 1993). Skinfold thickness has
been measured to estimate total body fat (TBF) and provide a fair assessment of the fat location.
Nearly all of the fat in the body lies beneath the skin, so thickness of subcutaneous fat reflects body
fat (Orphanidou, 1994). As the subcutaneous fat serves as a reservoir of energy during nutritional
deprivation, lower BF indicates a lower energy intake by children. The role of environment in the
development of adiposity is also evidenced in USA (Troiano, Flegal, Kuczmarski, Campbell, & John,
1995) and some developing countries (Martorell, Kettel Khan, Hughes, & Grummer-Strawn, 2000).
In very poor countries, such as those in Sub-Saharan Africa and South Asia, obesity among women
was greatly concentrated in an urban environment and among better educated women, whereas in
more developed regions, obesity levels were more equally distributed in the general population. The
distribution of BMI and subcutaneous fat in children of different ethnic origins - African or Indian
subcontinent descent living in Trinidad and Tobago, was studied by Gulliford, Mahabir, Rocke and
Chinn (2001). A study among young people of Romania by Rada (2017) pointed out that although
sedentary life was high among girls, boys showed higher rates of overweight and obesity and opined
that it may be due to the diet practices among girls.
According to Must and Anderson (2006), although BMI is frequently used to evaluate
obesity among children, it has its limitations like, there is no possibility to differentiate obesity due
to fat mass (FM) from that due to excess lean body mass. It is important to assess body composition
continuously and accurately during infancy which will help to evaluate the weight gained overtime.
Furthermore, it also provides useful information on nutritional requirements, the efficacy of diet and
medical interventions, and the influence of chronic diseases (Olhager & Forsum, 2003). The global
prevalence of overweight and obesity among children increased from 4.2 % in 1990 to 6.7 % in 2010
and is expected to reach 9.1 % by 2020 (de Onis, Blössner, & Borghi, 2010). The major patterns of
fat distribution develop in childhood and adolescence in both sexes. Males develop more trunk fat
than females, and this development is more clearly established after puberty (Bray & Bouchard,
1988). Children and adolescents with a high BMI also tend to have a high level of body fatness, but
because BMI is based only on weight and height, it can be an inaccurate indicator of body fatness,
particularly among those who have normal or relatively low levels of body fatness (Bray, DeLany,
Volaufova, Harsha, & Champagne, 2002). Many authors pointed out that relation of BMI to body
fatness differs based on race-ethnicity groups (Deurenberg, Deurenberg-Yap, Foo, Schmidt, & Wang,
2003; Freedman et al., 2008). Asians generally have more body fat and blacks have less body fat than
white Caucasians. Although, Ulijaszek and Kerr (1999) commented about the technical error of
measurements related with skinfold thicknesses, these are being widely used among children and
adolescents as they provide a more direct and accurate estimate of body fatness than BMI (Laurson,
Eisenmann, & Welk, 2011; Leitao, Rodrigues, Neves, & Carvalh, 2011; Going et al., 2011).
Furthermore, many authors are of opinion that, there is stronger association of body fatness with
skinfold thicknesses than with BMI (Bray et al., 2002; Sardinha, Going, Teixeira, & Lohman, 1999;
Steinberger et al., 2005; Freedman et al., 2007). In a study among children and adolescents aged 7 –
15 years from Vojvodina, North Serbia, it was reported that percent of skeletal muscle mass (% SMM)
increased with age in both sexes and was significantly influenced by gender, age and physical activity,
cumulatively and partially (Pavlica & Rakic, 2019). The role of physical activity in body composition
had also been investigated in another study (Nikolova, Mladenova, Boyadzhiev, & Paskaleva, 2019)
among 7-17 years aged children and adolescents from Plovdiv, Bulgaria. The authors had observed
that the increase in percentage body fat and values of the fat mass index and the decrease in frame
index were entirely or partially caused by reduced physical activity. Albu and Rada (2014) had
studied in detail the dynamics of anthropological markers among Romanian teenagers between 1978-
1999. They had found significant changes in anthropometry and body composition in this time span.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
67
Adolescence is one of the four known sensitive periods in life for the development of obesity,
the other three being intrauterine life, infancy and ages 5-7 years (Monyeki, van Lenthe, & Steyn,
1999). It begins with pubescence, the earliest signs of emergence of secondary sexual characters and
continues up to the morphological and physiological maturation to the adult status (WHO, 1995).
Unique changes that occur in an individual during this period are accompanied by progressive
achievement of biological maturity (Tanner, 1962). This period is very crucial since these are the
formative years in the life of an individual when major physical, psychological and behavioural
changes take place (Patil, Wasnik, & Wadke, 2009).
There are several socially disadvantaged communities in India, among which tribal
populations are the most deprived ones. Although, tribals constitute around 8.6% of the total
population of India, detailed information on their body composition is scanty (Khadilkar & Khadilkar,
2019). In this context, we have tried to investigate age variations and sexual dimorphism of body
composition of the tribals of a particular area of Eastern India.
In this context, our objective was to evaluate age variations and sexual dimorphism in
adiposity and body composition among rural tribal adolescents of Kharagpur, West Bengal, India.
Material and methods
Area under study. The present cross-sectional study was conducted in Higher Secondary
Schools of 10 villages (Changual, Gangarampur, Benapur, Balarampur, Sankoa, Gopinathpur,
Chakmakrampur, Mawa, Amlatoria, Chakturia) of Kharagpur Community Development Block II,
West Midnapore, West Bengal, India which are situatedaround10 km from Midnapore town, the
district head quarter. A total of 25.6% of the total population of the Block is constituted by tribal
groups.
The participants. Measurements as well as other information were collected from 788 tribal
adolescents (370 boys; 418 girls), aged 10-17 years. The students who were present in class were
randomly selected. Various tribal communities like Santhal, Bhumij, Munda, Mahali, Sabar live in
these villages. The living amenities were more or less same for all the groups. Hence, we considered
them as a single homogenous population termed ‘tribal group’. Age of the participants was calculated
from the Date of Birth recorded in the school registration books. Adolescents of non-tribal
communities were excluded from this study. Table 1 represents the age and sex wise distribution of
the participants.
Table 1
Distribution of the participants by age and sex
Sex Age in years Total
10 11 12 13 14 15 16 17
Boys 55 42 54 52 43 39 45 40 370
Girls 40 48 64 58 50 57 52 49 418
Total 95 90 118 110 93 96 97 89 788
Anthropometric variables. Height (kg), weight (cm), triceps skinfold (TRSF, mm) and sub-
scapular skinfold (SSSF, mm) were measured following standard methods (Lohman, Roche, &
Martorell, 1988) by the second and third (SB and PKR) authors. Skinfold measurements were used
to measure BF (%) from which fat mass (FM, kg) and fat-free mass (FFM, kg) were calculated.
Triceps (TRSF, mm) and subscapular (SSSF, mm) skinfold thicknesses were measured to the nearest
0.1mm using Holtain skinfold caliper. The following measures were derived: BMI, Percent Body Fat
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
68
(PBF), Fat Mass (FM), Fat Free Mass (FFM), Fat Mass Index (FMI) and Fat Free Mass Index
(FFMI).The equations used are presented in Table 2.
Table 2
BMI and body composition variables
Variables Formulae Reference
BMI Weight (kg)/Height (m)² WHO, 1995
PBF (Boys) 1.21 (TRSF+SSSF) -0.008 (TRSF+SSSF)2 -1.7 Slaughter et al., 1988
PBF (Girls) 1.33 (TRSF+ SSSF) -0.013 (TRSF+SSSF)2 -2.5
FM (kg) Body Weight (kg) x[PBF/ 100]
Van Itallie, Yang,
Heymsfield, Funk, &
Boileau, 1990
FFM (kg) Weight (kg) – Fat Mass (kg)
FMI (kg / m2) FM (kg) /Height2 (m2)
FFMI (kg / m2) Fat Free Mass (kg)/ Height2 (m2)
The technical error of measurements (TEM) was calculated for height and weight and they
were found to be within reference values as given by Ulijaszek and Kerr (1999). Thus, TEM were
not incorporated in any analyses.
Statistical analyses. Students’t-test and ANOVA were performed to study sexual
dimorphism and age variations, respectively. Pearson’s correlation coefficient (r) analyses was
undertaken to study the association between the continuous variables. All statistical analyses were
performed using statistical package for social sciences (SPSS, version 16.0).
Ethical approval. Ethical approval was obtained from Department of Anthropology,
Vidyasagar University. Permission for conducting this study was also obtained from each school
authority. Moreover, informed verbal consent was obtained from each participant.
Results
In case of PBF, among boys the mean values didn’t show gradual increase with age.
However, there was the gradual increase among girls and these values were much higher at all ages
than in boys (Figure 1). Although the sex differences were significant in most of the cases (except at
few ages) for FM, FFM, FMI and FFMI, both sexes showed an increasing trend with age. In case of
FM the mean values were higher among girls in all age groups, whereas, FFM displayed a reverse
trend (Figure 2). When age combined overall means were taken into account, except height, FFM and
FFMI, all other variables showed higher means among girls. All the variables showed significant
sexual dimorphism in each of the age groups but it was different in BMI, where it was significant in
case of only 14 and 15 years of age.
Figure 1 shows that there was a gradual increase of PBF among girls and these values were
much higher at all ages.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
69
Figure 1
Age specific sex variation in PBF
Figure 2 shows a reverse trend compared to the previous figures with boys having higher
values from age 13 onwards.
Figure 2
Age specific sex variation in FFM
Table 3 presents the age and sex-specific mean height, weight, BMI and the five body
composition measures. The mean values of all the variables significantly (p < 0.001) increased with
age. In case of height and weight, the mean values were lower among boys in earlier ages which were
reversed in the later ages. This was indicative of probably an earlier occurrence of adolescent growth
spurt among girls.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
70
Table 3
Age and sex-specific mean height, weight, BMI and the five body composition measures
* = p < 0.05; ** = p < 0.01; *** = p < 0.001
Variables Sex Age in years Total F
10 11 12 13 14 15 16 17
Height
(cm)
Boys 131.0
(7.5)
135.6
(6.01)
140.5
(8.4)
147.7
(7.6)
152.9
(10.7)
152.9
(9.3)
160.3
(6.6)
160.4
(7.6)
146.8
(13.1)
87.9***
Girls 133.7
(8.3)
139.1
(6.6)
144.2
(7.2)
145.9
(6.5)
148.7
(5.7)
149.9
(4.6)
150.4
(5.3)
150.9
(5.2)
145.7
(8.2)
43.9***
t -1.7 -2.6* -2.6* 1.3 2.4* 2.2* 8.2*** 7.1*** 1.5
Weight
(kg)
Boys 24.4
(4.3)
27.8
(5.2)
31.1
(6.5)
36.0
(6.2)
40.0
(7.0)
39.4
(8.1)
47.4
(8.0)
47.2
(7.0)
36.1
(10.3)
78.5***
Girls 25.8
(5.3)
29.1
(5.7)
32.9
(6.0)
36.0
(6.0)
40.2
(6.5)
41.1
(4.1)
42.4
(6.2)
41.4
(5.1)
36.4
(7.9)
57.9***
t -1.40 -1.16 -1.56 -0.02 -0.2 -1.4 3.5** 4.5*** -0.5
BMI
Boys 14.1
(1.4)
15.0
(1.9)
15.6
(2.0)
16.4
(2.1)
17.1
(2.4)
16.8
(2.6)
18.4
(2.2)
18.3
(2.0)
16.3
(2.5)
24.4***
Girls 14.3
(1.9)
14.9
(2.2)
15.7
(1.9)
16.8
(2.1)
18.1
(2.4)
18.3
(1.9)
18.7
(2.2)
18.2
(2.0)
16.9
(2.6)
32.5***
t -0.54 0.17 -0.29 -1.0 -2.1* -3.4** -0.7 0.21 -3.3**
PBF
Boys 10.8
(2.6)
12.5
(4.6)
13.2
(4.5)
13.2
(4.3)
12.9
(3.3)
14.0
(4.0)
14.6
(4.1)
14.4
(3.9)
13.1
(4.1)
4.7***
Girls 13.7
(3.9)
14.9
(3.8)
17.4
(3.9)
18.7
(4.4)
21.6
(4.7)
21.9
(3.6)
22.6
(4.0)
22.5
(3.8)
19.3
(5.1)
37.6***
t 4.5
***
2.7** -5.0** -6.6
***
-10.3
***
-10.1
***
-9.7
***
-10.0
***
-18.5
***
FM
Boys 2.7
(1.0)
3.6
(2.3)
4.3
(2.5)
4.9
(2.4)
5.2
(1.9)
5.6
(2.6)
7.1
(3.03)
6.9
(2.9)
4.9
(2.7)
19.6***
Girls 3.7
(1.8)
4.5
(2.0)
5.8
(2.3)
6.9
(2.5)
8.9
(3.2)
9.1
(2.2)
9.7
(2.9)
9.4
(2.4)
7.3
(3.2)
45.0***
t -3.4** -1.93 -3.4
***
-4.3
***
-6.5
***
-7.2
***
-4.3
***
-4.5
***
-11.1
***
FFM
Boys 21.7
(3.5)
24.2
(3.7)
26.8
(4.6)
31.1
(4.8)
34.7
(5.6)
33.8
(6.4)
40.3
(5.8)
40.3
(5.1)
31.1
(8.2)
92.7***
Girls 22.1
(3.8)
24.6
(4.1)
27.1
(4.1)
29.1
(3.9)
31.3
(3.8)
32.0
(2.7)
32.6
(3.8)
32.0
(3.4)
29.1
(5.0)
51.2***
t -0.502 -0.57 -0.39 2.4* 3.5** 1.9 7.9*** 9.2 4.3***
FMI
Boys 1.5
(0.5)
1.9
(1.1)
2.1
(1.1)
2.2
(1.1)
2.2
(0.7)
2.4
(1.0)
2.7
(1.1)
2.7
(1.0)
2.2
(1.0)
7.5***
Girls 2.0
(0.9)
2.3
(0.9)
2.7
(0.9)
3.2
(1.1)
4.0
(1.4)
4.1
(1.0)
4.3
(1.2)
4.1
(1.0)
3.4
(1.3)
34.8***
t -3.3** -1.61 -3.3** -4.5
***
-7.6
***
-8.0
***
-6.7
***
-6.8
***
-13.6
***
FFMI
Boys 12.6
(1.0)
13.1
(1.2)
13.5
(1.2)
14.2
(1.3)
14.9
(1.9)
14.4
(2.0)
15.6
(1.5)
15.6
(1.3)
14.2
(1.8)
29.2***
Girls 12.3
(1.2)
12.7
(1.4)
13.0
(1.2)
13.6
(1.1)
14.1
(1.3)
14.3
(1.1)
14.4
(1.3)
14.1
(1.3)
13.6
(1.4)
20.0***
t 1.3 1.56 2.2* 2.5* 2.2* 0.43 4.4*** 5.6*** 5.0***
Sex specific correlations of age with BMI and the body composition measures are presented
in Table 4. All the variables showed highly significant (p < 0.01) positive correlations with age. All
the fat measures (PBF, FM and FMI) displayed stronger correlations among girls. However in case
of all the non-fat measures (FFM and FFMI) the trend was reverse, i.e. much higher correlations were
noticed among boys. The sexual dimorphism was most marked in case of PBF followed by FMI. A
noteworthy finding was that the BMI showed similar correlations in both sexes.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
71
Table 4
Sex specific correlation of age with BMI and body composition measures
Variables r
Boys Girls
BMI 0.553** 0.561**
PBF 0.260** 0.600**
FM 0.515** 0.632**
FFM 0.787** 0.642**
FMI 0.340** 0.582**
FFMI 0.582** 0.464**
** = p < 0.01
Table 5 presents the sex specific correlations of BMI with the indicators of body
composition. In both sexes, all the measures showed significant positive correlations (p< 0.01) with
BMI. It was observed that all the fat measures (PBF, FM and FMI) displayed much stronger
associations with BMI in girls. The most noticeable sexual dimorphism was found in PBF.
Table 5
Sex specific correlation of BMI with the body composition measures
** = p < 0.01
Variables r
Boys Girls
PBF 0.646** 0.821**
FM 0.833** 0.901**
FFM 0.779** 0.839**
FMI 0.810** 0.923**
FFMI 0.939** 0.933**
Discussions
Adolescence is a decisive period of rapid physical growth attainment and development or
maturity with multiple physiological changes occurring between the childhood and adulthood. It
also includes body composition transforming with differential changes taking place between sexes
(WHO, 1995; Wells, 2007).
Mean height and BMI of the present adolescents were much higher than the Santhal
adolescent boys (134.8 cm) and (girls-142.8cm) respectively from Purulia, West Bengal (Das & Bose,
2011). However, mean weight among boys and girls were similar (Das & Bose, 2011). Mean height
(134.2 cm) and weight (29.9 kg) among adolescent boys of Kolam tribe of Telengana (Karri,
Ghritlahre, Das, & Bose, 2017) state were much lower than our participants. A study among rural
male adolescents from Naxalbari, Darjeeling District, West Bengal (Dey et al., 2011) found that the
height (154.4 cm) and weight (42.0 kg) among boys were much higher than the participants of the
present study. However, in comparison of the rural adolescent boys of West Bengal studied by Pal,
Pari, Sinha and Dhara (2017), the mean values of the present adolescent boys were slightly lower for
height and weight but these were slightly higher among the girls of the present study. Mean BMI
among the boys was slightly higher than adolescent boys (15.6 kg/m2) and slightly lower than found
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
72
among girl (17.4 kg/m2) Santhal adolescents from Purulia, West Bengal (Das & Bose, 2011).
Adolescent boys from Naxalbari, Darjeeling showed higher mean BMI (17.7 kg/m2) than boys of the
present study (Dey et al., 2011). Among the Rajbanshi adolescent girls from North Bengal, the three
anthropometric variables had similar (to our study) mean values (Roy, Barman, Mondal, & Sen,
2016).
The present study revealed that girls had higher mean PBF, FM and FMI than boys at all
ages. A reverse sex trend was observed in case of FFM and FFMI. This indicated that the level of
adiposity was significantly higher among girls. A similar trend has been reported in other studies
from India as well as other countries also (Dutta Chowdhury, Chakraborti, & Ghosh, 2007; Rakic &
Pavlica, 2014; Mandal & Bose, 2017; Mehdad et al., 2012; Rajkumari, Akoijam, Akoijam, &
Longjam, 2012; Freedman, Horlick, & Berenson, 2013; Nwizu, Njokanma, Okoromah, & David,
2014; Sharma & Mondal, 2018). Mean PBF among boys and girls of the present study were 2.8%
and 3.9% lower respectively, than those found among the adolescents from Imphal, Manipur, India
(Rajkumari et al., 2012). In the same study, it was observed that FM was 3.8 kg higher among both
the boys and girls than the participants of our study. A similar trend was also found among Moroccan
adolescents aged 11-17 years, where, PBF among boys was 15.9% higher and among girls it was
11.2% higher than our study (Mehdad et al., 2012). Similar results were observed in case of FM of
the participants of the same study and school children from Washington, USA (Freedman et al.,
2013). However, these were lower among Nigerian adolescents aged 10 – 18 years (Nwizu et al.,
2014) and among school going children and adolescents from Phanshidewa Block, Darjeeling
District, WB, India (Debnath, Mondal, & Sen, 2018). Our study provided preliminary evidence of a
significant spurt growth in PBF and FM. This indicated the approaching of peak velocities in height
and weight (Bell, 1993). It is noteworthy to mention here that the role of height is more important
than adiposity in predicting lean body mass (LBM or FFM) (Malina, Bouchard, & Beunen, 1988).
Mean FFM of the adolescents of the present study increased gradually with age in both sexes.
Sexual dimorphism became more pronounced at higher ages. The same trend had also been earlier
reported among Nigerian adolescents. They showed more or less 30.0% higher mean values among
boys and girls (Nwizu et al., 2014). However, another recent study found that there were no
significant sex differences among Santhal children (FFM: boys-22.2 kg; girls-21.2 kg) of Purulia,
West Bengal, and their mean values were lower than the present study (Dutta Chowdhury et al.,
2007).
The BMI was highly correlated with body composition parameters in both sexes and the
magnitude was greater among girls (except in FFMI). Similar results had been earlier reported from
Santhals of Purulia (Dutta Chowdhury et al., 2007), Moroccan adolescents (Mehdad et al., 2012),
adolescents from Imphal, Manipur (Rajkumari et al., 2012), rural adolescent girls from Kabri
Anglong, Assam (Sharma & Mondal, 2018) and Chakmas of Tripura (Saha & Sil, 2019). Maynard et
al. (2001) in their analysis of the data from the Fels Longitudinal Study had also showed a
significantly high correlation between BMI and body composition variables. Similar results had been
reported from black Jamaican children (Gaskin & Walker, 2003).
In the present study, the body composition measures that were significantly higher in girls
indicated that they tend to accumulate more fat than boys. In our study, we derived body composition
measures based on subscapular and triceps measurements. It has been earlier shown that girls possess
higher adiposity in their subscapula and triceps regions (Zimmermann, Gübeli, Puntener, & Molinari,
2004). The use of BMI to identify children with excess adiposity during the pubertal development
has an important limitation; it has been shown that BMI increases in adolescents from both sexes are
primarily determined by increases in FFM (or lean body mass, LBM) rather than in body fat
compartment (Yoo, Lee, Kim, & Sung, 2006). Pubertal ages are important for changing body
composition and it is more marked earlier among girls between pre and menarche individuals (Prado
Martinez, Marrodan Serrano, Acevedo Cantero, & Carmenate Moreno, 2017).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
73
Besides demonstrating distinct age variations in both sexes, our study provided unequivocal
evidence that there existed significant sexual dimorphism in body composition measures. We also
found that, in girls, fat measures were more strongly associated with both age as well as BMI which
is a measure of generalized obesity. The inverse was observed in boys, i.e. non-fat (or lean) body
composition measures had a stronger relationship with age. Taken together, these results clearly
indicated that with increasing age, there significantly more fat deposition among girls. Moreover,
increase in BMI in girls is concomitant with increasing fat deposition. This implied that there was a
distinct dimorphism in the increase between fat and non-fat (or lean) components with increasing
BMI. These morphological changes could be mediated by the attainment of puberty. More detailed
longitudinal studies are needed to fully comprehend the mechanism involved this significant sexual
dimorphism in fat deposition. Unfortunately, the present investigation was cross sectional in nature
which is major limitation of our study.
Conclusions
There were significant age and sex variations in body composition measures. Girls had
significantly more fat mass whereas boys had more lean body mass. All body composition measures
increased significantly with increasing age as well as BMI. Attainment of puberty, which involves
hormonal changes, could be a mediating factor causing these age variations and sexual dimorphism.
Further longitudinal studies are required to understand the mechanisms linked with these changes.
The uniqueness of our study is that it deals with age variations and sexual dimorphism in body
composition among tribals (indigenous people). Hitherto, to the best of our knowledge, such
investigations are scanty from India.
Conflict of interest: None
Acknowledgements
All subjects who participated in the study are gratefully acknowledged. Special thanks are
due to the parents and the School authorities for their kind cooperation and help.
Funding
The authors received no financial support for the research, authorship, and/or publication of
this article.
Abbreviations used
SSSF – Sub scapular skinfold
TRSF – Triceps skinfold
BMI – Body mass index
FM -Fat Mass
FFM – Fat free mass (also known as Lean Body Mass, LBM)
FMI – Fat mass index
FFMI – Fat free mass index
PBF – Percent body fat
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
74
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HIGH RISK OF POSTPARTUM HAEMORRHAGE AT BOUAKÉ UNIVERSITY
HOSPITAL (NORTH-CENTRAL CÔTE D’IVOIRE)
DOI: http://doi.org/10.26758/11.1.6
Zahouo Pascale Ghislaine KOUAMÉ (1), Adou Serge Judicaël ANOUA (1), N’Doumy Noël ABE
(1)
(1) Alassane Ouattara University, Côte d’Ivoire
Address correspondence to: Adou Serge Judicaël Anoua, Department of Anthropology & Sociology,
Alassane Ouattara University, BP V18 Bouaké 01, Bouaké, Côte d’Ivoire, Ph. : +225 07070136; E-
mail: anoua_08@yahoo.fr
Abstract
Objectives. Postpartum haemorrhage is one of several direct causes of maternal death in Côte
d’Ivoire. It is recurrent in the department of gynaecology and obstetrics at Bouaké University Hospital
(CHU de Bouaké), but little is known to date about the underlying risk factors. The present study
aims to describe the levels and trends displayed by the risk factors of postpartum haemorrhage before
determining the contributing social factors in the aforesaid department.
Material and methods. This study is retrospective in nature, concerning the period from 2014 to
2016. Data was obtained from delivery records and through individual interviews. The overall
approach adopted is an anthropological one.
Results. Postpartum haemorrhage is significant in light of its very high and increasing incidence
(22.31%) among multiparous mothers. Within the latter category, fatal complications are a critical
problem, with an annual average estimated at 35.98% and on the rise. The overall situation is alarming
in view of this progressive deterioration. The persistence of the reproductive morbidity is attributable
to various economic, social, cultural, and infrastructural factors.
Conclusions. Communicational strategies are proposed as a type of community intervention
conducive to social and behavioural change, with multiparous mothers as a priority target group,
followed by older mothers in the medium term and by adolescent mothers in the long term. This
should raise awareness about high-risk reproductive behaviours and practices as well as the
environmental, economic, social, cultural, and infrastructural factors correlated to postpartum
haemorrhage, with the ultimate goal of improving the quality and safety of reproductive practices.
Keywords: postpartum haemorrhage, reproductive behaviour, high risk, obstetric emergency,
maternal morbidity, Côte d’Ivoire.
Introduction
Postpartum haemorrhage is currently an especially concerning instance of maternal
reproductive morbidity. According to WHO (2014, p. 8), it affects about 2% of parturient women in
the world. Its impact on them is enormous. It seems to promote in these women a state of post-
traumatic stress such as a feeling of death and loss of control, a bad memory of childbirth, avoidance
of elements reminding them of childbirth, sleep disorders (Faure, 2011). In addition, other women
suffer from complications of transfusion, resuscitation, and infertility in case of hysterectomy
(Deneux-Tharaux, Bonnet, & Tort, 2014). Sometimes complications such as acute anuric renal failure
and inferior vena cava thrombus are highlighted (Deneau, Jean-Michel, Salah, Benyaghla, & Kalfon,
2017). Furthermore, it is responsible for almost a quarter of all maternal deaths, which makes it the
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
79
leading cause of maternal deaths (WHO, 2014, p. 8). In the majority of low-income countries, its
prevalence is especially notable. This is the case of Côte d’Ivoire too, where postpartum haemorrhage
is the most frequently observed direct cause of maternal death. Its incidence has been estimated at
42% of women in the national representative sample in Côte d’Ivoire’s National Health Development
Plan for 2016-2020 (MSHP, p. 18).
The characteristics of this maternal morbidity are related to several aspects of public and
community health. There are in turn conditioned by the financial, geographic, social and material
constraints to which mothers are subject (Fenomanana, Riel, Rakotomena, Andrianjatovo, &
Andrianampanalinarivo, 2009). The overlap of these diverse factors adds to the complexity of the
issue of maternal morbidity, which the existing literature has approached from multiple perspectives.
From a sociodemographic point of view, it has been noted that postpartum haemorrhage correlates
with age (Alouini, Randriambololona, & Randriamboavonjy, 2015) and with multiparity (Mazouz,
Sabri, & Hamadouch, 2018, p. 30), whereas from a medical and healthcare point of view, relevant
factors include restricted access to centres for obstetric emergencies and obstetric complications
(Mukuna, Okenge, Sepou, & Modia, 2018). In the latter case, uterine atony and soft tissue tearing or
uterine rupture (Diakité, 2015) as well as intervals of oxytocin increase of less than 20 minutes during
spontaneous labour (Loscul et al., 2016) have been found to be the most common causes. Sometimes
these complications are aggravated by factors such as delays in care. This is often justified by
resistance generated by the organization and operation of obstetric emergency services (Faye Dieme
et al., 2017).
The health care policy of Côte d’Ivoire aims to reduce postpartum haemorrhage by
developing the skills of staff who provide emergency obstetric and neonatal care. The same is true
by improving the quality and range of care services in all regions of the country, so that mothers can
receive adequate and even optimal treatment. This issue is prominently addressed by the National
Health Development Plan for 2016-2020, in its fifth strategic component, pertaining to the health of
mothers, new-borns, children, adolescents, and the youth, which sets the objective of improving the
health of the aforementioned categories by 2020 and reducing mortality by 50% (MSHP, 2016, p.
53).
However, the implementation of these initiatives and response actions is undeniably limited.
In the specific case of the department of gynaecology and obstetrics at Bouaké University Hospital,
there are several shortcomings to be pointed out following an exploratory survey of the manager and
health workers in the department. These are notably the upsurge of cases of postpartum haemorrhage
and delays in providing care in case of an obstetric emergency. The social aspect remains crucial in
the search for solutions to these problems. Indeed, there are sociological factors with underlying
sociodemographic and epidemiological variables that are of importance for combating the morbidity
under discussion. In particular, high-risk reproductive behaviours are a risk factor for postpartum
haemorrhage, along with environmental, economic, social and cultural determinants.
It is thus within an anthropological perspective that is formulated the hypothesis that efforts
to prevent postpartum haemorrhage must include a dynamic process of long-term health education,
aimed at reducing high-risk behaviours and other risk factors. This is considered as a necessity since
a mother is the mainstay of the family, by virtue of her role in covering household expenses. Her
survival is thus essential because of her productive contributions. The present study aims to describe
the levels and trends displayed by the high risk factors for postpartum haemorrhage before
determining the social factors that contribute to in the department of gynaecology and obstetrics at
Bouaké University Hospital. Thus, for the purpose of the analysis, it appears necessary to situate the
incidence and trends of postpartum haemorrhage in adolescent, older, and multiparous mothers, to
present the incidence and trends of deaths related to this morbidity in this category of mothers, and
finally to expose the social factors associated with its dynamics. Before addressing these matters, a
presentation of the methodology is in order.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
80
Material and Methods
Scope of the Study
The research was carried out in Bouaké University Hospital, in North-Central Côte d’Ivoire.
This is the only specialised medical unit for obstetric complications in the region. It is a public,
national institution with a threefold vocation – medical care, education, and research in the field of
health – and it is equipped with a department for gynaecology and obstetrics according to its 2016
activity report. It is the unit for delivery and obstetric emergencies of this department that was selected
as the scope for this study.
Research Type and Population
The present study has a descriptive and interpretive (Thorne, 2008) approach and a
retrospective viewpoint. It was conducted from the perspective of social anthropology, applied to
informants from the department of gynaecology and obstetrics. The latter included an obstetrician-
gynaecologist, a midwife, five women who had been treated for an obstetric emergency, and five
relatives of these women. Thus, there was a total of twelve informants in the study, selected for their
fluency in French and the experiences with postpartum haemorrhage that they could relate; in other
words, they were chosen as a convenience sample. To do this, a basic survey of a list of people present
at the time of the survey was used as a sampling technique. They were then interviewed so that the
social factors that influence postpartum haemorrhage could be identified. Furthermore, the delivery
records for the period 2014-2016 were examined, with a view to determine the levels and trends
displayed by postpartum haemorrhage and consequent death in adolescent, older, and multiparous
mothers.
Ethics and Data Collection
For the approval of the research, the scientific board of the Department of Anthropology and
Sociology of Alassane Ouattara University in Côte d’Ivoire reviewed and ratified the procedures to
be used to get informed verbal consent from the participants of the study. The collected data were
subsequently anonymized and could no longer be linked to any individual informant.
The research took place between the 15th of August and the 15th of December of 2016 and
consisted of two stages. First, a quantitative analysis of the delivery records made available by the
department of gynaecology and obstetrics was carried out. The period under study spanned three
years, from 2014 to 2016 and the data was collected following a previously established grid. The
numerical data collected represented the variables of age, number of births, maternal death, and
postpartum haemorrhage, noted for each mother included in the records. The collection of the data
was carried out by three students, each one working on one of the three observation years, in a space
allocated to them by the director of the department of gynaecology and obstetrics. This first stage was
followed by a qualitative investigation performed with the aid of an interview guide focused on the
social factors relevant to haemorrhage in parturients, during or following childbirth. The interviews
were conducted individually with the aforementioned twelve informers, namely the obstetrician-
gynaecologist, the midwife, the five women who had experienced postpartum haemorrhage, and five
friends and relatives thereof, and were organised according to the availability of the respondents.
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Data Management and Analysis
The data drawn from the delivery records were digitally analysed with the use of the program
Epi Info 5.3. The grids were validated once the delivery records had been surveyed and the data
representing the variables of age, number of births, maternal death, and postpartum haemorrhage
were coded before being entered into the chosen software on a computer. The statistical analysis that
was then conducted served to identify the levels and trends of postpartum haemorrhage in adolescent,
older, and multiparous mothers, as well as the mortality rate associated with this morbidity in these
three categories of mothers. The relevance of the analysis methods rests upon the theory of
reproductive transition, which is a reduced model of demographic dividend, at the scale of a
healthcare network (Abé, 2013). This theory led to the establishment of a priority ranking of the
response actions proposed, reflecting the respective risk levels of the categories of mothers.
As for the data obtained by means of the interview guide, they were tallied manually and
subjected to a thematic content analysis (Paillé & Mucchielli, 2012). Within the information gleaned
in this way, the main properties and trends of the social factors contributing to postpartum
haemorrhage were pinpointed. These were then further analysed so that their significance could be
elucidated. To this end, the theory of personal constructs set forth by Carré and Fenouillet (2019) was
relied upon, for a more insightful interpretation of the personal and subjective experiences of
postpartum haemorrhage that were recorded. In the following, there will be presented the results of
the study and what they have revealed about the department of gynaecology and obstetrics at Boauké
University Hospital.
Results
The results can be broken down into three sets: 1) incidence and trends of postpartum
haemorrhage per category of mothers in the period 2014-2016; 2) incidence and trends of maternal
mortality due to postpartum haemorrhage per category of mothers in the period 2014-2016; and 3)
the social factors correlated to postpartum haemorrhage.
Postpartum Haemorrhage per Category of Mothers
Table 1
Incidence and trends of postpartum haemorrhage in mothers from 2014 to 2016
Postpartum haemorrhage in adolescent, older, and multiparous mothers
Bouaké PPH in
mothers
In
adolescent
mothers
(< 19 yo)
In older
mothers
(> 35 yo)
In
multiparous
mothers
(> 4 births)
Dominant
risk factor
Year n % n % n % n %
Multiparity
2014 105 13.20 09 8.57 17 16.19 23 21.90
2015 101 12.47 07 6.93 21 20.79 20 19.80
2016 107 9.69 11 10.20 25 23.36 27 25.23
Yearly
average
11.78 8.59 20.11 22.31
Trend Decreasing Increasing Increasing Increasing
Status Alarming
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
82
In the department of gynaecology and obstetrics at Bouaké University Hospital, postpartum
haemorrhage displayed a high average incidence of 11.78% per year, albeit with an apparent decrease
between successive years.
Although it appeared to be relatively lower for adolescent mothers 8.59% and older mothers
20.11%, it exhibited to be more significant for its high 22.31% for multiparous mothers.
On the whole, postpartum haemorrhage predominantly affected multiparous mothers.
However, the overall state of affairs and its trends with a gradual rise over time observation period
2014-2016 are deplorable in the case of adolescent, older, and multiparous mothers alike.
In the following subsection, there will be presented the patterns of maternal mortality due to
postpartum haemorrhage in each category of mothers.
Maternal Mortality Due to Postpartum Haemorrhage per Category of Mothers
Table 2
Incidence and trends of maternal mortality due to postpartum haemorrhage in from 2014 to 2016
Mortality due to postpartum haemorrhage in adolescent, older, and multiparous
mothers
Bouaké Maternal
deaths due to
PPH
In adolescent
mothers
(< 19 yo)
In older
mothers
(> 35 yo)
In multiparous
mothers
(> 4 births)
Dominant
risk factor
Year n % n % n % n %
Multiparity
2014 10 27.78 0 0.00 3 30.00 4 40.00
2015 15 36.58 1 6.67 5 33.33 5 33.33
2016 24 39.34 2 7.69 9 34.61 9 34.61
Yearly
average
31.57 4.79 32.65 35.98
Trend Increasing Increasing Increasing Increasing
Status Alarming
There was a high risk of maternal deaths due to postpartum haemorrhage, with an average
yearly incidence of 31.57% and an increase over the three observation years in the department of
gynaecology and obstetrics at Bouaké University Hospital.
Adolescent mothers displayed per year a relatively low average rate of 4.79%, and older
mothers a high average frequency of 32.65%. The highest average yearly incidence of deaths due to
postpartum haemorrhage, 35.98%, was recorded in the case of multiparous mothers.
Thus, maternal mortality due to postpartum haemorrhage was especially significant in the
case of multiparous mothers, with the overall situation being alarming for all three categories of
mothers under consideration.
In the following subsection, there will be turned to the social factors that contribute to
postpartum haemorrhage.
Social factors that contribute to postpartum haemorrhage
The analysis of the data has shown that a parturient’s decision whether or not to seek
obstetric care could depend on her willingness to receive emergency care, since a parturient or her
family might not have the necessary financial resources to pay for the healthcare provided in case of
an emergency. This was evident in the dissatisfaction with the cost of transport by ambulance voiced
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
83
by several women referred to the centre for obstetric emergencies because of postpartum
haemorrhage. This is one of the reasons that the women refrained from requesting obstetric services
or deferred their decision to do so. One of them lamented the high expenses as follows:
When my giving birth started to wear out the midwife, she asked for me be to driven to the
ER in an ambulance, but my husband didn’t know where to get the 20,000 francs [XOF] that they
wanted to charge me for the trip in the ambulance. With the help of relatives, we mustered the money,
but once I got to the ER, there was expensive medication to pay for. So it’s because of all of that that
some women would die when they lost a lot of blood because of a complication of childbirth
(Interview with a woman referred to the centre for obstetric emergencies in Bouaké).
Such issues also led women to postpone their decision to visit a health centre, which in turn
aggravates the risk of maternal death, as the obstetrician-gynaecologist from the department of
gynaecology and obstetrics at the Bouaké University Hospital who was interviewed explained in the
following words:
Putting off visits to the unit for obstetric emergencies was one of the principal reasons for
death due to blood loss in parturients. Their reluctance was due to their insufficient financial means
or their preference for a home birth, among other factors (Interview with an obstetrician-
gynaecologist in Bouaké).
Dismissing the warning signs of postpartum haemorrhage must also be recognised as a risk
factor for the women that were sent to the centre for obstetric emergencies. Indeed, some of the
pregnant women had experienced haemorrhage prior to delivery, which could be a sign of a problem
with the placenta which poses a risk of later postpartum haemorrhage. This could kill the mother or
the fetus, but the women who had been sent to the emergency centre did not perceive their symptoms
in this way. In their view, bleeding during or after childbirth was a consequence of the diet of the
parturient during her pregnancy, as one of the respondents affirmed:
If a woman bleeds after giving birth, it’s because she’s been eating food which custom
forbids. That’s what she must have been doing. So if she gets pregnant again, she should stop eating
everything that’s forbidden for a pregnant woman, otherwise she’ll bleed again (Interview with a
woman referred to the centre for obstetric emergencies in Bouaké).
Such lack of awareness is thus also a risk factor, considering that it had delayed the expectant
mothers’ decision to seek obstetric care and thus increased the chances of subsequent postpartum
haemorrhage.
Independently of such delays in seeking emergency care, the very access to such care could
be impeded by a lack of means of transport at the parturient’s disposition. Indeed, some parturients
might arrive in time at the maternity hospital closest to their place of residence, only to find that that
there was no ambulance available to drive them to the centre for obstetric emergencies. This would
aggravate the risk of obstetric complications such as postpartum haemorrhage. A relative of a woman
referred to the centre for obstetric emergencies recounted this kind of experience:
My niece was referred to the ER but she died as a result of profuse bleeding after giving
birth. First, when we got to the village hospital, she gave birth normally, but then they said that she
was bleeding and that she would have to be taken to the ER. There was no ambulance and we had
trouble finding a car quickly. The road was also in poor condition, so by the time we got to the ER,
she was already dead (Interview with the relative of a woman referred to the centre for obstetric
emergencies in Bouaké).
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This example proves that access to emergency obstetric care may be belated. Inadequate
organisation and management also stand out as a factor conducive to delays in providing medical care
to parturients. In particular, the dysfunctionality of the referral system exacerbates the risk of
postpartum haemorrhage by occasioning such delays. Furthermore, the healthcare staff declared that
their equipment and supplies and the range of services they could provide were often meagre. The
midwife interviewed illustrated this deficiency as follows:
In the pharmacy, the lack of essential medication like magnesium sulphate, the scarcity of
fresh frozen plasma, and the untimely shortage of blood were greatly to be deplored (Interview with
a midwife at the centre for obstetric emergencies in Bouaké).
It is thus apparent that among the factors which discourage seeking obstetric care, limited
access and supplies are notable obstacles.
Discussions
Two main facts merit a detailed examination, namely the high risk of postpartum
haemorrhage at the department of gynaecology and obstetrics at Bouaké University Hospital and the
social factors that contribute to this reproductive morbidity.
The risk of postpartum haemorrhage is the most severe in case of multiparity, since this
morbidity was especially prevalent in mothers who had given birth to more than four children. In
Faure’s study (2011) of postpartum haemorrhage in France, it is mentioned that anomalies in uterine
contractility caused by multiparity occur in 59% of cases of postpartum haemorrhage (p. 13).
Additionally, in Diallo’s study (2012) of postpartum haemorrhage in Mali, it is noted that grand
multiparity heightens the risk of improper uterine contraction and retraction, which can then give rise
to postpartum haemorrhage (p. 30). Taking these data into account, one sees why multiparity was an
important determinant of postpartum haemorrhage as a reproductive morbidity in the department of
gynaecology and obstetrics at Bouaké University Hospital.
In this medical unit, postpartum haemorrhage exhibited the highest rate (22.31%) in
multiparous mothers, with a tendency to increase over time, observed in the period 2014-2016. The
incidence and trends of this reproductive morbidity in multiparous mothers were thus quite
catastrophic. Similar observations have been made by Randriambelomanana et al. (2011), in a study
of 26 women having undergone an obstetric hysterectomy, in which grand multiparas were most at
risk of needing this procedure, which followed postpartum bleeding in 19% of the total cases. Belaidi,
Benchachou, and Bennabi (2015), in turn, report a rate of postpartum haemorrhage of 56.71% in
multiparous mothers in their study of the frequency of the risk factors for this complication in Algeria
(p. 55). On the other hand, Descargues, Pitette, Gravier, Roman, and Lemoine (2001) indicate that
primiparity is also a factor that significantly increases the risk of postpartum haemorrhage. Similarly,
Nikiema (2011) notes in his study that 36% of postpartum haemorrhage cases were primiparas, more
numerous than the multipara making up 6.8% (p. 80).
It is thus apparent that this reproductive morbidity affects all mothers regardless of their
parity. However, considering that all pregnancies entail a risk of death, repeated procreation increases
this risk. That is why multiparous mothers have stood out as a risk category, including through their
mortality rate in case of postpartum haemorrhage in the department of gynaecology and obstetrics at
Boauké University Hospital, especially since the incidence of mortality due to postpartum
haemorrhage among multiparous mothers was found to be clearly increasing in the observation period
2014-2016, with a high annual average of 35.98%. Consequently, the situation was particularly
alarming. Multiparous mothers were most at risk of death due to postpartum haemorrhage.
Multiparity as a risk factor of maternal death is reported by Mahbouli et al. (2003), with 40%
of the cases being attributable to immediate or delayed postpartum haemorrhage. Similarly, for
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85
Roman et al. (2004), grand multiparity was an obstetric and neonatal excess risk, presumably in part
because it increased the likelihood of maternal death due to postpartum haemorrhage, and
Fenomanana et al. (2009) claim in a study aimed at the identification of risk factors for maternal death
that multiparity significantly correlated with the reproductive morbidity under discussion. Finally,
Mbeva, Karemere, Prudence, Nyavanda, and Mundama (2018), in their study aimed at determining
the causes and circumstances of maternal deaths in hospital conditions, find that bleeding was the
leading cause of death, accounting for 63.4% of cases, out which 40% fell in the category of
multiparous mothers.
Though it has been recognised that multiparity is a significant risk factor for the occurrence
of postpartum haemorrhage and consequent death, the fact remains that multiple social factors
contribute to this reproductive morbidity. The relevant social factors can be categorised as three types
of delays: a delay in deciding to seek obstetric care, a delay in transport to the emergency department,
and a delay in the provision of care to parturients.
As far as the delay in deciding to seek obstetric care is concerned, it is first of all due to the
difficulty of covering the expenses associated with the transfer to the emergency department, as
reported by the women interviewed who had been admitted to the department of gynaecology and
obstetrics at Bouaké University Hospital. In particular, patients need to pay the cost of the fuel for
the trip and of the services provided by the driver of the ambulance, if one is at all available. In default
of an ambulance, they would be compelled to engage the services of a private driver, often beyond
their means. Concrete figures are provided by Thiam (2014), who reveals that the cost of the transfer
to an obstetric department due to bleeding ranges between 25,000 and 30,000 XOF for patients driven
directly from a rural health post, reaching up to 50,000 for those using public transport. He explains
that these prices prevent low-income patients from Senegal from accessing emergency obstetric care.
The situation is similar in Mali: Cissé (2014) reports that referrals to the department of gynaecology
and obstetrics of the health centre in Markala due to bleeding in the third trimester involved direct
transport of the parturients at a high cost, more than some of the families could afford; hence, the
eventual admission to the emergency department of many parturients would be delayed for hours (pp. 7-
8).
Besides the difficulty of covering the expenses associated with a transfer to an obstetric
department, ignorance of the warning signs of postpartum haemorrhage also contributes to the delay
in a parturient’s decision to seek emergency obstetric care. Furthermore, the interviews conducted
for the present study clarified that the persistence of traditional social attitudes discourages recourse
to such care. Such unfavourable social circumstances have been pinpointed as a risk factor for
postpartum haemorrhage by Subtil, Sommé, Ardiet, and Depret-Mosser (2004). The period of
pregnancy itself is often a target of prejudice and other cultural constraints which hinder access to
emergency obstetric care (Sepou et al., 2011, p. 7). In the context of the department of gynaecology
and obstetrics at Bouaké University Hospital too, insufficient financial means compounded by
unawareness of the warning signs of postpartum haemorrhage contribute to delaying the decision to
seek obstetric care which might result in a referral due to postpartum haemorrhage.
As for the delay in reaching the emergency department, the respondents interviewed at the
department of gynaecology and obstetrics at Bouaké University Hospital agreed that accessing
emergency care was indeed difficult. They cited the lack of means of transport as the main problem.
In this regard, Sepou et al. (2011) have underscored that even when there are ambulances available
in certain medical units in the Central African Republic, they often fail to provide transport to the
referred patients, because the attending expenses need to be covered by the relatives of the latter, who
are essentially destitute (p. 7). In his thesis regarding Mali, Cissé (2014) additionally points out the
scarcity of modern means of transport for patients referred due to an obstetric emergency, as well as
the defectiveness of the vehicles used and the poor condition of the roads between the community
health centres and the maternity hospitals, both of which impede the transport of patients which
present bleeding in the third trimester (p. 7). Moreover, Fofana (2018) notes that the numerous
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patients transported by taxi, mostly due to immediate postpartum haemorrhage, without an
accompanying medical professional, arrived from medical units which do not have ambulances at
their disposition (p. 75). In light of these facts, it is indisputable that in case of postpartum
haemorrhage, the precarious transport conditions are a factor that prolongs the delay in reaching the
emergency centre of the department of gynaecology and obstetrics at Bouaké University Hospital
too.
Lastly, as regards the delay in the provision of care to parturients, the participants
interviewed at the department of gynaecology and obstetrics at Bouaké University Hospital attributed
it to inadequate management, as well as insufficient equipment and medications in the emergency
centre. Kéïta (2008) also points out insufficient supplies in the department of gynaecology and
obstetrics of the referral health centre of Commune V of the District of Bamako: a shortage of
emergency products and blood which is a serious obstacle to the efficient treatment of patients which
present bleeding in the third trimester of their pregnancy (p. 50). Similarly, Adjoby et al. (2014)
identify belated blood transfusion as a factor contributing to mortality in patients admitted for an
obstetric emergency. Morau, Ducloy, Le Roux, and Weber (2018), in turn, draws attention to
organisational faults in the treatment of postpartum haemorrhage in France. The suboptimal aspects
of the emergency obstetric care that he identifies include delays in making a diagnosis, treating
internal bleeding, and starting resuscitation procedures, as well as insufficient prenatal orientation of
the patients towards appropriate medical centres and improper coordination among the medical staff.
Based on the same French data, Tessier, Leroux, and Guseva-Canu (2017) indicate that the provision
of emergency obstetric care is more dysfunctional in the case of patients in a state of socioeconomic
precarity, which increases the risk of maternal death due to morbidities such as postpartum
haemorrhage. All these studies present situations analogous to the correlation between inadequate
management and the delay in the provision of care to patients experiencing postpartum haemorrhage
at the department of gynaecology and obstetrics at Bouaké University Hospital.
Conclusions
Postpartum haemorrhage is a morbidity that predominantly affects multiparas rather than
older or adolescent mothers. In the triennium studied at Bouaké University Hospital, the yearly
average of postpartum haemorrhage was 22.31%, with a rise between successive years, while the
average yearly rate of consequent maternal deaths was 35.98%, with the same tendency to increase.
In this case study, the trend of this morbidity and of the associated mortality was alarming especially
among multiparous mothers, because of the clearly growing rates. These bleak figures at the
department of gynaecology and obstetrics at Bouaké University Hospital are partly due to social
factors such as insufficient financial resources, ignorance of the warning signs of postpartum
haemorrhage, precarious transport conditions, and inadequate management. The enumerated factors
contribute to delays in the decision to seek out obstetric care, in transport to the centre for obstetric
emergencies, and in the provision of care at the aforementioned department to parturients presenting
postpartum haemorrhage, which in turn exacerbate this reproductive morbidity. These results raise
the question of what measures can be taken and how they could be implemented in order to accelerate
the reduction of the incidence of postpartum haemorrhage and the mitigation of its high risk factors?
A concrete solution to the problem could be the planning of communicational strategies that could
induce social and behavioural change, as a form of community intervention. The response action must
furthermore respect an order of priority. The category of mothers to be targeted as a first priority
would be multiparas, due to the especially high incidence of postpartum haemorrhage and consequent
death that they exhibit. The second category would be older mothers, to be targeted in the medium
term, as they also present a high rate of postpartum haemorrhage and consequent death. Finally, the
third category of mothers, to be targeted in the long term, are adolescent mothers, in view of their
intermediate rate of postpartum haemorrhage and consequent death. The population in question needs
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
87
to be led to intelligently re-examine their high-risk reproductive behaviours and practices, as well as
the environmental, economic, social, and cultural factors that contribute to postpartum haemorrhage.
It is only in light of real, identified problems that appropriate action can be envisaged and carried
through with the ultimate goal of increasing the quality and safety of reproductive practices.
Furthermore, it would be interesting to carry out a survey on the sociological logics underlying the
differences in morbidity in these different social categories. It would make it possible to highlight the
explanatory model of postpartum haemorrhage in adolescent, older, and multiparous mothers, and
their incidence of understanding of this morbidity. However, it should be noted at the outset that an
interpretative approach may be used in this study. In this case, this orientation presents itself as an
opportunity to shed relevant light on the risk factors for the occurrence of postpartum haemorrhage
outside of the demographic, economic and logistical deficit variables. This perspective is defined as
an openness to conflicts of representation or targeted contradictions between lived cultural practices
and public health norms in relation to the postpartum haemorrhage. This approach would make it
possible to act on these points of impact in order to achieve the desired change to reduce the risk
factors for this morbidity.
Acknowledgements
Authors wish to express their gratitude to the women referred to the centre for obstetric
emergencies due to postpartum haemorrhage as well as their relatives for their participation in the
present study and the many hours they set aside to this end. They would also like to thank the director
of the department of gynaecology and obstetrics at Bouaké University Hospital as well as the
obstetrician-gynaecologist and the midwife who were interviewed, for their availability and their
cooperation during the period of data collection.
Conflicts of Interest
The authors have no conflict of interest to declare.
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DIMENSIONS OF CRIME INVOLVING WOMEN IN DRUG TRAFFICKING -
LITERATURE REVIEW FROM DEPENDENT BEHAVIOR TO RELAPSE
DOI: http://doi.org/10.26758/11.1.7
Miana DINA (1), Jose Manuel Rodriguez GOMEZ (2), Cornelia RADA (3)
All authors of article have contributed equally.
(1) PhD. Student, School of Advanced Studies of the Romanian Academy, "Constantin Rădulescu-
Motru" Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy,
Bucharest, Romania;
(2) Guardia Civil de Madrid, Ministerio Del Interior, Espania, e-mail: pinodeloro@hotmail.com;
(3)"Francisc I. Rainer" Anthropology Institute of the Romanian Academy, e-mail:
corneliarada@yahoo.com
Address correspondence to: Miana Dina, National Administration of Penitentiaries, Directorate of
Social Reintegration, Maria Ghiculeasa, No.47, 2th Distinct, Bucharest, 023761, Romania. Ph.:+40-
021- 27583; Fax: +40-021-242.05.05; E-mail: grebenar.miana@yahoo.com
Abstract
Objectives. The aim of this study was to review the most important factors influencing women's
involvement in drug trafficking.
Material and methods. A systematic search of literature was carried out using Web of Science,
Academic Search Complete, ProQuest Central, PsychInfo. The inclusion criteria were met by fifty-
two studies. In order to facilitate the understanding of the behaviour of women who commit this
crime, factor analysis was grouped into social-cultural, personal and psychological factors.
Results. The main social and cultural factors considered were the adopted political system, the racial
element, the cultural-regional peculiarities, the geographical positioning, the socio-economic status
and the sociofamilial environment. The personal factors identified were age, occupation, lifestyle,
system of norms and values, and psychological ones referred to indicators of psychological disorders,
addictive behavior, the ability to control reactions and the perceived level of self-efficacy.
Conclusions. The factors with the highest share of drug trafficking among women were group
membership, economic and social status, educational level of parents and friends, prison history and
drug use. If in the rural area the main factor that determines women to get involved in drug trafficking
is the lack of a job and a low level of education, in the urban area, the influence of the group is
significant. Regarding the reasons behind the involvement of women in such criminal acts or in the
manifestation of addictive behaviors, these are often compensatory mechanisms, adopted in the
absence of effective coping strategies.
Keywords: women, drugs, trafficking, addiction, relapse.
Introduction
Although the global increase in female drug trafficking has highlighted the need to identify
determinants, a limited number of researches have been carried out on this issue over time (Faupel,
2010; Ritchie, 2017). Also, in scientific debates and studies, the link between drug use and trafficking
in women was one of the less observed and debated topics (Faupel, 1987).
Since specialists in the field have observed that, despite the experience of incarceration, a
large proportion of women continue to use drugs and carry out trafficking even after being released
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from prison, the importance of the psychological dimensions that can influence this type of behavior
have been pointed out (Kensy, Stengal, Nougier, & Birgin, 2012). According to Bergman (2018) it
is the presence of an addictive behavior, namely the use of illegal substances with an onset prior to
the involvement in drug trafficking, not only facilitated the commission of the criminal act but also
the state of relapse.
In terms of global consumption, in Europe it is estimated that more than 92 million people
aged 15 to 64 years (which represents more than 25% of the Union's population) have tried illegal
drugs at some point in their lives. In Germany, approximately 3.7 million of the population reported
frequent cannabis use (Atzendorf, Rauschert, Seitz, Lochhühler, & Kraus, 2019), and in Italy, "in
2009-2016, there was an increase in the number of people using drugs, 20% confirming the use of
more than one drug, 18% for cannabis and cocaine, 6% for benzodiazepines and 3.5% for methadone"
(Carfora, Campobasso, Cassandro, Petrella, & Borriello, 2018).
In southern Europe, drug use is constantly increasing, in Portugal, about 35% of the
population reported drug use, ethanol being the most commonly identified psychoactive substance,
i.e. in 55% of cases, between January 1990 and December 2007 (Costa et al., 2012). At the same time
in Spain, between 2003 and 2016, 10% of the population reported cannabis use, and in Bulgaria 3.5%
of cases supported this fact (Montanari, Guarita, Mounteney, Zipfel, & Simon, 2017).
In northern Europe, according to researchers Buvik, Bye and Gripenberg (2019), Nordic
countries differentiate themselves from others by a much lower rate of consumption. In Sweden,
drug use varies by age and region. Cannabis use was more common in southern Sweden than in the
northern region. At the same time, high alcohol consumption and illegal drug use appear to be more
widespread in those parts of Sweden that are closer to the European continent (Bränström &
Andrésson, 2008).
In Romania, as reported by the study conducted in 2019 by the National Anti-Drug Agency
(ANA) "compared to the European average, lifetime use (at least once in a lifetime) is lower for all
categories of illicit drugs analysed. The most widely used illicit drug among adolescents continues to
be cannabis/hashish, followed by new psychoactive substances (NPS)". The study shows that "there
is a better perception of the risks of experimental use of new psychoactive substances, amphetamines
and ecstasy, with an increasing proportion of those who attribute high risks to such consumption. The
greatest risks are for amphetamine use and cannabis use" (ANA, 2019).
In the USA, after 2012, heroine and cocaine use was frequently associated with a
considerable mortality rate (Walker, Pratt, Schoenborn, & Druss, 2017) and in Australia "after the
year 2000, the prevalence of drugs (other than alcohol) was present in 26.7% of cases, and
psychotropic drugs in 23.5%, namely cannabis (13.5%), opioids (4.9%), stimulants (4.1%),
benzodiazepines (4.1%) and other psychotropic drugs (2.7%)" (Drummer et al., 2003).
Even in states where the political system is characterised by a high level of control over the
population, the phenomenon of drug use and trafficking has seen a considerable increase. In Russia,
according to the study conducted by Kartashev and his collaborators (2016) between 2011 and 2015,
drug use and trafficking has increased considerably, with 23.8% of drug trafficking committed by
organised groups, and in Jordan, between 2008 and 2014, 36.5% of cases confirmed psychotropic
drug use, with users aged between 19 to 29 (Al-Abdallat et al., 2016).
Given that more than 70% of illegal drug use is used at retail level, in those states that have
become strategic regions for the international drug market (Belgium, Spain, the Netherlands), women
can hold important roles (Bergman, 2018).
The idea has emerged that women involved in the drug world belong to the category of
"specialist criminals". They are qualified in at least one or two offences, which they rely on to produce
their own income. Sometimes committing a single offence cannot provide the desired financial
support, and therefore the achievement of at least two offences increases this possibility. Such
specialisation involves learning important skills that facilitate not only the commission of the crime
but also ways of detecting and avoiding arrest (James, Gosho, & Wohl, 1979).
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In view of the above circumstances, it is useful to carry out a systematic search of the
literature in order to identify the factors that motivate women to engage in drug trafficking, both
locally and internationally.
Material and methods
Purpose and Objectives
The purpose of this study was to explore existing research on the topic of determinants in
drug trafficking in women. Thus, the objective of this study was to highlight the main social-cultural,
personal, but also psychological factors encountered in the commission of this criminal act.
The analysis of the specialized studies and their results focused on the following research
questions:
1. What social-cultural factors are involved in drug trafficking in women?
2. What personal factors are found in the choice to commit this crime?
3. What are the psychological factors that cause women to commit drug trafficking?
Search strategy
A systematic search of the literature was carried out and the following databases were used:
THOMSON ISI - Web of Science, EBSCO – Academic Search Complete, ProQuest Central,
PsychInfo, but also numerous manual searches via Google Academic Search Engine. Among the main
journals identified are The Journal of Ethnicity in Substance Abuse, Drugs & Society, International
Feminist Journal of Politics, Journal of Criminal Justice Education, Journal of Crime and Justice.
The search covered the period from 1979 to August 2020.
Two types of variable categories were used, namely, demographic variables that included
the gender – female and age category – at least 14 years, as well as psychological, aspects of
vulnerability, respectively.
As far as the psychological picture is concerned, the main vulnerable dimensions that
facilitate both involvement in such crimes and the perpetuation of such behaviour have been analysed.
The target was to identify the main determinant factors, to understand what motivated the appearance
of women in the drug market, but also to outline a complex picture of women drug dealers.
Selection of studies
The first author independently selected the studies with iligible potential according to the
search criteria. In the first phase, the selection was based on title and summary, and in the second
phase on the full-text article. All studies identified during the first selection phase were re-evaluated
in the second selection phase. The inclusion criteria consisted in the age category – participants to be
at least 14 years old, gender – to be female and to refer to psychological characteristics whose form
of expression may have significant consequences in terms of the manifestation of behavior according
to the socio-cultural norms.
The following keywords were used: trafficking, drugs, women, addiction and relapse. For
each keyword a certain number of studies were explored, namely women = seven studies, drugs = 21
(twenty-one) studies, trafficking = seven studies, dependence = six studies, relapse = 11 (eleven)
studies. The selection process of the studies is summarised in Figure 1.
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Figure 1
The selection process of the studies included in the article
Data extraction
Data extraction and evaluation of the quality of studies were carried out by the first author
and independently verified by the third author. Disagreements were resolved by consensus. Data on
the target group, the presence of information to support the information, as well as recruitment
methods were highlighted (the main condition was expressed voluntary agreement).
The methodological quality of the studies included was assessed according to the following
criteria: sample size, adequacy of randomization and management of missing data.
The quality of one study was assessed as high when all three criteria were met, an average
when only two criteria were met and low when only one was met. 10 (ten) low-level studies, 21
(twenty-one) of average quality and 21 (twenty-one) high-quality studies (Figure 2) were evaluated.
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Figure 2
The evaluation process of the studies included in the article
Tables 1, 2, 3, 4 and 5, located after the Study limitations section, show the adjacent studies
and conclusions for each keyword used in this article. Information regarding author(s), year of
publication, place of study, type and size of the sample were retained.
Results
The following social-cultural factors responsible for women's involvement in drug
trafficking were identified in 24 studies: the political system adopted (criminal justice); racial
discrimination; geographical positioning, cultural-regional peculiarities (promotion of nightlife);
socio-economic status (poverty); socio-familial environment (reference group, identity incongruity,
number of children, absence of roles and responsibilities, educational level of the family) (Figure 3).
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Figure 3
Social-cultural factors involved in the case of women who have committed drug trafficking
The political
system
adopted
Geographic
positioning
Racial
discriminatio
n
Socio-family
enviroment
Socio-
economic
status
Regional
cultural
features
The personal factors of women who committed drug trafficking were analyzed in 10 studies.
These are: lifestyle (carceral history, risk behaviours, prostitution, drinking and driving); personal
values (disregard for the rights of others, lack of morality); age (adolescence); occupation (joining
criminal groups, organised crime, human trafficking and money laundering) (Figure 4).
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Figure 4
Personal factors involved in the case of women who have committed drug trafficking
Personalfactors
Prostitution
Occupation
Personel values
Lifestyle
Prison history
Age
The following psychological factors of women involved in drug trafficking in women were
identified in 18 studies: indicators of psychological disorders (depressive mood, suicidal ideation,
anxiety, emotional lability, emotional and behavioral imbalance); perceived level of self-efficacy
(self-esteem, confidence in one's own problem-solving skills); ability to control one's own reactions
(disguise, self-control); addictive behaviour (drug use, adrenaline and ecstasy) (Figure 5).
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Figure 5
Psychological factors involved in women who have committed drug trafficking
The indicators of psychological
disorders
The emotional
labiliy
The ideation and suicidal
intention
Despresive mood
The anxiety
The perceived level of self-efficacy
The self-esteem
The confidence in one s own
problem-solving skills
Dependent behaviour
The ability to control one s own
reactionDrug use
The adrenalinThe self -control
Dissimulation
Psychological factors
Discussions
Social-cultural factors
Although the war on drugs in the US was declared as early as 1971 by President Richard
Nixon, attention to crime in women returned after a period of pause, i.e. after the 1980s, when the
literature began to look again with interest on the involvement of women in drug trafficking.
According to Fondevila, Massa and Meneses-Reyes (2020) researchers in the 21st century, there has
been a higher incarceration rate in the United States than in any other country, but with immediate
effects on the minority population. As per to the three authors, between 1986 and 1995, the arrest of
adult women for drug abuse violations increased by "91.1% compared to 53.8% for men, and from
2010 to 2014, women's arrests increased by 9%, while for men they decreased by 7.5%".
Despite the fact that this fight against drugs concerned the distribution and use of drugs, the
particular effects for women occurred in the form of their criminalisation and selective incarceration.
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According to Johnson and Young (2002) this increased selectivity is found mainly in African women.
Following a qualitative study of five incarcerated African women, former drug users and drug
traffickers, the analysis revealed that they were in financial difficulties and did not receive support in
this regard. As a result of this situation, women were stigmatized in several ways, including sexual
abuse, drug use, and drug trafficking. At the same time, conforming to Schemenauer (2012) and
Moloney, Hunt and Joe-Laidler (2015) most often female couriers are described as victims of a racial
subculture, Madonnas that carries out drug trafficking in order to benefit from some male protection.
As can be seen, an important role in criminal justice policies is gender bias, social class and
discriminatory race-based elements (Nicewarner, 2019). Considered to be partially effective, several
authors consider that in many cases of drug use and trafficking, the restorative justice policies can be
more appropriate ways, as they include simultaneous interventions for both the offender and the
victim (Dandnord & Griffiths, 2006; Dignan, 2005; Van Ness, Morris & Maxwell, 2001; Braithwaite,
2002). In fact, in agreement with Oancea and Micle (2015) law enforcement is "a process of social
influence", and for an effective rehabilitation program, careful focus is needed, both on dealing with
antisocial attitudes and on cognitive development, designed to help them solve problems.
Another phenomenon that has led to the emergence of women in the USA on the drug market
and in criminal activity is the absence of the probation system in regions at risk of criminal acts
(Robbins, Martin, & Surratt, 2009). The mere incarceration of a person from a disadvantaged area
and the lack of focus on programs to provide support in obtaining financial resources has to some
extent led to a continuity of women's involvement in drug trafficking (Olson, Stalans, & Escobar,
2016).
In Europe, the phenomenon of drug trafficking has focused more on state interests, "from
the individual policies of the liberal Netherlands to Sweden's repressive policies" (Chatwin, 2003).
In consonance with Chatwin (2016) across Europe, there are no common indicators of success that
allow drug policies to be judged, the cultural peculiarities having their say depending on each region.
If in Italy drug trafficking is primarily influenced by the existence of specific routes, social and
geographical proximity being key factors that explain the configuration of heroin supply (Giommoni,
Aziani, & Berlusconi, 2017), in the UK, drug trafficking is facilitated by the particularity of leisure
spaces, such as cafes, dance clubs, those spaces that offer pleasure for the consumer society, and can
represent an opportunity in the conduct of drug-related crimes (Measham, 2004). Also, in Romania
as reported by Baciu's qualitative study (2018) attended by 30 students from the Faculty of Medicine
in Bucharest, aged 20-21 years, it seems that the students considered that the places where illegal
drugs could be used are the most withdrawn, unlit, as safe from other people as possible, at parties,
in clubs or in parks and parking lots, at night.
Nor should the strategic role given by the geographical positioning of these states be omitted.
For example, Romania fulfils the role of "transit country", facilitating the involvement of women in
drug trafficking. The emergence of new routes for heroin trafficking to intermediate destinations such
as Georgia requires a growing diversification of criminal groups in order to achieve their objective.
Concealing criminal infrastructure with commercial activities that avoid possible risks, ensures a
major role for women in this regard (Nucu, 2018).
According to the Direction of Investigation of Organized Crime and Terrorism Crimes
[DIICOT], Romania has become a "target country" of risk drugs, especially in the case of cannabis,
and in recent times the number of cases of illicit cannabis plantsh has also increased. Even in this
situation, women can play a key role. Given that the prevalence of women in the countryside is higher
than men, but also that obtaining financial income is more difficult for women than for men, in this
context of physical work, involvement in such activities is perceived by them as a solution. If in rural
areas the lack of jobs causes women to commit drug trafficking, in major cities they are influenced
rather by the group of friends and the ways of promoting nightlife (Ţical, 2019).
Another factor is the influence of the reference group and the entourage. The results of a
study of 500 participants in Saudi Arabia showed that the predictor with the highest share in substance
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use and trafficking is the influence of the membership group (Beaver et al., 2016). Similarly, in Italy,
the results of a study of 33,185 adolescents between the ages of 15 and 19 highlighted the influence
of the membership group in terms of drug use and trafficking, as well as the high educational level
or, on the contrary, of parents and friends (Denoth, Siciliano, Iozzo, Fortunato, & Molinaro, 2011).
As per to Stanciu and Cotruş (2014) it seems that young people whose parents have a lower social
status and have no resources, or who have parents of high status, are more inclined to drug
consumption, due to lack of supervision and with a considerable financial support, create this
opportunity for the world of drugs.
At the same time, in Romania the results of a quantitative study, carried out in the period
2017-2018 on a sample of 459 students and students showed that the example offered by friends
influenced the behavior of adolescents and young people more than that offered by the family, most
of them using drugs under the influence of friends or at their urging, to "be of their own", "to be cool",
"to see what it is like to smoke cannabis" (Baciu, 2019).
The influence of one’s background can determine the degree of involvement in such
activities. The existence of models in the family, the lack of responsibilities or of children, influence
the commission of crime by adopting behaviors against social norms (Fowler, Dinitto, & Webb,
2005). A qualitative study from New Zealand highlights that women who do not have children and
use drugs tend to commit more serious crimes, i.e. to carry out drug trafficking in more dangerous
conditions or in greater quantities. This non-existence of a possible affective bond, which could have
been given by motherhood, increases the probability of manifesting risky behaviors (Hutton, 2005).
Personal factors
US specialists said that the lifestyle and implicit social norms by which a person is guided
are key elements in the commission of such a crime (Flynn & Hoffer, 2019; Bergseth, Jens, Bergeron-
Vigesaa, & McDonald, 2011; Dodge & Pogrebin, 2001). Thus, involvement in criminal activities and
criminal history can be significant factors in shaping this lifestyle for women who consume and carry
out drug trafficking (Bui & Morash, 2010). In their study of the needs of incarcerated women,
consisting of 402 women who committed crimes, Holtfreter and Morash (2003) highlighted the
implications of custodial sentences, notably the lack of community programs and services that can
provide specialized assistance for the purpose of lowering the relapse rate and for adopting a different
lifestyle.
At the same time, the presence of risk behaviours is part of this lifestyle, Jørgenrud et al.
(2018) stating in a study of 5031 male and female participants, from Norway, between April 2016
and April 2017, that speeding and drink driving use are found in drug traffickers. Alantes, Fraile and
Page (2002) also argue that the occurrence of such risky behaviour is often found in women who are
involved in drug crime.
Similarly, Calafat et al. (2009) in his study of 1363 participants in nine European cities
concluded that in their case, the most common risk behaviour linked to drug trafficking turns out to
be prostitution.
Other authors (Hughes, Chalmers, & Klimoski, 2018) suggested through a systematic
analysis carried out in Australia, in two distinct periods, namely 2005-2006 and 2014-2015, that drug
trafficking is most likely linked to money laundering, fraud, corruption and human trafficking.
Therefore, the main occupation of people who commit drug trafficking is organised crime.
Bellis and his colleagues (2008) through a study of 1,314 participants aged 16 to 35 from
nine European cities point out that drug trafficking occurs more in teenage girls, but who are also
involved in other criminal activities. It also seems that in large cities where the concept of freedom is
lived at intense levels, drug use and trafficking is closely related to the states of excitation or ecstasy
in sexual intercourse. As a result, girls under the age of 16 who were engaged in cocaine use and
trafficking were five times more likely to have had more sexual partners in the past 12 months.
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Psychological factors
Psychological disorders, i.e. personality disorders or anxiety disorders are often found in
women involved in such criminal activities. In line with several authors (Wexler, Cuadrado, &
Stevens, 1998; Stevens, Andrade, & Ruiz, 2009) there appears to be a direct relationship between the
addictive behavior, the seriousness of the crime committed and the presence of several signs of
psychological disorders. At the same time, Brownstein, Baxi, Goldstein and Ryan (1992) using data
from 414 homicide cases in New York, highlighted the association of depression with constant drug
use or overdose against a background of emotional instability.
Although depressive symptoms were correlated with people who were trafficking drugs for
the purpose of obtaining money for personal use, Iwamoto, Liu and McCoy (2011) in their study of
163 Asian women, they did not identify correlations between drug trafficking and coping strategies.
In fact, the manifestation of dependent behaviours often constitutes compensatory mechanisms in the
absence of effective coping strategies. In-depth interviews of several incarcerated women allowed an
understanding of the evolution from victim to survivor and then to the offender. Women who have
been subjected to different forms of abuse are subject to these compensatory mechanisms, such as
drug use and trafficking (Gilfus, 1993).
Emotional liability, emotional and behavioral imbalance are also psychological
characteristics found in women with a history of drug use and trafficking, Murphy, Stevens, McGrath,
Wexler and Reardon (1998), concluding these aspects in their study of 98 women enrolled in a
residential drug treatment center in Tucson, Arizona.
This spectrum also includes low self-esteem, how the person perceives himself as image and
self-confidence, feelings of shame and submissive behavior. As per to studies by Haselschwerdt,
Maddox and Hlavaty (2020) on 23 women in California, as well as studies by Radosh (2008), these
are psychological dimensions found in women convicted of illicit drug use and trafficking. According
to Micle and his colleagues (2013) it is self-esteem that sustains the person in those difficult situations
in life, and a person with negative self-esteem will tend towards states of unhappiness and anxiety.
Another register lists the conclusions of Marsh's qualitative study (2016) on a sample of 16
women from Ecuador who participated in international drug trafficking, which highlighted the
existence of a high level of self-control, concealment as well as good problem-solving skills. The
same aspects were discovered in studies conducted by Dotherte, Jacinto, Sales, & Murphy (2009) on
a sample of 80 drug dealers in California, but also by Ludwick, Murphy and Sales (2015) on a sample
of 160 drug dealers in the San Francisco Bay Area.
Grace (2017) concludes that in the UK, another factor involved in drug trafficking is drug
use itself. Women use drugs not only for pleasure, but also to cope with difficult life circumstances,
such as domestic abuse, and addictive behaviour thus becoming a compensatory measure in the
absence of effective coping strategies.
And in Spain, drug use is very common among women incarcerated for drug trafficking.
Sánchez, Fearn and Vaughn (2018) said in a research that examined the prevalence and correlations
of drug use in the penitentiary, on a random sample in four regions of Spain, that the previous history
of drug use was significantly associated with substance use in prison, with trafficking women more
prone to addictive behaviour.
In view of the international report on the drug situation in Europe and the rate of use as well
as the market, by "age group 15-34 years, the prevalence of drug use ranges from 0.4% in Turkey to
22.1% in France for cannabis, from 0.2% in Greece and Romania to 4.2% in the United Kingdom for
cocaine, and from 0.1% or less in Romania, Italy and Portugal at 2.5% in Estonia for amphetamine".
According to the researchers, drug trafficking is closely linked to drug use, so dependent women are
more inclined to practice drug trafficking (Mounteney et al., 2016).
Also, in Romania, drug trafficking is closely linked to drug use, with dependent women
more likely to commit this crime (Stanciu & Cotruş, 2014).
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The Australian Institute of Forensics draws attention to important differences in drug use
patterns in women compared to men. Thus, the risk factors for drug use differ significantly, depending
on both the experienced history and the perception of the phenomena in each person's life. If in the
case of women a leading role is represented by a history of traumatic potential, namely sexual and
physical abuse, as well as early exposure to dependent behaviour in the family environment, in the
case of men, the perception of the surrounding world, influenced by the entourage and the need to
affirm masculinity, is an essential element. Understanding this connection between the underlying
variables of drug use can help develop interventions and crime reduction strategies for female
offenders (Taylor, 2015).
In view of the above, in order for addicts to be perceived as people who have a serious
problem, and not as a "chaff" of society, with no chance of recovery, it is important not only to
increase the level of education but also to inform society about drug use (Baciu, 2017).
Conclusions
This study aims to identify the main factors underlying women's involvement in drug
trafficking, as well as to highlight their psychological characteristics, with the aim of shaping ways
to stop this phenomenon.
Regarding the first question of this study - What social-cultural factors are involved in drug
trafficking in women? it can be observed that the social-cultural factors that have an impact on
women's involvement in drug trafficking are the political system adopted, discrimination on the basis
of race, the cultural peculiarities of each region, geographical positioning, socio-economic status, but
also the socio-family environment.
Society's focus on criminal and less on restorative policies has facilitated the imprisonment
of women who have committed drug trafficking but could not control the criminal repression.
Although this type of policy ensures that potential sources of crime are reduced, full control is not
possible, nor can we speak of eradicating the criminal phenomenon.
If in the United States of America discrimination based on race (black population) facilitated
this measure, in the case of Europe the cultural peculiarities and the perception of the concept of
freedom led women to a large extent to commit this type of crime.
In northern Europe, where the educational level is higher, drug trafficking is much lower,
and in the southern part of Europe the incidence of drug trafficking in women is much higher. At the
same time, if in the rural area the main factor that causes women to get involved in drug trafficking
is the lack of employment and a low educational level, in the urban area, the influence of the
membership group is significant.
It is obvious that, not only the educational level of the person concerned, influences this
behaviour, but also of the family, in this case of the parents. Thus, whether it is a high level, which
causes parents to be more concerned with professional activity, at the expense of spending time with
their own child and careful monitoring him, or it is a low level, which reduces the chances of
providing an appropriate family model for the development of prosocial values.
At the same time, the absence of roles and statuses, the absence of children or
responsibilities, emphasizes this perception of freedom taken to the extreme, the idea of living the
moment, regardless of the consequences, becoming a priority in this type of situation. Freedom, led
to the extreme by disregarding moral principles, leads women to follow different models in the
membership group and to engage in such illegal acts.
As well, the influence of large cities and nightlife facilitates both trafficking and drug use.
The existence of a space that can represent an opportunity for drug use leads to the emergence of drug
trafficking. In Romania, the influence of the sociofamilial environment, the lack of studies or the
existence of jobs in the vicinity of the home, leads women to get involved in this type of criminal
acts, allowing them to obtain financial income.
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Regarding the second question of the study – What personal factors are found in the choice
to commit this crime? the studies analysed have shown that age, occupation, lifestyle and therefore
personal values are the main personal factors found in women involved in drug trafficking. Lifestyle
characterized by the manifestation of risk behaviours such as drunk driving, prostitution, the
commission of criminal acts in a repeated manner and therefore the existence of the criminal history,
support this involvement of women in drug trafficking.
Since lifestyle is the strategic option adopted by a person, the activities to which he or she
will decide to turn will be those that will guide decisions, behaviours and living conditions. In this
context, the appropriation of a system of anti-social values, such as disregard for the rights of others
and lack of morality, is nothing more than a tribute to the beliefs and representations he or she has
formed about the world and life, and by virtue of which he or she chooses, behaves and acts. The
decision to be part of criminal groups, especially those that commit human trafficking and money
laundering, is part of this lifestyle, based on occupations against the legal system, but which constitute
financial sources of living.
In the case of young women, especially in the case of teenage girls, the group of friends, and
the entourage are elements that influence this value system. The need to be accepted, to be like others
or to be the center of attention, causes them to enter a vicious circle, in which drug trafficking
correlates with drug use. Therefore, the younger women are, the greater their likelihood of drug
trafficking.
The third question – What are the psychological factors that cause women to commit drug
trafficking? refers to indicators of psychological disorders, perceived level of self-efficacy, ability to
control their own reactions, but also to addictive behavior. The presence of signs of psychological
disorders such as depressive mood, suicidal ideation, anxiety, emotional lability, emotional and
behavioural imbalance can often be psychological factors that facilitate women's involvement in drug
trafficking.
Negative self-assessment of one's own chances of success, failure to accept weaknesses and
flaws, and severe self-criticism are the basis of a lack of balance. At the same time, feelings of guilt,
fear or negative beliefs about oneself contribute to a generalized state of anxiety and dependent
personality structure.
High levels of stress and a state of emotional vulnerability can lead to depressive states,
negative emotional states, as well as involvement in different risk behaviors. These include drug
abuse. A woman addicted to drugs may be at high risk in terms of involvement in drug trafficking, as
there is a certainty that she will be able to benefit from the physical element that ensures pleasure and
determines the momentary well-being, namely the drug.
The absence of coping strategies, poor concealment capacity and low level of self-control
lead these women, in certain situations, to adopt drug trafficking as a compensatory mechanism.
Although this psychological vulnerability is very common in women who traffic drugs, the category
of women demonstrating outstanding skills in the coordination of these crimes should not be omitted.
On the one hand, women who commit drug trafficking, can belong to the category of those
who do not trust themselves, are easily influenced, have a poor ability to adapt to new situations and
are hesitant in their behaviour, and on the other hand there is the category of those who lack empathy,
guide their behaviour according to their financial objective, tend to overestimate their capabilities,
disregard moral values and have good problem-solving skills.
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General conclusions
In order to be able to stop this phenomenon, it is necessary first of all to apply measures to
raise awareness at the level of society, the consequences and risks that drugs have. Media prevention
campaigns, but especially those aimed at schools from disadvantaged backgrounds, can facilitate this
awareness of risks. At the same time, creating a closer link between school and family, by supporting
parenting sessions by school specialists, guiding parents in adopting parenting style and advising in
difficult situations, can be a method that reduces the involvement of adolescents in this drug world.
The following measures may be included in this group: increasing the employment
opportunities of people with low levels of education, developing the social support system for women
who do not receive family help or who are victims of domestic violence, and the existence of national
programs for free psychological counselling.
It aligns with the elements that may contribute to the decrease in the relapse rate and the
programmes carried out in prisons with women convicted of trafficking and illicit consumption of
dogs and the identification of networks to ensure the different needs of prisoners. At the same time,
another factor aimed at the reintegration of women into the community may be the analysis and
intervention on social networks, which supported their criminal activity in the past.
In Romania, the causes of the growth of the female population convicted of drug trafficking
also include the insufficient development of social services, which is why measures of a criminal
nature are applied, rather than social measures towards women who break the law. The absence of
organisations to support women in difficulty and to act towards helping them adapt to society is also
a sensitive matter for drug-related crimes.
As well, alternating criminal and restorative justice policies can positively influence this
approach. The development of centres for drug users, depending on existing cases, can contribute to
a decrease in the recidivism rate by including them in a specialised programme.
Study limitations
This article has several limitations. Because 25% of the studies had access to the abstract
only, as full access required buying them for a fee, this can influence the results in a negative way.
Secondly, the low number of researches on this subject has reduced the chances of highlighting
several aspects leading to an understanding of this phenomenon.
In the future, a possible metaanalysis that analyzes studies in a differentiated manner, i.e.
qualitative studies separate from quantitative ones, can bring significant information and a much
higher level of knowledge.
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Table 1
Analyzed studies and adjacent conclusions for the keyword - women
Authors, year of publication Place of study Study population N
James, Gosho, & Wohl, (1979). University of Washington,
Seattle, Washington.
Drug-addicted women
and prostitutes.
268
Findings: For all women addicted to heroin, drug resale and prostitution were the usual means of support.
Bränström & Andrésson, (2008). Sweden. Women with criminal
records.
14.400
Findings: The particular effects of drug policy.
Gilfus, (1993). University of Wisconsin,
Madison.
Incarcerated women. 20
Findings: Victimization of women - a factor influencing criminal activity.
Murphy, Stevens, McGrath, Wexler,
& Reardon, (1998).
Tucson, Arizona. Abused women. 98
Findings: The victim profile of women involved in crime.
Stevens, Andrade, & Ruiz, (2009). Tucson, Arizona. Women drug users. 200
Findings:Specific psychological factors involved in drug trafficking.
Haselschwerdt, Maddox, & Hlavaty,
(2020).
California. Abused women. 23
Findings: The role of vulnerability elements.
Dodge & Pogrebin, (2001). University of Colorado,
Denver.
Incarcerated women. 54
Findings: Collateral effects of women's incarceration.
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107
Table 2
Analyzed studies and adjacent conclusions for the keyword – drugs
Authors, year of publication Place of study Study population N
Alantes, Fraile, & Page, (2002). University of Valencia,
Spain.
Women involved in
crime.
50
Findings: Risk behavior in drug trafficking.
Radosh, (2008). Department of Womens
Studies, Western.
Women involved in drug
trafficking.
40
Findings: The racial element in drug trafficking.
Moloney, Hunt, & Joe-Laidler, (2015). San Francisco, California. Women involved in drug
trafficking.
253
Findings: Perception of advantages and disadvantages in drug trafficking.
Hughes, Chalmers, & Klimoski,
(2018).
National Drug and Alcohol
Research Center, Australia.
Women drug users. 1000
Fondevila, Massa, & Meneses-Reyes,
(2020).
Mexico city, Mexico. Women drug users. 1000
Findings: Involvement of women in drug trafficking-related crimes.
Hutton, (2005). Victoria University of
Wellington, New Zealand.
Women drug users. 3
Findings: Drugs and risk behaviors in drug trafficking.
Flynn & Hoffer, (2019). Case Western Reserve
University, Cleveland,
Ohio.
Women drug users. 52
Findings: Social implications of drug trafficking in women
Chatwin, (2003). England and Europen
Union.
Women involved in drug
use and trafficking.
-
Findings: The impact of political systems on drug trafficking.
Chatwin, (2016). Swedan and Netherlands.
Women involved in drug
use and trafficking.
-
Findings: Impact of cultural peculiarities on drug trafficking.
Bellis et al. (2008). European countries. Women drug traffickers. 1314
Findings: The connection betweeen adrenaline and drug trafficking.
Measham, (2004). Lancaster University, UK.
Women involved in drug
use and trafficking.
-
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108
Authors, year of publication Place of study Study population N
Findings: The impact of nightclubs in the phenomenon of drug trafficking.
Nucu, (2018). Romania. Women involved in drug
use and trafficking.
-
Findings: Effects of geographical positioning in drug trafficking.
Ţical, (2019). Romania. Women involved in drug
use and trafficking.
-
Findings: Economic motivation in drug trafficking.
Giommoni, Aziani, & Berlusconi,
(2017).
Italy. Women involved in drug
use and trafficking.
50
Findings: The connection between social proximity and drug trafficking.
Mounteney, (2016). European countries. Women drug users. 15.000
Findings: The connection between dependent behavior and drug-trafficking.
Beaver et al. (2016). Saudi Arabia. Women drug users. 500
Findings: The role of the entourage in drug use and trafficking
Denoth, Siciliano, Iozzo, Fortunato,
& Molinaro, (2011).
Italy. Teenage drug users. 33.
185
Findings: The role of the entourage in drug use and trafficking.
Stanciu & Cotruş,
(2014).
Romania.
Teenage drug users. -
Findings: The role of social factors in drug use and trafficking.
Baciu, (2018). Romania. Students. 30
Findings: Favorite places for drug use.
Baciu, (2019). Romania. Students. 459
Findings: The influence of the membership group on drug use.
Baciu, (2017). Romania. Drug users. -
Findings: Informing the company about drug use
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109
Table 3
Analyzed studies and adjacent conclusions for the keyword – traffic
Authors, year of publication Place of study Study population N
Johnson & Young, (2002). United States of America. Abused women. 5
Findings: The psychological implications of the victim.
Schemenauer, (2012). Columbia. Women drug traffickers. 100
Findings: Confidence in one's own ability to conceal
Whitney, (2016). Ecuador. Women drug traffickers. 16
Findings: The psychological implications of the victim.
Jørgenrud et al. (2018). Norway. Women with a history of
addiction.
5031
Findings: Risk behaviors in drug trafficking.
Ludwick, Murphy, & Sales, (2015). San Francisco. Women drug traffickers. 160
Findings:Perception of the advantages and disadvantages of drug trafficking by women.
Calafat et al. (2009). European countries. Women with a history of
addiction.
1363
Findings: Risk behaviors in drug trafficking.
Dotherte, Jacinto, Sales, & Murphy,
(2009).
California. Women with a history of
addiction.
80
Findings:The implications of addictive behavior.
Table 4
Analyzed studies and adicent conclusions for the keyword – addiction
Authors, year of publication Place of study Study population N
Grace, (2017). England. Women who committed
drug trafficking.
89
Findings: Addiction - survival strategy.
Robbins, Martin, & Surratt, (2009). U.S.A. Women drug users. 50
Findings: Intervention - measure to prevent relapse
Bui & Morash, (2010). U.S.A. Incarcerated women. 20
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110
Authors, year of publication Place of study Study population N
Findings: Involvement of the probation service in the return process.
Sánchez, Fearn, & Vaughn, (2018). Spain. Women with a history of
addiction.
100
Findings: The use of substances in prison can be a barrier to the rehabilitation objectives of these women.
Wexler, Cuadrado, & Stevens,
(1998).
South Florida. Women with a history of
addiction.
83
Findings: The presence of psychological disorders in addictive behavior.
Brownstein, Baxi, Goldstein, & Ryan,
(1992).
New York. Women in communities
dealing with drug
trafficking.
414
Findings: Increased risk of suicide.
Table 5
Analyzed studies and adjacent conclusions for the keyword – relapse
Authors, year of publication Place of study Study population N
Fowler, Dinitto, & Webb, (2005). U.S.A. Women drug users. 51
Findings: Individual intervention in addicted behavior.
Olson, Stalans, & Escobar, (2016). Loyola University,
Chicago.
Incarcerated women. 60
Findings: Risk factors for relapse.
Bergseth, Jens, Bergeron-Vigesaa,
& McDonald, (2011).
Chicago. Incarcerated women. -
Holtfreter & Morash, (2003). U.S.A. Incarcerated women. 402
Findings: Means to stop recidivism in drug use and trafficking.
Dandnord & Griffiths, (2006). New York. Convicted people. -
Dignan, (2004). Glasgow. Convicted people. -
Szabo, (2010). Romania. Convicted people. -
Braithwaite, (2002). England. Convicted people. -
Findings: The importance of the political system at the level of society.
Oancea & Micle, (2015). Romania. Convicted people. -
Findings: The importance of dealing with antisocial attitudes.
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111
Authors, year of publication Place of study Study population N
Taylor, (2015). Philadelphia, U.S.A. Incarcerated women. 40
Findings: Influence of the support environment by gender.
Micle, Oancea, Saucan, &
Dragomirescu, (2013).
Romania. Convicted persons. 100
Findings: Inability of subjects to select important information.
Acknowledgements
This study is part of the doctoral research project entitled "Dimensions of personality,
emotions and cognitions in people deprived of freedom", carried out at the School of Advanced
Studies of the Romanian Academy, "Constantin Rădulescu-Motru" Institute of Philosophy and
Psychology, Department of Psychology, Romanian Academy, Bucharest, Romania.
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THE IMPORTANCE OF WELL-BEING AND SATISFACTION WITH LIFE IN READING-
COMPREHENSION AND MATHEMATICAL ABILITIES IN DEAF AND HEARING
INDIVIDUALS
DOI: http://doi.org/10.26758/11.1.8
Yahir GONZALEZ (1), Diego-Oswaldo CAMACHO-VEGA (2)
(1) (2) Faculty of Medicine and Psychology, Universidad Autónoma de Baja California, USA
(2) E-mail: yahir.gonzalez@uabc.edu.mx
Address correspondence to: Diego Camacho, Universidad Autónoma de Baja California. Facultad de
Medicina y Psicología. Calzada Universidad 14418, Parque Internacional Industrial Tijuana, 22390
Tijuana, B.C. Ph.: 664 682 1233; E-mail: diego.camacho@uabc.edu.mx
Abstract
Objectives. The primary objective of this study is to evaluate if there are significant differences in
reading-comprehension and mathematics between deaf and hearing individuals, identify if the level
of Psychological Well-Being and Subjective Well-Being is related to higher mastery in reading-
comprehension and mathematics, and finally, determine if self-perceived disadvantages in reading
and mathematics by deaf individuals are related with their mastery in reading and mathematics tasks.
Material and methods. A mixed-method was conducted including correlational and topological
analysis of speech. The sample was constituted by 58 volunteers: five deaf individuals (age M =28.4)
and 53 hearings (age M =18.75). Participants responded to the Satisfaction with Life Scale and the
Ryff´s Scales of Psychological Well-Being after solving the Adults Reading Evaluation and the
Buenos Aires Mathematics test.
Results. Higher scores were found for the hearing group in reading and mathematics. No correlations
were found between Satisfaction with Life and reading and mathematics neither between
Psychological Well-Being and reading and mathematics for both groups. The qualitative analysis
indicated that deaf individuals perceived no differences in their reading-comprehension and
mathematics skills regarding hearings, but they scored significantly lower than hearings.
Conclusions. This study corroborated results from previous research about the differences in reading-
comprehension and mathematical abilities between deaf and hearing individuals. This study identifies
that differences between deaf and hearings might be more related to other factors such as the lack of
awareness of difficulties in reading-comprehension and mathematics, while satisfaction with life and
psychological well-being appears to be related to employment difficulties.
Keywords: Deaf, reading-comprehension, mathematics, psychological well-being, subjective well-
being.
Introduction
According to the Organisation for Economic Co-operation and Development (OECD)
cognitive abilities refer to "a set of thinking strategies that enable the use of language, numbers,
reasoning and acquired knowledge, comprising verbal, non-verbal and high-order thinking skills"
(OECD, 2019, p. 86). The OECD (2013) through the Programme for the International Assessment of
Adult Competencies (PIAAC) identifies the cognitive abilities that are essential for adult life:
Literacy, Numeracy, and Problem Solving in Technology-rich Environments (OECD, 2013) which
are relevant in numerous social and working contexts and are necessary for participation and full
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integration in the labor market, education, and the social and civic development (Prada & Rucci,
2016). This study focuses on the cognitive skills of reading-comprehension and mathematical
abilities. Reading-comprehension is the capacity to understand, evaluate and apply written texts to
develop personal skills, achieve goals and participate in society while mathematical ability is defined
as the capacity to access, interpret and apply data and mathematical concepts in answer to overcome
the diverse situations in daily life (OECD, 2013). Particularly, this research considers the
manipulation of elements, logical-deductive reasoning, symbolic representation, and analytic
reasoning as mathematics abilities (Cortada & Macbeth, 2007).
Previous studies have analyzed both reading-comprehension and mathematical abilities
based only on hearing individuals. Therefore, there is a need of assessing these abilities in vulnerable
groups such as deaf individuals who are considered by the World Health Organisation (WHO, 2020)
as people with profound hearing loss which implies very poor or null access to sound.
Studies that consider deaf-individuals are relevant because it has been found that deaf people
perform low in reading tasks, being a clear minority who achieve a reading skill equivalent to the
expected at the end of elementary education (Moreno-Pérez, Saldaña, & Rodríguez-Ortiz, 2015).
These differences can be explained in part by the differences in phonological processes between deaf
and hearing individuals (Herrera, 2005; Kyle & Cain, 2015; Moreno-Pérez et al., 2015; Wauters, Van
Bon, & Tellings, 2006). Additionally, deaf individuals who did not acquire sign language (SL) show
structural differences compared with those who acquired previously the SL. The main differences
consist in spoken language acquisition difficulties, as well as the limited linguistic experience
including low access to lexical, syntax, semantics, speech as elements of language, and weak reading
instruction processes implied in the level of reading and writing, which implies better achievement
for deaf readers with the dominion of SL in reading and writing tasks. (Figueroa & Rosa Lissi, 2005).
Similarly, previous research suggests that deaf individuals show lower performance than
hearing in mathematics assignments (Andin, Rönnberg, & Rudner, 2014; Bull, Blato-Valle, &
Fabich, 2006; Kelly, Lang, & Pagliaro, 2003; Masataka, 2006; Pagliaro & Ansell, 2012). It is
considered that hearing loss and environments with little language stimulation influence low scores
because they deprive deaf people of learning opportunities, a situation that reduces their exposition
to early numerical concepts which consequently leads to a lack of the necessary elements for further
mathematical learning, contributing to the difficulty that deaf individuals experience with
arithmetical estimations when values should be accessed from symbols (Bull et al., 2011). That
becomes more relevant considering the importance of mastering whole numbers and basic
mathematical operation before starting fractional numbers (Mousley & Kelly, 2017). Otherwise,
Marschark, Morrison, Lukomski, Borgna and Convertino (2013) point out that deaf signers have
some advantage in the visual-spatial working memory, a condition that translates into a better
development in visual mathematical problems but only in schematization and organization, not in
mathematical processing itself compared to non-signer equals and hearing peers.
In addition to the lack of educational opportunities, some evidence about the association
between cognitive and life satisfaction has suggested a close correlation (Enkvist, Ekström, &
Elmståhl, 2013). In the same way, prior evidence suggested a significant correlation between
psychological well-being and cognitive skills (Llewellyn, Lang, Langa, & Huppert, 2008) but
research about these topics is not yet clear in deaf groups.
Deaf people are known to be at much greater risk of developing psychological problems
(Gascon-Ramos, 2007) but the relationship between psychological issues and educational problems
in this population is still unclear. Psychological Well-being has become relevant due to its
relationship with facts as employments or happiness, the ease or difficulty to find employment,
academic performance, and social participation, being more notorious in female and student
population (Moreta-Herrera, López-Calle, Gordón-Villalba, Ortíz-Ochoa, & Gaibor-González, 2018;
Wiklunda, Nikolaevb, Shirc, Food, & Bradleye, 2019). There are two broad lines of study for Well-
being in Psychology: a) psychological well-being, based on the concept of eudaimonia which is
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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linked to the ideal of happiness, (Padrós & Medina, 2015) b) subjective well-being, based on the
concept of hedonism, related to satisfaction and avoidance of suffering (Moreta, Gaibor, & Barrera,
2017; Zubieta & Delfino, 2010), both included inside the framework of the Positive Mental Health.
In this study the concept of Psychological Well-Being (PWB) refers to what makes us feel
alive and authentic, helping us to grow as individuals. Therefore, it includes social and individual
indicators including the evaluation that people make about their circumstances and function in
society, the way they face their conditions in life, the reach of success, and personal development.
Subjective Well-Being (SWB) focalizes the perception that people have of their current
condition (Cárdenas et al., 2012; Moreta et al., 2017; Padrós & Medina, 2015) and asks how and why
people can perceive their life positively (Moreta et al., 2017). Subjective well-being is compound by
cognitive and emotional elements (positive or negative emotions). Its cognitive element is the
satisfaction with life defined as a global opinion that the individual has about his life comparing his
overall success versus his expectations (Cabañero et al., 2004; Cárdenas et al., 2012).
Based on the beforehand explanation, the present study aims to evaluate if there are
significant differences in reading-comprehension and mathematical abilities between deaf and
hearing individuals, identify if the level of Psychological Well-Being and Subjective Well-Being is
related to higher mastery in reading-comprehension and mathematics, and finally, determine if a self-
perceived disadvantage in reading and mathematics by deaf individuals is related with their mastery
in reading and mathematics tasks.
Material and methods
A mixed method was applied with a correlational focus for quantitative aspects of the study
and a transversal topological analysis of speech for qualitative aspects (the qualitative approach was
only considered for the deaf group). Due to the lack of instruments to measure cognitive skills,
psychological well-being, and satisfaction with life, this study searches to obtain objective and
subjective/self-report measures of cognitive abilities of reading comprehension and mathematical
ability.
Sample
The study was conducted on a sample of 58 volunteers from a Mexican population that
accepted to participate in the study after signing the informed consent. Then, two groups were formed.
The first group corresponded to five deaf individuals (DG) (3 females and 2 males) (DG mean age
M= 28.4), all bilateral, profound, prelingual deaf who reached university education and practiced
Sign Language (specifically the Mexican Sign Language or MSL). This group was selected with the
collaboration of an SL translator. None of the participants had an auxiliary implant and all of them
spoke SL. The second group was formed by 53 hearing participants (HG mean age = 19) where 67%
were females.
Instruments
All participants completed the Adults Reading Evaluation test (ELA) (Matute, Chamorro,
González, Ventura, & Parra, 2015), the Buenos Aires Mathematics Test (TMBA) developed by
Cortada and Macbeth (2007), the Satisfaction with Life Scale (SWLS) developed by Diener,
Emmons, Larsen and Griffin (1985), and the Ryff´s Scales of Psychological Well-Being (SPWB)
(Díaz et al., 2006). An MS PowerPoint presentation with video-recordings supported by the
explanation of a Sign Language interpreter was delivered for the deaf group (DG) during the whole
evaluation. Only the reading passage from ELA was not translated to SL. Following the
recommendations of Kyle and Cain (2015) who suggest that deaf individuals have difficulties
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understanding abstract or poorly concrete contents, all the scales were reduced to 3 choices (Yes = 1,
I don´t know = 2, no = 3) for the DG.
The ELA is an instrument that assesses reading precision, speed, and comprehension. For
this study, we focused on the comprehension dimension of the instrument using the reading passage
provided by the instrument. To test mathematics ability, a 10-items adaptation of the TMBA was
administrated. This questionnaire evaluates the manipulation of elements; logical-deductive
reasoning; symbolic representation; and analytic reasoning. TMBA was reduced from 50 to 10 items
choosing the items with higher correlation indicated by Cortada and Macbeth´s study (2007) (items
2, 13, 18, 22, 25, 28, 34, 38, 39, 49 from the original 50-item questionnaire). Each one related to one
of the dimensions assessed in the test, namely: simple arithmetic calculations (item 4); operation with
decimals (items 1, 5, and 6); proportions, percentages, and rule of three (items 3 and 10); algebraic
solving (items 8 and 7); and geometry problems (items 2 and 9).
The SWLS is a 5-item scale to evaluate the global judgment about self-perceived satisfaction
with life.
Finally, the SPWB is a 29-items scale to measure six factors of Psychological Well-Being:
1) Self-acceptance, 2) Autonomy, 3) Positive Relationships, 4) Environmental Mastery, 5) Purpose
in Life and 6) Personal Growth.
Procedure
Both groups completed the full evaluation in the faculty computer laboratory. For the
assessment of DG the SL interpreter helped to locate the participants giving them the instructions
orally. Complementary, an MS PowerPoint presentation was shown on the same screen. For the HG
sample, the formulary was given with no modifications. Cronbach-alpha values for each scale are
shown in Table 1.
Quantitative analysis
A descriptive analysis of all the natural scores of each sub-test in the formulary was done,
then an exploratory analysis of the data distribution was calculated for each group. After that,
significant differences between both groups were examined in each sub-test of the formulary using
the Mann-Whitney U test for independent non-parametrical samples, and finally, the correlation
coefficients were obtained with Pearson´s r in the DG because of the normal distribution of data
showed from the Shapiro-Wilk test, while the Spearman's rank correlation coefficient rs was applied
in the HG due to the non-normal distribution of data in this group.
Qualitative analysis
Deaf participants were interviewed with a semi-structured interview supported by the LS.
Then, a topological analysis of speech was conducted. This process was audio-recorded and
subsequently, the information was analyzed using the ATLAS.ti 8 software.
Results
Quantitative results
To determine significant differences between groups, the Mann-Whitney´s U was calculated
for the whole set of tests (Table 1).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Table 1
Differences between groups and reliability by scale
Scales Groups M SD U(56) p Cronbach-
alpha
SWLS DG 12.20 2.59 122.50 .780
.65
HG 12.26 2.94 .77
ELA DG 1.60 1.14 14.500 <.001 .62
HG 5.89 2.09 .50
TMBA DG 2.20 1.48 21.000 <.001 .33
HG 5.21 1.69 .35
SPWB DG 76.20 5.07 4.00 <.001 .61
HG 62.66 6.81 .74 Notes.
SWLS = Satisfaction with Life Scale
ELA = Reading Evaluation for AdultsEvaluación de Lectura para Adultos
TMBA = Test de Matemáticas Buenos Aires
SPWB = Ryff’s Psychological Well-Being Scales
As is shown in Table 1, the results indicated significant differences (p <.01) between the DG
and HG for ELA U(56) = 122, and TMBA U(56) = 21. For further analysis of our data, we compare
all items of the TMBA between DG and HG. We found significant differences for items 9 (geometry
problems scale), and item 10 (proportions, percentages, and rule scale). Meanwhile, significantly
higher values were found for the DG in the SPWB scale U(56) = 4, p <.01.
To achieve the second objective of this research which tried to determine if reading-
comprehension and mathematical abilities are correlated with Psychological Well-Being, the
Spearman´s Rank-Order Correlation was calculated for HG while the Pearson´s Product-Moment
Correlation test was conducted for DG due to the distribution of the dataset.
For DG, no significant correlation (p .05) was found between SWLS and reading-
comprehension as well as no significant correlation was found between SWLS and mathematical-
abilities. Similar results were found for HG (Table 2).
Table 2
Correlations between ELA, TMBA, and SWLS, SPWB
SWLS SPWB
Coeficient p Coeficient p
ELA DG .81 .09 .33 .60
HG -.20 .14 -.00 .99
TMBA DG .27 .66 .41 .50
HG -.06 .66 .05 .72 Note. rs Spearman was calculated for HG, whereas r Pearson for DG.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Qualitative results
To determine if self-perceived disadvantages in deaf individuals are related to results in
reading-comprehension and mathematics tasks for deaf individuals, the qualitative analysis indicated
that deaf individuals self-perceive their cognitive skills as high (Table 3 shows the inductive
codification based on the theoretical framework, the analytic categories defined as high and low and
examples of unit analysis). Individuals from the DG do not self-perceive differences in reading and
mathematics skills regarding hearings. They expressed that their SPWB and their SWLS is affected
by inequalities in job opportunities more than disadvantages in the analyzed cognitive skills. Besides,
learning for life, family, friends, and healthy social relations were considered important factors related
to their PWB and SWLS. While participants referred to positive high levels regarding the six factors
evaluated by the SPWB. Finally, deaf individuals experience a lack of social inclusion which has
resulted in difficulties to get hired and complications to obtain autonomy in their life.
Table 3
Matrix of codification and examples
Inductive
codification Analytic categories Analysis unit (examples)
RCA
Declared
Reading
comprehension
ability
High: Between 70-100 points on
a 0-100 scale. "80" - A
Low: Between 0-50 points on a
0-100 scale. "40 - 45" - C
MA Declared
mathematical
ability
High: Between 70-100 points on
a 0-100 scale. "90" - B
Low: Between 0-50 points on a
0-100 scale. "50" - A
PWB Psychological
well-being
Range between 70-100 points on
a 0-100 scale. "80-90" – A
The participant relates certain
elements with his/her own PWB
"Having a job, family well-being,
social relationships, that would make
my life better" - A. The participant declares their
interest in autonomy in their life
or give example related to
autonomy in their life.
"I´m looking to be autonomous" - A.
SWB Subjective
Well- Being
The participant relates certain
elements with his/her own SWB
"When you have a good job and go
ahead that is satisfaction" - B.
Participants relate the role of
their job in their SWB
"Obviously when you have a good job,
and the salary is good your satisfaction
with life" - B.
IEA Influence of the
environment on
self-esteem
Understand sentences where is
evident the feeling of inferiority
related to self-esteem, self-
image, etc.
"Hearing people always will be higher
than us in advantage with deaf people"
– B.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
123
Inductive
codification Analytic categories Analysis unit (examples)
Participants give examples
about how they have shown
resilience.
"Is about awake and go ahead in life,
there are deaf people who do not accept
it and deaf people who accept it. It is
about your attitude" – C.
LPWB
Learning as an
important
element in
his/her
psychological
well-being
Participants relate the learning
of how an important factor for
PWB.
"Based on many mistakes and lessons
learned, I have practiced and developed
my quality of life" – B.
PREM
Problems
related to the
environment
where he is part
of a minority.
Participants refer to a lack of
inclusion explaining the
situation of their own life.
"I do not declare I´m deaf until the
recruiter calls me to know my perfect
CV, during the interview they know
about my reality. I do not declare I´m
deaf because they will say no" – B. Participants refer to specific
problems when they started their
professional life.
"I have my degree, but I will search
everywhere because they tell me no
because I´m a deaf woman" – A.
Discussions
According to the obtained results, there is evidence to state that the hearing group performed
significantly better than deaf individuals on reading-comprehension and mathematical tasks in line
with results from Kyle and Cain (2015), Wauters et al. (2006), Herrera (2005), Moreno et al. (2015),
and Figueroa and Rosa Lissi (2005). Considering that reading and mathematics are one of the most
important problems in education for the Mexican population (i.e. Mexico was ranked below the
average in the PISA evaluation in both, reading and mathematics) (OECD, 2018), the fact of low
mastery in these abilities in hearing population implies that the problem for deaf individuals might
be a very important issue to consider in future research and educational policies.
The reason for the differences in performance between hearing and deaf individuals is
currently unclear but the researchers agree with the hypothesis that the early development of language
has a profound impact (Faletty, 2016; Fontané-Ventura, 2005; Myklebust, 1971). Sign language
could settle the basis of oral language acquisition (ex. Spanish, English, etc.) (Herrera, 2005). Andin
et al. (2014) and Bull et al. (2006) found that oral-phonologic knowledge influences multiplication
tasks, underlining the importance of early development of language, being broadly evident in deaf
individuals. Nevertheless, we did not consider when sign language was acquired by deaf individuals,
we cannot assume this suggestion until we develop more research considering this factor.
Particularly, comparing all items of the TMBA, our analysis suggests differences between
DG and HG in the proportions, percentages, and rule scale, as well as in the geometry problems scale.
Consequently, future work should therefore include measurements to prove whether these factors are
indeed significantly different.
It is important to note that the problem in reading and mathematics is hard in the entire
hearing population in our country but unfortunately no data is available about deaf individuals. The
fact of lower mastery in reading and mathematics could express different issues. For example,
Hernández-Ontiveros and Camacho-Vega (2020) suggested that our educational system does not
attempt to integrate deaf students. It avoids hearing loss students to develop oral skills in addition to
a lack of development of the sign language since early childhood (Okada et al. 2015). Based on this
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
124
asseveration, the analysis of reading and math solving problems between deaf and hearing individuals
implies some difficulties mainly based on the context of the education received by deaf individuals.
Another important factor to understand disadvantages in reading and mathematics in deaf individuals
is the role of teachers in the educational processes. First, according to Kelly et al. (2003), teachers
must have certificates. In higher education is common in our country that teachers demonstrate
experience in their field before giving courses, but these experiences should indicate certification in
pedagogical strategies for reading and mathematics, even more, when teaching deaf individuals.
Kelly et al. (2003) also suggested that teachers should focus more on tasks which require analytical
strategies and cognitively challenging problem rather than on task involving surface cues, language
comprehension, and exercise drills for deaf students.
Moreover, results from the qualitative analysis indicated that deaf individuals do not
perceive their reading and mathematics skills as low, but they obtained significantly lower scores in
both tasks regarding hearings. This is a highlight proposed by our research because it might imply
that deaf individuals may not be aware of cognitive differences compared to hearings. Thus, this lack
of awareness about their difficulty in addition to the lack of opportunities in education might be an
important approach for future research. It is necessary to create social and political awareness about
the inclusion of deaf individuals in similar educational and adequate support such as sign language
in their early years to create similar opportunities between deaf and hearings and create adequate
strategies for better cognitive development.
Even deaf individuals referred not to have difficulties in the cognitive skills analyzed, they
indicated another important disadvantage regarding hearings. Deaf individuals referred that
employment is an important factor for their psychological well-being and satisfaction with life,
ranked as the most important element followed by family-friends’ relationships. They indicated that
these disadvantages are more related to the fact of being deaf individuals rather than their abilities or
experience for the job solicited. Further research is needed to understand the role of hiring difficulties
in deaf individuals because it was not the objective of this study. Besides, our results suggested
significant differences in SPWB between DH and HG but a deep analysis is needed to understand
more about these differences.
Additionally, deaf individuals face several problems in their learning process that hearing
people do not experience. This study focused on deaf individuals who reached an undergraduate level
obtained at a university or technical degree and results evince that there is a lack of institutional
consideration about deaf’s difficulties to understand sentences with complex grammar structure,
including abstract or not concrete sentences (Kyle & Cain, 2015).
Finally, this study had some limitations. First. The voluntary integration of the deaf community could
respond to a lack of social integration. This research indicates there is still a lot of work to do before
inviting deaf people to participate in research studies about their condition. For this reason, our
sample should be increased to obtain more reliable results.
Conclusions
In conclusion, this study supports research about the differences between reading-
comprehension and mathematics in hearing and deaf individuals. It appears that certainly, deaf
individuals develop lower than hearing individuals in reading and mathematics tasks. This study
considered samples from deaf and hearing individuals with higher education studies to avoid bias
based on educational level. Therefore, the paired-samples considering grade can reduce the bias of
knowledge and abilities in both groups. Thus, the differences were significantly lower for deaf
individuals and results suggest that educational level is not a factor that explains per se the differences
between groups.
Second, no evidence of correlation based on the statistical analysis was found between
cognitive abilities and psychological well-being or between cognitive abilities and satisfaction with
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
125
life, but the qualitative analysis indicated an important finding: deaf individuals do not perceive
difficulties in reading and mathematics which is not congruent with the results obtained in the tasks,
suggesting a lack of awareness about their abilities.
If well, reading and mathematics abilities appear to be of no significances for deaf
individuals in their psychological well-being and satisfaction with life, the most important factor
related to their SPWB and SWLS appears to be the lack of job opportunities.
Finally, this study fills the need to propose instruments to measure the well-being and
subjective well-being in deaf individuals showing that the SPWB and the SWLS are highly correlated
questionnaires and its application fits in both samples for furthermore studies, in addition to the
evaluation of reading and mathematics abilities using the ELA and the TMBA test respectively.
Acknowledgments
We would like to thank the Universidad Autónoma de Baja California for all the facilities
provided and to Sara Rivera for her valuable help translating to MLS all the necessary content for the
deaf-individual participants and supporting them during all the study. Additionally, we would like to
thank Maria Guadalupe Delgadillo for helping us to develop the qualitative analysis of this research.
Abbreviations
DG Deaf Group
HG Hearing Group
SWLS Satisfaction with Life Scale
ELA Reading Evaluation for Adults
TMBA Test de Matemáticas Buenos Aires
SPWB. Ryff’s Psychological Well-Being Scales
PWB Psychological Well-Being
RCA Declared Reading comprehension ability
MA Declared mathematical ability
PWB Psychological well-being
SWB Subjective Well- Being
IEA Influence of the environment on self-esteem
LPWB Learning as an important element in his/her psychological well-being
PREM Problems related to the environment where he is part of a minority.
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BODY IMAGE AVOIDANCE QUESTIONNAIRE AND ASSOCIATED FACTORS: A
STUDY OF A GROUP OF MOROCCAN ADOLESCENTS
DOI: http://doi.org/10.26758/11.1.9
Raja ZAKARIA (1), Hakima AMOR (1), Abdellatif BAALI (1), Noureddine ELKHOUDRI (2)
(1) Laboratory of Human Ecology, Faculty of Sciences Semlalia, "Cadi Ayyad" University, Marrakesh,
Morocco; E-mail: amor@uca.ac.ma; abdellatifbaali@hotmail.com
(2) Higher Institute of Health Sciences, "Hassan I" University, Settat, Morocco; E-mail:
noureddinebio@hotmail.com
Address correspondence to: Raja Zakaria, Laboratory of Human Ecology, Department of Biology,
Faculty of Sciences Semlalia, Avenue Prince Moulay Abdellah, BP 2390, Marrakesh, Morocco. Ph:
0212 614-545787; E-mail: rajazakaria1@gmail.com
Abstract
Objectives. The aim of this study is to assess physical appearance behavior avoidance among a group
of Moroccan adolescents and to identify the associated factors.
Material and methods. The data were gathered from a cross-sectional study conducted on 487
adolescents (223 boys and 264 girls), with the average age of 14.6 years. Gender, age, body mass
index (BMI), and satisfaction of their body weight and height were considered in this study. Body
satisfaction was evaluated by two questions: "Are you satisfied with your body weight?" and "are
you satisfied with your body height?". The Body Image Avoidance Questionnaire (BIAQ) test was
used to assess the adopted behaviors.
Results. The average score on the BIAQ test was 24.4. According to the different factors of the BIAQ
test, the factors "clothing", "grooming and weighing", and "eating restraint", were more noticed
among adolescents. The results showed that behavioral avoidance was associated with gender, age,
BMI, and body dissatisfaction. It was females, the youngest group of adolescents, overweight, and
those dissatisfied with their body weight or height who had the highest scores. This reflects the fact
that adolescents resort to physical appearance behavior avoidance or control including practices such
as dressing, grooming, and weighing.
Conclusions. It is recommended by health professionals to enhance awareness among adolescents
about the risks of adopting such behaviors on their physical and mental health, to correct the narrow
and unrealistic standards of physical appearance, and to encourage healthy behaviors.
Keywords: body image, behavior avoidance, adolescents, Marrakesh, Morocco.
Introduction
Body image is defined as one’s attitude towards one’s body, particularly its size, shape, and
aesthetics (Cash, 1990). Adolescence is a critical period for body image development because of the
various social, cultural, physical, and psychological changes occurring in this period (Campagna &
Souza, 2006). These transformations also involve major upheavals in body image (Blyth, Simmons,
& Zakin, 1985). Body image disturbance is conceptualized as a multidimensional construct with
perceptual, attitudinal, and behavioral components (Banfield & McCabe, 2002). The perceptual
component is defined as the relative inaccuracy of individuals’ judgment regarding the shape of their
whole body or various body parts (Slade, 1994). The attitudinal component involves dissatisfaction
with body shape or size (Gardner, 2001). The behavioral component comprises body avoidance,
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including tendencies to avoid situations that elicit worry about physical appearance (Rosen, Srebnik,
Saltzberg, & Wendt, 1991), and body checking, the behavioral manifestation aimed at gaining
information on body shape, size, or weight (Shafran, Fairburn, Robinson, & Lask, 2004). According
to Stapleton, McIntyre and Bannatyne (2014), body image disturbance "serves as an important risk
factor in the development of eating disturbances and other unhealthy behaviors". Among these,
avoidance behaviors that typically refer to a range of behaviors intended to avoid information
regarding one’s shape, weight, or size. Examples of these behaviors include not weighing oneself,
avoiding looking in mirrors wearing loose-fitted clothing, and avoidance situations in which revealing
clothing may be required, such as the gym or the beach (Walker, Anderson, & Hildebrandt, 2009).
These behaviors may play a significant role in the development of disturbed eating behaviors and in
the maintenance of body image disturbance (Fairburn, Cooper, & Shafran, 2003).
Maïano, Morin, Monthuy-Blanc, and Garbarino (2009) remarked that, unlike the perceptual
and attitudinal components of Body Image Disturbances, the behavior one benefited from very few
assessment instruments to measure either body avoidance (e.g., Body Image Avoidance
Questionnaire, Physical Appearance Behavior Avoidance Test) or body checking or both (e.g., Body
Checking and Avoidance Questionnaire). Among these, the BIAQ is "the most widely used", as
revealed by the literature review.
Overweight has gained increasing attention in developing countries as an issue that needs to
be addressed (Musaiger et al., 2016). Adolescence is a sensitive period marked by important physical
and social changes that can lead to a negative body image. Therefore, changes related to the body or
body parts increases vulnerability to the use of unhealthy body change strategies, such as avoidance
behaviors.
Thus, this study seeks to evaluate the avoidance behaviors and their association with gender,
age, BMI, and satisfaction of their body weight and height among a group of Moroccan adolescents.
Material and methods
Participants
This cross-sectional survey was carried out in several secondary schools in Marrakesh,
Morocco. The survey took place between 2014 and 2016. Marrakesh is situated in the center of
Morocco, and its population rises to 928 850 inhabitants. During the studied period (2014-2016) there
were 56 secondary schools located with a total secondary school student population of 78306. A
random cluster sampling technique was used in this study. The sampling frame comprised a list of all
56 secondary schools in educational districts in Marrakesh. Six out of the 56 schools were selected
via random sampling. The sample population included students from the six selected schools. Three
classes were randomly picked up from each of the selected schools. The students were randomly
chosen from those classes. Those who refused to participate were excluded from the study. The total
obtained sample was 487 male and female adolescents aged 10 to 18 years, with 223 boys (45.8%)
and 264 girls (54.2%).
According to the World Health Organization (WHO, 2017) classification, the sample was
divided into two groups: early adolescents (between 10-14 years old) and middle to late adolescents
(between 15-19 years old).
Measures
Weight status. Height and weight measurements were undertaken twice in private areas.
Weight was measured in light clothes and no shoes to the nearest 0.1 kg by a portable digital Seca.
Height was measured while subjects were in the standing position, not wearing shoes, hat, hair bows,
combs, and with the normal position of shoulder to the nearest 0.1 cm by a portable/wall-mounted
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stadiometer with movable headpiece. An average of two values for each measurement was
documented. Body mass index (BMI) was calculated by the following formula: weight (kg)/height
(m2) and standard deviation scores (BMI z-scores) were gathered using the age and sex according to
the WHO standards reference (De Onis et al., 2007). Adolescents were also categorized according to
their BMI z-score in three groups: Overweight (BMI obesity included; z-score is ≥+1), normal weight
(BMI z-Score between– 2 and +1), and underweight adolescents (BMI z-sore is ≤ -2).
Avoidance and physical control behaviors. The behavioral trends, which frequently
accompany body image disturbances of adolescents, were assessed by BIAQ test (Body Image
Avoidance Questionnaire) (Rosen et al., 1991); the scale consisted of 19 items. The test could be
subdivided into 4 factors allowing to evaluate the adopted behaviours. The questionnaire has 19 items
across four behavioral themes: clothing (disguising or covering up the body through clothing choices;
items 1-4, 13, 15-18), social activities (avoidance of social situations that involve eating or focusing
on appearance; items 8-11), eating restraint (dietary restriction; items 5-7), and grooming/weighing
(checking behaviors such as scrutinizing oneself in the mirror and weighing…; items 12, 14, 19).
Each item on this factor is scored on a 6-point scale ranging from 0 (never) to 5 (always) (Table 1).
The findings suggest that the higher is the individual score, the more likely the individual resort to
physical appearance behavior avoidance.
The BIAQ test has demonstrated good psychometric properties among patients with eating
disorders as well as healthy adults or adolescents (Lydecker, Cotter, & Mazzeo, 2014; Maïano et al.,
2009; Rosen et al., 1991; Senín-Calderón, Santos-Morocho, & Rodríguez-Testal, 2020; Stapleton et
al., 2014).
In the present study, the translation-back translation procedure was used. Two translations
of the questionnaire from English to Arabic were conducted by two independent, bilingual, and
qualified translators. One bilingual expert translated the questionnaire into Arabic. The second expert,
who was kept unfamiliar with the original questionnaire, translated this Arabic version back into
English. Then a final version was prepared with the help of the research team’s native Arabic
speakers, who examined the translation quality, ensured its validity and measured reliability in the
Moroccan context. The final Arabic version was piloted, with very few comments returned that were
corrected.
Body satisfaction. Body satisfaction was evaluated by two questions: "are you satisfied with
your body weight?" and "are you satisfied with your body height?".
Procedure
The study was approved by the Moroccan Ministry of Education and the State Department
of Education of the city of Marrakesh. None of the participants were forced to participate in this
study, they were reassured that any dissent on their part would not affect them in any way, and the
purpose of the study was explained to them as well. A written consent form was obtained from the
participating adolescents and their parents. The data was collected by the researcher who interviewed
adolescents individually at their school in one session. The interview lasted 30 minutes on average.
Then anthropometric measurements were taken. The information was collected anonymously and
confidentially.
Analysis
The statistical treatment of data was carried out by WHO AnthroPlus 2007 program (WHO,
2009) which determines BMI z-scores and Statistical Package for the Social Sciences Program (SPSS
for Windows, version 18) was also used for all statistical analysis. Qualitative variables were
described by their size and percentage. Quantitative variables were described by their mean and
standard deviation. Intergroup comparisons were made by Mann-Whitney and Kruskall-Wallis test
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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for quantitative variables and by Chi-square tests for qualitative variables.
Results
Age, weight status, and body satisfaction
The age of adolescents ranged from 10 to 18 years while the average age was 14.6 years
(SD=2.8). Adolescents aged 10 to 14 years were relatively more represented than their counterparts
in the 15-18 years age group, 53.6 % and 46.4%, respectively. On average, males were older than
females (14.9 ± 2.8 vs 14.4 ± 2.8); there were no significant differences among different age groups
(U Mann-Whitney=1.9; p=0.07). Of adolescents, 78.9% had normal weight, 8.6% underweight, and
12.5% overweight (8.4% pre -obese and 4.1% obese). While considering adolescents' perception of
their body weight and height, the majority of them were satisfied, 78.4% and 84.6% respectively.
Avoidance and physical control behaviors
Overall, the total BIAQ score for the adolescents in this sample varied from 4 to 54 with an
average of 24.4 (SD = 9.7; median = 23). The alpha value of Cronbach is equal to 0.723. Table 1
presents the results of the evaluation of the different items of the BIAQ scale. The highest scores were
those scoring 3 (often), 4 (usually), and 5 (always). This reflects the adolescents' resort to body
avoidance behaviors. The dimensions "clothing", "grooming and weighing" and "eating restraint",
especially the restriction of the amount of food consumed, were more noticed among adolescents.
Table 1
Assessing adolescents using the BIAQ test: Percentage of adolescents adopting the following
behaviours
Factors and Items 0 1 2 3 4 5
Factor 1: Clothing
- I wear baggy clothes 43.1 18.3 24.6 5.1 4.7 4.1
- I wear clothes that I do not like 66.1 12.3 15.4 2.1 2.5 1.6
- I wear darker colour clothing 10.7 13.3 36.6 15.0 12.3 12.1
- I wear a special set of clothing, e.g, my "fat
clothes" 83.2 8.4 5.7 1.4 0.6 0.6
- I am inactive 48.9 14.6 29.0 5.3 1.2 1.0
- I avoid physical intimacy 50.3 5.1 10.9 5.1 6.2 22.4
- I wear clothes that will divert attention from
my weight 56.7 6.0 14.2 4.9 6.0 12.3
- I avoid going clothes shopping 92.0 2.9 3.3 0.6 0.8 0.4
- I don't wear "revealing" clothes (eg, bathing
suits, tank tops, or shorts...) 61.0 3.3 8.2 3.3 4.3 19.9
Factor 2: Eating restraint
- I restrict the amount of food I eat 56.1 6.4 15.4 5.5 7.2 9.4
- I only eat fruits, vegetables, and other low
calorie foods 70.6 7.4 7.2 4.5 4.7 5.5
- I fast for a day or longer 88.5 2.7 4.1 1.6 0.8 2.3
Factor 3: Social activity
- I do not go out socially if I will be "checked
out" 60.2 5.7 9.9 3.7 2.5 18.1
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Factors and Items 0 1 2 3 4 5
- I do not go out socially if the people I am with
will discuss weight 56.7 4.5 8.6 3.7 3.7 22.8
- I do not go out socially if the people I am with
are thinner than me 84.8 2.7 5.7 1.2 1.0 4.5
- I do not go out socially if this involves eating 90.8 2.5 4.1 0.8 0.6 1.2
Factor 4: Grooming and weighing
- I weight myself 18.7 27.9 35.5 5.1 6.6 6.2
- I look at myself in the mirror 1.6 3.3 11.5 8.8 13.8 61.0
- I get dressed up or made up 29.6 10.9 23.0 8.6 10.1 17.9
0: Never; 1: Rarely; 2: Sometimes; 3: Often; 4: Usually; 5: Always
An examination of the relationship between the BIAQ score and the used variables is
presented in Table 2. The results of the comparison of the avoidance behaviors among adolescents
by gender, age, BMI categories, and body satisfaction with weight or height, showed that behavioral
avoidance was associated with all the used variables: the average of BIAQ score was higher for the
females than males (p<0.05). Young adolescents had a significantly higher BIAQ scores as compared
to their younger counterparts (p<0.001). According to the weight categories, overweight adolescents
reached the highest BIAQ scores (32.0) as compared to adolescents with normal weight (23.4) or
underweight (22.4) (p<0.001). The dissatisfied adolescents with their body weight or height had a
high average BIAQ score (28.9) and (27.6), respectively. BIAQ was found to be strongly associated
with body weight satisfaction (p<0.001). In fact, the youngest, female adolescents, overweight and
those dissatisfied with their body weight or height showed these behaviors or strategies (way of
dressing, of eating, of behaving in public).
Table 2
Mean scores of the BIAQ test according to gender, age, BMI categories, and body satisfaction
Variables Modalities n Mean ± SD Testsa, b
Gender Boys 223 23.3 ± 9.7
2.5 a ; p<0.05 Girls 264 25.3 ± 9.6
Age 10-14 years 261 26.1 ± 9.5
4.8 a ; p<0.001 15-18 years 226 22.5 ± 9.5
BMI categories
Underweight 42 22.4 ± 8.8
36.1 b ; p<0.001 Normal weight 384 23.4 ± 9.1
Overweight 61 32.0 ± 10.4
Body weight
satisfaction
Satisfied 382 23.2 ± 9.1 5.0 a ; p<0.001
Dissatisfied 105 28.9 ± 10.2
Body height
satisfaction
Satisfied 412 23.8 ± 9.4 2.8 a ; p<0.01
Dissatisfied 75 27.6 ± 10.6 aMann-Whitney test; bKruskal Wallis test
Discussions
Body image dissatisfaction was a particular phenomenon of Western societies, recent studies
have shown an increasing level of body image dissatisfaction in non-Western Arabic countries,
including Morocco. Body image dissatisfaction is prevalent among adolescents in Arabic countries
with socio-cultural conditions relatively similar to that of their Moroccan counterparts. In United
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134
Arab Emirates, Schulte and Thomas (2013) found that 73% of adolescents indicated body
dissatisfaction (78% of females, 58% of males). In Lebanon, 39% of adolescents underestimated or
overestimated their body weight (Assaad et al., 2018). In Egypt, about 25.6% of males and 40% of
females had some level of body image concern among undergraduate students (El Ansari, Dibba,
Labeeb, & Stock, 2014). In Morocco, body dissatisfaction was prevalent in 61.0% of the adolescents,
of whom 38.2% wanted to gain weight while 22.8% wanted to lose it (Zakaria, Amor, & Baali, 2021).
Furthermore, as the world becomes increasingly globalized, Western beauty practices have
spread rapidly in many countries. Morocco is no exception. It is a country which has undergone deep
transformations, an unprecedented process of modernization and a series of socio-economic and
socio-cultural changes (High Commission for Planning (HCP), 2018). These changes included a
transformation in dressing styles from long loose dresses to Western modern styles. The combination
of these factors of acculturation would change body image ideals of Moroccan adolescents and
contribute to adopt some negative attitudes.
For knowledge, this is the first nationwide study of its kind to be carried out in Morocco and
the Arab region that investigates body image avoidance and associated factors in adolescent males
and females.
The average score of the BIAQ test in this study was 24.4 (SD = 9.7). This was higher than
the score found among Spanish adolescents (23.6 ± 11.0) (Senín-Calderón et al., 2020). It is worth
noting that "clothing", "grooming and weighing", and "eating restraint" factors reached the highest
score, particularly food restriction.
Adolescents were more concerned about the most visible part of the body and the face (often
looking at the mirror, putting on makeup). They also weigh themselves frequently as a means of
controlling their body weight. In the context of weight control, self-monitoring of weight in
adolescents was a strategy that can be used to monitor body weight variation. This concern about
body weight could have negative consequences on body image (Dionne & Yeudall, 2005; Friend,
Bauer, Madden, & Neumark-Sztainer, 2012), which will push the individual to adopt means of loss
or gain weight if one’s current weight exceeds or falls behind the one desired (Neumark-Sztainer, van
den Berg, Hannan, & Story, 2006). In addition, the frequency of weighing may worsen body image
according to Ogden and Whyman (1997), the self-frequent weighing was associated with worse body
image among women with normal weight. The adolescents in this study used grooming behaviors
more than weighing to control and change their physical appearances and physical aesthetics by
frequently looking in the mirror and using cosmetics to increase physical attractiveness.
Subsequently, as international studies have shown, these subjects become more concerned about their
body image (Cash, Dawson, Davis, & Bowen, 1989). As for the clothing factor, women who declared
themselves dissatisfied / perceived themselves as failing to meet the ideal standards usually wear
clothes that allow them to control their appearance and hide their size and shape (Rudd & Lennon,
2000), also the men interested and concerned about their body used clothing to manipulate their
appearance (Frith & Gleeson, 2004). In the present study, adolescents avoid the use of tight clothing;
because they probably choose to dress in the Islamic style (do not reveal body contours/silhouette).
This fact was also revealed in various studies in Arab countries, Muslim oriented, having the same
socio-cultural conditions (e.g. El Ansari et al., 2014). In addition, body satisfaction with their body
weight and height could also have a direct impact on eating behaviors to achieve the perceived ideal
body and to have a sense of control and even lead the individual to practice chronic diets (Calderon,
Yu, & Jambbazian, 2004; Stice, Presnell, & Spangler, 2002).
Young adolescents in pubertal development are more likely to adopt these behaviors because
rapid changes in physical appearance happening during this period (Patton & Viner, 2007) could lead
to enhanced preoccupation with physical appearance, especially among girls (Grogan & Richards,
2002). This dissatisfaction of girls may be due to the fact that puberty leads to a departure from the
thin-ideal of Western feminine beauty by an excessive accumulation of fat in certain parts of their
body (Steinberg & Morris, 2001; Waylen & Wolke, 2004).
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
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Another formative factor that contributes to body dissatisfaction is the social comparison
(Leahey, Crowther, & Mickelson, 2007). Social comparison theory claims that people have an innate
drive to evaluate themselves, often in comparison to others; it emphasizes the importance of social
comparisons in self-evaluation and social behavior (Festinger, 1954; Wood, 1989). This process is
also true about body image. Meta-analyses have revealed that when women compare themselves with
thinner females, their body dissatisfaction increases (Bailey & Ricciardelli, 2010). Being overweight
is also one of the factors that may cause adolescent dissatisfaction (Latiff, Muhamad, & Rahman,
2018); overweight adolescents in this study used more these behavioral avoidance strategies.
Conclusions
In the present study, adolescents reported body avoidance behaviors, especially those related
to grooming, weighing, and clothing. The results support the association of these manifestations with
the adolescents' gender, age, weight status, and perception of their weight and height. It is worth
noting that the phenomenon affects mostly females, the youngest and overweight adolescents.
Adolescents tend to adopt avoidance behavior to cope with body dissatisfaction. It is recommended
by health experts to enhance awareness among adolescents about the risks of doing so on their
physical and mental health, to correct the narrow and unrealistic standards of physical appearance,
and to encourage healthy behaviors.
Acknowledgments
The authors would like to thank all students and their parents for their participation in this
study. Special thanks go to the Ministry of National Education authority of Marrakesh and school
staff.
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ANXIETY, DEPRESSION, STRESS, EMOTIONALITY AND AGGRESSIVITY - FACTORS
THAT MAY INFLUENCE IRRATIONAL ALCOHOL CONSUMPTION AND RISKY
SEXUAL BEHAVIOR
DOI: http://doi.org/10.26758/11.1.10
Mihaela LUNGU(1), Elena Lucreția NEACȘU (2), Cornelia RADA (3)
All authors of article have contributed equally.
(1) PhD. Student, School of Advanced Studies of the Romanian Academy, "Constantin Rădulescu-
Motru" Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy,
Bucharest, Romania;
(2) PhD. Student, "Educational Sciences" Doctoral School of The State Pedagogical University "I.
Creangă" from Chișinău, Republic of Moldova; E-mail: lucyneacsu79@yahoo.com
(3) "Francisc I. Rainer" Anthropology Institute of the Romanian Academy, Bucharest, Romania; E-
mail: corneliarada@yahoo.com
Address correspondence to: Mihaela Lungu, Str. Gheorghe Asachi, No. 1, Bl. B7, Sc. A, Ap.12,
Pitești, 110318, Argeș, Romania. Ph: +40 751072206; E-mail: maylla_lungu@yahoo.com
Abstract
Objectives. This literature review aimed to reveal the relationship between psychological factors
such as anxiety, depression, stress, emotionality and aggression on the one hand, and irrational
alcohol consumption and risky sexual activity on the other hand, in students (19-25 years) and
adjacent age groups.
Material and methods. The study was conducted by analyzing the literature published between 2010
and 2020. The search was conducted in Romanian and English, in 9 international publications, by the
following key phrases and terms, separately or in combination: anxiety, depression, stress,
emotionality, aggressiveness, alcohol consumption, drinking motives, binge drinking, sexual
behavior, risky sex.
Results. Applying repeated exclusion criteria, 31 articles remained in the analysis. Among these, risk
behaviors were rarely analyzed in connection with psychological factors. Most studies that investigate
risky behaviors regarding alcohol consumption and sexual activity, address them according to gender,
educational level, age groups. Women were more prone to anxiety and depression, but also to show
more psychological aggression compared to men who showed more physical aggression, even in
sexual activity. Researches included aggression as a behavioral trait, and emotionality has been used
as a variable in studies to validate standardized tools. Irrational alcohol consumption has been
significantly associated with risky sexual activity and various forms of aggression.
Conclusions. The risk of manifesting and developing depressive and anxiety symptoms is higher in
victims of aggression, in people with risky sexual activity, and in consumers of irrational alcohol. In
students and young people, stress has high values, contributing to the tendency towards risky
behaviors. It is necessary to promote successful coping strategies and mechanisms, both in individual
and group level, as well as the development of prevention strategies and therapeutic procedures to
improve the listed risk behaviors.
Keywords: anxiety, depression, aggression, alcohol consumption, sexual activity.
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Introduction
The mental balance of people is a condition of normal life as important as physical or somatic
health.
The number of people suffering from anxiety, depression, and stress is constantly increasing
worldwide, and young people, teenagers or even children do not seem to have a higher protection
factor than adults or the elderly. Research shows that students are a social category highly exposed
to high levels of stress, anxiety, and depression (Bryan, Baker, & Tou, 2017; Tutino, Shaughnessy,
& Ouimet, 2018; McDougall, Langille, Steenbeek, Asbridge, & Andreou, 2019), and this can lead to
aggressive behaviors towards the intimate partner (Davis et al. 2012; Agardh, Tumwine, Asamoah,
& Cantor-Graae, 2012b) or in other situations.
Regarding of risky sexual behavior, there is less research and their strategies differ a lot. The
prevalence and transmission of HIV/AIDS and syphilis are still to the attention of the authorities and
have been monitored at the level of limited research (Monu et al., 2020), but also of institutions with
long-term decision-making and action, such an example being the European Center for Disease
Prevention and Control (2019). The results showed that there are parts of the population that are very
poorly informed about risky sexual behavior.
The association between risky behaviors and psychological factors occurs most often in
scientific studies with medical themes, associated with diseases (Guruprasad, Ramakrishnan, & Shah,
2015), dysfunctions such as infertility (Yang et al., 2017; Lalinec-Michaud & Engelsmann, 1984),
unhealthy diet (Ahmed, Al-Radhwan, Al-Azmi, & Al-Beajan, 2014), or special social contexts (Foli,
South, Lim, & Hebdon, 2012; Hebdon, Foli, South, & Lim, 2012).
Alcohol is one of the most consumed and dangerous psychoactive substances. In the United
States, Stahre, Roeber, Kanny, Brewer and Zhang said in 2010 that one in ten deaths at the age of 20-
64 was due to excessive alcohol use. In 2019, new information emerged, showing that although for
teenagers and some young people it was forbidden to buy alcohol, 24% of 8th graders had already
tried alcohol, as well as 77% of students and 85% of young people (19-28 years) (Schulenberg et al.,
2019).
The 2019 World Health Organization report stated that Romania does not have a written
national policy on alcohol consumption (World Health Organization, 2019) and no monitoring system
on this behavior, although it is ranked 7th among European countries and ranked 9th in the world with
12.6 l annual per capita alcohol consumption (World Health Organization, 2018). Worldwide, the
same source reports that there are three million deaths due to alcohol consumption each year, and
40% of alcohol consumers experienced at least one heavy drinking event per month.
Rada and Ispas (2016), following a study conducted on 1539 young people in Romania, aged
between 18 and 30, in 2013 and 2014, argued that heavy episodic/occasional drinking - binge drinking
- is a phenomenon that has attracted the attention of researchers in recent years on both adolescence
and early youth. The same idea was taken over by Aluja, Lucas, Blanch, and Blanco (2019) in a study
conducted on 668 young people in the same age range.
Starting from all this and partially knowing the effects that psychological imbalances can
produce personally or in community, the present study aims to broaden the field of knowledge by
connecting the results of several scientific studies and to identify areas that require further study.
Material and methods
Depression and anxiety are among the most common imbalances in the mental system and
often prove to be the cause of risky behaviors for people both individually and in the community.
Either stress reaches at post-traumatic or acute clinical levels, or is manifested in the form of transient
symptoms, it accompanies the life and activity of most people affecting their quality. The present
analysis is the scientific base for the study of psychological factors involved in risky behaviors among
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students in Romania. It reveals the state of information accessed in 2020 on the psychological factors
such as anxiety, depression, stress, emotionality, and aggressivity in relation to alcohol consumption
and sexual activity, especially behaviors considered risky. The research directions of the analysis
carried out aimed at: identifying relationships between anxiety, depression, stress, aggressivity, and
emotionality in students (19-25 years) and adjacent age groups; exploring the influence of
psychological factors associated with risky behaviors regarding alcohol consumption and sexual
activity; identifying the need for further research on the influence of anxiety, depression, stress,
aggressivity, and emotionality on risky behaviors.
The analysis of the literature was done starting from two directions simultaneously. The first
direction of literature analysis followed psychological factors, aiming in particular the relationships
between anxiety, depression, stress, aggressivity, and emotionality. The second direction of analysis
focused on risky behaviors, tracking alcohol consumption, sexual activity, and harmful physical
activity.
A larger volume of publications on this topic was studied, but only materials from verified
sources that provided consistent information on the topic were selected for inclusion in the analysis.
The primary purpose of the present analysis was to explore the existing volume of information on the
influence of personality factors on risky behaviors, and into the background aimed to identify less
researched areas, but with the potential to provide relevant information for education, public health
policies and psychotherapy.
The next plan of research questions was based on the analysis of specialized studies and their
results:
How psychological factors such as anxiety, depression, stress, aggressivity, and emotionality
and risky behaviors are defined and characterized? What are the relationships between anxiety,
depression, stress, aggressivity, and emotionality explored in students?
What are the influences between the psychological factors mentioned and alcohol
consumption and/or harmful sexual activity? Are there also influences of risky behaviors on
psychological factors, among students and young people?
What aspects of the relationship between the psychological factors and the risky behaviors
mentioned are less researched and could bring valuable information for decision-makers and
psychotherapists?
The present research is an analysis of the literature on the relationship between psychological
factors such as anxiety, depression, stress, aggressivity, and emotionality, on the one hand, and
potentially harmful behaviors related to alcohol consumption and sexual activity, on the other hand.
The study was conducted through the systematic analysis of the scientific literature,
published between 2010-2020, including correlation between personality factors and risky behaviors.
The process consisted of stages of search, selection, and systematic analysis of scientific articles in
relation to the set of indicators and criteria detailed below.
The indicators that formed the basis of the analysis of the research results presented in the
selected articles were as follows: a) The presence of some personality factors measured in students
and the relations between them; b) The existence of correlations between personality factors and risky
behaviors; c) The existence of significant correlations between harmful forms of alcohol consumption
and sexual activity.
The search for study publications was done in English and Romanian, the search process
was done in the following databases: Sage Journals, APA, BioMed Central, US National Library of
Medicine, Journal of Studies on Alcohol and Drugs, ELSEVIER, SpringerLink and ScienceDirect,
after the following key phrases and terms, taken separately or in combination: anxiety, depression,
stress, emotionality, aggressivity/aggressiveness, alcohol consumption, drinking motives, binge
drinking, sexual behavior, risky sex.
The searches were performed between November 2019 and October 2020.
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From the results of the online search, 551 titles and abstracts were reviewed, of which were
retained for the analysis of the full publication those that simultaneously met the following criteria:
the article was published in the period 2010-2020; presented quantitative or qualitative research
results relevant to the purpose of this research (study topic included: anxiety, depression, stress,
emotionality, aggressivity, risky sexual behavior, risky alcohol consumption, or a combination
thereof), at least one variable measured such behavior; the studies were published in journals or other
scientifically verified publications. Figure 1 illustrates the way the concepts in the study were
analysed and the relationships between them.
Figure 1.
Levels of analysis of the literature according to the relationships between the factors studied
Applying the selection criteria in a first stage, 93 public articles were retained for the analysis
of the text. In the next stage, 29 studies were eliminated and which, although they corresponded to
the search for keywords and conceptual constructs, were either strictly medical (not psychological),
or revealed rather demographic information (translation of the concept of gender, by the word sex).
In the third stage, a number of 33 articles were eliminated, the results of which did not provide
information relevant to the objectives of the present study. Thus, 31 scientific research articles
remained in the final stage, in order to be deepened. A summary of the main elements of analysis for
each article is included in Tables 2, 3, 4, and 5. Of the 31 remaining articles in the analysis, 3 dealt
with risky behaviors (on alcohol consumption and sexual activity), 11 reported results for the
prevalence and implications of psychological factors, and 17 studied both psychological factors and
risky behaviors.
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Results
The table below shows the distribution of research topics in the total number of articles
included in the analysis.
Table 1
Distribution by topics of interest of the studied articles Psychological factors
Anxiety Depression Stress Emotionality Aggressivity
No association with risky
behaviors
9 11 4 3 2
Risky behavior Alcohol
consumption
3 4 0 0 3
Sexual
activity
6 11 3 1 5
Total 18 26 7 4 10
In the research studied, risky behaviors were rarely analyzed in connection with psychic
components of personality/psychological factors. However, there is scientific concern in this regard.
Ngo et al. published in 2018 the results of a survey of 735 young people, according to which 27.2%
of respondents had exercised physical violence in couple, and 16.5% sexual violence in couple. The
results did not show gender differences in the presence of anxiety, nor were they conclusive whether
it precedes behavioral violence or vice versa. Shwartz, O’Rourke, and Daoud (2020), however, in a
study of 1,055 women in Israel, aged 18-48, on the relationship between postpartum depression and
intimate partner violence, found that unplanned pregnancy increases the risk of violence of the
intimate partner as well as that of postpartum depression. Significant associations have been found
between different risky behaviors such as irrational alcohol consumption and potentially harmful
sexual activity (Davis et al., 2012; Choudhry, Agardh, Stafström, & Östergren, 2014), but less in
relation to psychological components.
In a multimodal, predominantly qualitative study, Lloyd, af Klinteberg, and DeMarinis,
(2017) claimed that in Sweden, after 2004, young people were the largest group of psychiatric
patients. In Australia, 20% -25% of young people between the ages of 12 and 25 were estimated to
suffer from mental health problems as published in 2019 by Masters, Zimmer-Gembeck, and Farrell,
in a study conducted on 391 Australian students. Similar estimates have been made for Western
Europe and the United States. Predominant symptoms of anxiety and depression were found more in
adolescent girls than in boys, more in women than in men (Masters et al. 2019; Lloyd et al., 2017; ul
Haq, Irum Sajjad Dar, Aslam, & Mahmood, 2018). Lloyd et al. (2017) conducted a study on 53
women between the ages of 21 and 25 who were in treatment or waiting within a psychotherapy
clinic, and found that participants with high scores on depression had a negative concept about
themselves and the lack or inability to use existential resources (concept about self and world,
religion, ontological security, etc.).
ul Haq et al. published in 2018 the results of a study conducted in 2017 on 361 students at
Punjab University in Lahore, India. Exploring the levels of anxiety, depression and stress related to
various demographic factors, they found that male participants were more anxious, depressed and
stressed compared to female, students who reported parents with medium and high educational
instruction had fewer symptoms and stated that there were higher levels of anxiety where the
participant’s father was educated below the high school level.
Defined as anticipation of danger and characterized by muscle tension, alertness, necessary
to prepare for an expected danger, as well as through avoidance - cautious behavior (American
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Psychiatric Association, 2016, p.189), anxiety is one of the most common conditions. Unlike fear,
long-term anticipations of anxiety refer to negative events, which are usually (not exclusively)
psychological in nature (Lovibond & Lovibond, 1995). For the present research, articles containing
any of the following categories were searched and analyzed: social anxiety disorder/social phobia,
agoraphobia, generalized anxiety disorder, nonspecific anxiety disorder, combinations thereof,
symptoms or manifestations whether evaluated clinically or only in research purpose.
"Depression seems to be a state characterized mainly by a low level of self-esteem and
initiative, associated with the perception of a low probability of achieving significant personal goals
for the individual" (Lovibond & Lovibond, 1995, p. 31). In the present study were included all forms
of depression according to the American Psychiatric Association (2016, p. 155-188), but also specific
symptoms or manifestations.
Mutalik, Moni, Choudhari, and Bhogale, in a study published in 2016, in which they
explored depression, anxiety and stress in students in Bagalkot, India, found high levels in all three
measured parameters. In Canada, it has been estimated that 8% of people over the age of 18 will
experience depression at some point in their lives. Also, 60% of respondents to a study of University
of Alberta students reported depressive symptoms (McDougall et al. 2019). The same study
mentioned above, published in 2018 by ul Haq and his collaborators, showed that the symptoms of
depression and stress have higher values in students living with family than those living alone or with
friends and that those coming from illiterate mothers have higher levels of anxiety also.
According to the longitudinal study published in 2019 (Carney et al., 2019) and conducted
on 662 soldiers over 18 years of age in the United States, infected with HIV, found that those with
clinically diagnosed depression reported the lowest condom use in sexual intercourse with new
partners compared to those with mild depressive symptoms. Depression seems to be an important
factor in choosing risky behaviors in students as well. It may influence the decision to drop out of
university, as mentioned by McDougall et al. in 2019, in a study conducted on 6,639 Canadian female
students under the age of 30. "Young adults are more vulnerable to depression and stress being in a
period of transition of identity formation" (ul Haq et al., 2018, p. 1). Other researchers have concluded
that depression is the most common mental disorder in students.
From a wider range of disorders, the general term of stress "can be conceived as a persistent
state of hyperactivation that reflects the difficulty of coping with the difficult demands of life"
(Lovibond & Lovibond, 1995, p. 32). Psychological disorder increasingly present in postmodern
society, stress, in its various forms, accompanies the individual at all stages of age. For the present
study, attention was paid to all forms of stress included in studies on young people (18-25 years),
teenagers or adults.
Post-traumatic stress disorder and depression have been associated with intimate partner
violence in men in South Africa as well as in developed countries, as Breet, Seedat, and Kagee
mentioned in an article published in 2019. The article is the result of a cross-sectional study conducted
on 221 HIV/AIDS survivors. Psychological imbalances and poor mental health can be risk factors
for aggressivity. Irritability and anger, as symptoms associated with post-traumatic stress disorder,
may increase the likelihood of committing intimate partner violence (Breet et al., 2019). The same
study revealed that men who reported more severe symptoms of post-traumatic stress reported 3 times
more sexual coercion (committed), while women who reported more severe symptoms of post-
traumatic stress disorder were 3 times more likely to commit psychological aggression.
Ahmed et al., in a study published in 2014, conducted on 407 students at the University of
Kuwait, over the age of 18, found that stressed female students had a significantly higher tendency
than boys to choose unhealthy food.
As an infinitum continuum, the psychological factor emotionality designates the dynamics
of the person’s affective spectrum, polarizing from "emotional stability, or, at the opposite pole, a
person’s neuroticism" (Fahrenberg, Hampel, & Selg, 2001, p. 45).
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The increased risk of psychological pathology has been associated with emotional disorders
(Masters et al., 2019). Emotionality has also been described as "the ease with which emotions are
aroused", defining negative emotionality as the experience of the generally negative environment of
individuals interacting with other people (Wolff & Baglivio, 2017, p.5). Analyzing a database of
27,720 juvenile delinquents who completed the sanctioning service in Florida, Wolff and Baglivio
found that hostile childhood experiences are activated in the form of negative emotionality.
Moreover, they said about children with a predominantly negative perception of others and the
environment and those whose (negative) emotions are easier to activate, that they were more likely
to engage in antisocial and therefore risky behaviors.
Aggressivity refers to that personality factor characterized either by self-control or by "a
high level of spontaneous aggressivity, (...) a general state of hostility towards others and towards the
events they face" (Fahrenberg et al., 2001, p. 32).
Although exposure to violence, as a control, may not differ by gender, a 2005 study of 1,220
students in Uganda (Agardh et al., 2012.b) found that symptoms of mental imbalance could be
expressed differently. This was relevant in a broader conceptual context, with women experiencing
more sexual violence and men experiencing more physical aggressivity. Brett et al. in 2019 showed
that when analyzing the tendency to act aggressively, men are more prone to physical aggressivity
while women are more prone to psychological aggressivity. In Romania, following a study of 869
respondents between 18 and 75 years old, Rada (2014) found that psychological abuse of men against
women was the most common type of reported violence, and 35% of respondents had witnessed
parental violence during childhood.
A study carried out in Romania between 2014-2015 among 836 young people aged 19-23
years living in a romantic relationship revealed that men perceived significantly higher levels of
aggressiveness in couple than women. The most surprising result showed that "men were three times
more exposed to forced sexual intercourse than women" (Faludi, 2018).
In teenagers, experiencing and committing violence in a cogeneration context (with
colleagues and/or couple) amplifies the risk of internalizing symptoms, as found by Garthe, Sullivan,
and Behrhorst (2018), in a study conducted on 1,087 teenagers in disadvantaged areas of the United
States of America, achieved through the education system.
Only one of the reviewed and studied studies concerns aggressivity as a personality factor
(Fahrenberg et al., 2001), the vast majority considering aggressivity as a type of behavior
(aggressivity, violence; physical or mental). Lloyd et al. (2017) found that participants with high
scores on depression also recorded high scores on inhibiting aggressivity.
For most states, the mental health of citizens has become one of the priority directions of
public health policies. Even in some African countries, the national strategic health plan contains
aspects of mental health, as shown by Agardh, Cantor-Graae and Ostergren (2012a).
The present study considered the following potentially harmful behaviors: irrational alcohol
consumption, risky sexual activity and sedentary lifestyle, later extended to the dimensions of
physical activity.
Alcohol consumption is one of the factors with a great influence on the social group and
society in general. Kilwein and Looby in 2018 reported reasons for socializing for alcohol
consumption, following a study of 108 students, aged 18 to 24, in the central-western United States.
The research was supported a year later by Looby, Bravo, Kilwein, Zimmerman and Pearson in 2019,
who found similar conclusions, conducting a research on 2,039 students from 10 universities in the
United States, with an average age of 19.79 years. The influence of colleagues/ cogeneration rather
than parents was also reported by Rada and Ispas (2016).
Understanding the risks associated with sexual activity requires both a psycho-social and a
psycho-medical approach. The definition of sexual health according to the World Health
Organization: "A state of physical, emotional, mental and social well-being in relation to sexuality;
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it is not merely the absence of disease, dysfunction or infirmity" (Glasier, Gülmezoglu, Schmid,
Moreno, & Van Look, 2006, p. 1596).
In order to determine the sexual quality of a person’s life, it is necessary to consider the
subjective interpretation of personal experiences and satisfaction. Tutino et al., in a study of 306
students (boys), published in 2018, concluded that sexual arousal could be the most sensitive
dimension of sexual functionality in the presence of mental health deficiencies. Another finding of
the study was that mental health difficulties may have a greater impact on men’s sexual function and
quality of life compared to frequency. "Sexual victimization and depression are common in university
campuses, especially for women" (McDougall et al., 2019, p. 1).
Risky alcohol consumption is viewed both in terms of the potential harm to human
individuals and the destruction of goods that may result from it. Its measurement is made both
quantitatively based on an international standard related to culture - Standard Unit of alcohol and as
a frequency. Exceeding 4 standard units for women and 5 standard units for men on a single occasion
is considered dangerous.
The standard unit (US) of alcohol consumption is also controversial, especially in relation
to the country/culture in which the research is carried out: in France - contains 10 g of pure alcohol,
as explained by Costa et al. (2020) in a study conducted between 2016-2018, in France, on 179
subjects over 18 years of age. In Romania, Ministry of Health, National Institute of Public Health,
National Center for Health Assessment and Promotion and Sibiu Regional Center for Public Health
(Ministerul Sănătății, Institutul Național de Sănătate Publică, Centrul Național de Evaluare și
Promovare a Stării de Sănătate și Centrul Regional de Sănătate Publică, Sibiu, 2019) established the
standard unit of alcohol consumption at 12 g of pure alcohol. Both episodes of excessive drinking
and sexual risks are behaviors with specific traits, related to culture (Petrova et al., 2019).
Carney et al. found in a study published in 2019 on 662 active HIV-infected soldiers in the
United States that consumption of alcohol is a high-risk factor for respondents with recent onset of
depressive symptoms. They concluded that there is a linear relationship between daily alcohol
consumption and the increased risk of engaging in harmful sexual behaviors.
Like other researchers, Choudhry et al., in 2014, concluded, based on a cross-sectional study
conducted on 1,954 students in Uganda, that a possible explanation for the association of alcohol
consumption with sexual activity and having multiple sexual partners would be that individuals who
believe that alcohol will make them less agitated, more sexually uninhibited, and those who are more
at ease in a potentially sexual situation are more likely to drink before a possible sexual interaction
in certain social contexts (in a bar, at a meeting, or party).
In some circumstances, the risks associated with sexual activity can be multiple and are
studied according to national priorities or contexts. Maina, Orindi, Osindo, and Ziraba (2020), in a
study conducted in 2017, on 606 girls aged 10-14 in Kenya, included in the definition of sexual
activity, as non-penetrative sexual activities: kissing, holding hands, touching or caressing and
spending time together.
Like sexual activity, risky sex is defined in several forms: sexual intercourse with two or
more partners in the last 12 months (Choudhry et al., 2014) or even in the last 3 months (Carney et
al., 2019); inconsistent condom use with new partners (Carney et al., 2019, Choudhry et al. 2019,
Agardh et al. 2012a); sexual assault and/or coercion (Davis et al. 2012; Choudhary, Smith, &
Bossarte, 2012); commercial and intergenerational sex (Choudhry et al., 2014).
Analyzing the gender difference, Breet et al. (2019) found that boys had a tendency almost
2 times higher (42.9%) than girls (23.8%) to commit sexual coercion. At the same time, Tutino et al.
(2018) found that mental health difficulties can have a greater impact on men’s sexual functionality
and quality of sex life.
McDougall and colleagues (2019) associating risky sex with psychological characteristics
found that 6.8% of study participants, female students under 30, were victims of unconsented sex
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during university courses. Moreover, they were 2.1 times more likely to be at risk of depression than
those who had not experienced sexual victimization.
Discussions
Looking to identify relationships between anxiety, depression, stress, aggressivity, and
emotionality in students (19-25 years old), the following questions were used: How are the
psychological factors such as anxiety, depression, stress, aggressivity and emotionality and risky
behaviors defined and characterized? What are the relationships between anxiety, depression, stress,
aggressivity, and emotionality explored in students?
It was found that the definition of personality factors was mostly common and was based in
particular on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2016). Most of the studies found addressed either separately or
comparatively anxiety, depression, and stress (Mutalik et al., 2016; ul Haq et al. 2018; Tutino et al.,
2018; Bryan et al., 2017; Agardh et al. 2012a) and there are many studies that address these issues in
relation to intimate partner violence (Yavuzer, Albayrak, & Kılıçarslan, 2019; Ngo et al., 2018;
Agardh et al., 2012b).
The exploration of the influence of psychological factors associated with risky behaviors on
alcohol consumption and sexual activity was conducted by looking for answers to the questions: What
are the researched influences between the mentioned personality factors and alcohol, sexual activity
and harmful physical activity? Are there also influences of risky behaviors on psychological factors?
The answer to the second question was negative: none of the studies included in the analysis
investigated how the behavior influences the psychological factors.
The most common factor is the aggressivity factor as being investigated in relation to risky
behaviors regarding alcohol consumption and sexual activity (Ngo et al. 2018; Davis et al. 2012;
Agardh et al., 2012a, 2012b; Breet et al., 2019), but very often in research on psychological factors
such as depression and anxiety there are also variables on potentially harmful sexual activity (Kalina
et al., 2011; Tutino et al., 2018; Breet et al., 2019; Rada, 2020) and sometimes irrational alcohol
consumption (Choudhry et al., 2014; Carney et al., 2019; Agardh et al., 2012a; McDugall et al., 2018).
In order to identify the need for further research on the influence of anxiety, depression,
stress, aggressivity and emotionality on risky behaviors, it was studied what aspects of the
relationship between psychological factors and the risky behaviors mentioned are less researched and
could bring valuable information for decision-makers and psychotherapists. It was found that
although there is interest in these associations, the age stages have not yet been studied separately,
and in terms of students there are still questions whose answer may influence age-specific educational
and therapeutic strategies (Figure 2).
In tables 2, 3, 4, 5 after the Acknowledgments section the analysis of the studies discussed
in this article can be consulted by categories as follows: studies that had students as subjects, studies
that investigated both psychological factors and risky behaviors, studies that investigated
psychological factors unrelated to risky behaviors and studies that investigated only risky behaviors
in students.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
148
Figure 2.
Analysis of the need to deepen and conduct studies on the correlation between risky behaviors and
psychological factors
- anxiety was associated with threatning and inhibition of aggression in
women, and with effective physical violence (sexual coercion) in men
- high anxiety scores were associated with high number of partners (in men)
and inconsistent condom use
• Requires further research
- substance abuse - including alcohol - was associated with an increased risk
of depression
• Requires further research
• Not enough studies
- was associated with anger in men with depression
- was associated in women with the threatning, and in men with actual
physical violence, sexual coercion
- (HIV) Respondents with severe depression and those with a recent onset
were more likely to engage in risky sexual behaviors than those with mild
depression
- low levels of pleasure during intercourse and lack of sexual activity was
associated with depression
- high scores on depression were associated with large numbers of sexual
partners
- depression mediates in: the relationship between body image and sexual
well-being; between self-objectification and sexual functionality
• Further research can improve the quality of life
• Not enough studies
- men who reported more severe symptoms of post-traumatic stress,
reported 3 times more acts of sexual coercion (committed)
• Not enough studies
• Not enough studies
- emotional regulation difficulties leaded to poor sexual health in terms of
functionality and satisfaction
• Not enough studies
- high alcohol consumption is associated with greater aggression, physical
and sexual violence in couples, and with condoms non-usage
- rapes (by incapacity) were positively associated with alcohol consumption
by the aggressor, 51.5% penetrative sexual assaults involved alcohol
consumption
• Requires further research
- a percentage of 42.9% men and 23.8% women (out of 210 HIV/ AIDS
survivors, in South Africa) committed sexual coercion
• Not enough studies
An
xie
tyD
epres
sion
Str
ess
Ag
gres
sivit
y
Em
oti
on
ali
ty
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
149
Conclusions
There are few studies that simultaneously investigate psychological factors and risk
behaviors in students, most researching their prevalence. Anxiety and depression are very common
and prevalent conditions in students. It was observed that the effects of mental imbalances are
consistent and due to them mental health is one of the priorities of health policies. At the same time,
although stress is one of the most common and widespread challenges of the 21st century, it does not
benefit from in-depth studies on the psychological and behavioral repercussions.
Female subjects seem to tend to experience more anxiety and depression, but also to show
more psychological aggressivity compared to male subjects who showed more physical aggressivity,
even in sexual activity.
Emotionality as a psychological factor was mostly examined in studies aimed at validating
psychodiagnostic tools and less to survey the population or correlate it with other personality or
behavioral factors.
Aggressivity has been included in studies most often as a behavioral component (expressive)
and not as a psychological factor.
According to the analyzed studies, the mental health difficulties generated sexual
dysfunctions (especially in men) and predisposed to risky behaviors for health. Irrational alcohol
consumption has been significantly associated with risky sexual activity and various forms of
aggression.
Irrational alcohol consumption and risky sexual activity have been mostly investigated as
distinct elements or in terms of physical effects on people. They have rarely been associated with
personality factors.
Following the research direction coming from risky behaviors to imbalances of
psychological factors, it was found that the risk of manifestation and development of symptoms and
disorders such as anxiety and depression is higher in victims of aggressivity, people with risky sexual
activity and those who consume alcohol irrationally.
The main limitation of the study is that it included insufficient databases in the analysis.
In the subsequent analyzes would be useful to identify articles, studies addressing successful
coping strategies and mechanisms at an individual and group level, the development of prevention
strategies applicable to teenagers and young people and therapeutic procedures to improve the listed
risky behaviors.
Table 2
Analysis of studies that had students as subjects
References Sample Methodology
Psychological
factors
1. Bryan et al.,
(2017).
537 US volunteer
students, (18-60)
average 21.75 years,
74.7% women,
managed online
(extra course
credits).
Cross-sectional study
Brief Symptom Inventory-18 (BSI-18),
The Daily Drinking Questionnaire, The
Rutgers Alcohol Problem Index (RAPI),
The Authenticity Inventory-3 (AI-3), The
Three-Item Loneliness Scale (TILS)
anxiety,
depression
Conclusions and
findings Loneliness correlates positively with poor mental health, anxiety and depression.
2. McDougall et
al., (2019).
6939 students under
30, Maritime
Canada
Online cross-sectional study, 20-25
minutes, 44 multiple-choice items, +
Center for Epidemiologic Studies depression
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
150
References Sample Methodology
Psychological
factors
Depression
(CES-D12),
Conclusions and
findings A percentage of 36.7% of students are at risk of depression
3. Ngo et al.,
(2018).
735 young people
(18-25 years old,
average 21.5) 270F
and 465M
Ahimsa Project, Revised Conflict Tactics
Scales (CTS-2), Alcohol Use Disorders
Identification Test–Consumption (AUDIT-
C), Five Factor Mindfulness
Questionnaire–Short Form, Brief
Symptom
Inventory
anxiety,
aggressivity
Conclusions and
findings
No gender differences in anxiety. It is unclear whether anxiety precedes aggressivity
(mental behavior) or vice versa
4. Pelletier,
Lytle, and
Laska, (2016).
441 students under
35 (Body Mass
Index of 20-
35kg/m2),
community colleges
Minnesota, USA
Cross-sectional study
Shorr height boards (Irwin Shorr, Olney,
MD) and Tanita scales (Tanita TBF-300A
Body Composition Analyzer, Arlington
Heights, Cohen Perceived Stress Scale, stress
Conclusions and
findings
High levels of stress have been associated with a high prevalence of overweight and
obesity.
5. Agardh et al.,
(2012a).
980 students (80%
of the total
university), Uganda
Cross-sectional study
self-administered questionnaire (132
items) + Hopkins Symptoms Checklist-25
and Symptom Checklist-90
anxiety,
depression, anger
Conclusions and
findings
High scores in anxiety are associated with high number of partners (M) and inconsistent
use of condom (M). High scores in depression (15% M, 16% F) associated with a large
number of sexual partners (F, M), Sexual activity can be related to anger, a strong
element in men with depression.
6. Agardh et al.,
(2012b).
1220 students,
University of
Mbarara, Uganda
(under 23 years and
over), average 23
years, 64.6% M,
35.4% F
Cross-sectional study
self-administered questionnaire (132
items), English language, + Hopkins
Symptom
Checklist (HSCL-25) and Symptom
Checklist-90 (SCL-90) anxiety/depression
Conclusions and
findings
Poor mental health is (anxiety and depression) associated in women with threats, and in
men with effective physical violence. Women have higher scores in depression, but the
relationship between depression and violence is similar (F, M). Sexual coercion has been
significantly associated with poor mental health (F, M)
7. Cazan, and
Truța, (2015).
341 (260F, 81 M)
Romanian students,
(average age 20.65)
Validation study (cross-sectional)
The Adolescent Resilience Scale, The
Student-life Stress Inventory (SSI); The
Satisfaction with Life Scale,
stress,
emotionality
Conclusions and
findings
Stressors worked as mediators between resilience, reaction to stress and life satisfaction.
Emotional regulation has a mediating effect on reactions to stress.
8. Mutalik et al.,
(2016).
118 students (42%
M) in the first year,
18-25 years
(average 21)
Cross-sectional study
Depression, Anxiety and Stress Scale
(DASS 21), General Health Questionnaire
28 (GHQ 28)
anxiety,
depression, stress
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
151
References Sample Methodology
Psychological
factors
Conclusions and
findings High levels of depression, anxiety and stress were identified.
9. ul Haq et al.,
(2018).
361 students,
Punjab University,
Lahore, Pakistan
Cross-sectional study
self-administered questionnaire:
demographic data + DASS-21
anxiety,
depression, stress
Conclusions and
findings
Male participants had higher levels of anxiety, depression and stress compared to female
participants. Students with educated parents had fewer symptoms. High levels of
anxiety, depression and stress were found where the mother was illiterate. The level of
anxiety is higher where the father is educated below the level of high school graduation.
Symptoms of depression and stress have higher values in students living with family
than those living alone or with friends (anxiety does not differ).
10. Yavuzer et
al., (2019).
904 students
(average 25 years)
volunteers
different
specializations
Anatolia (Turkey)
65.7% F, 34.3% M
Cross-sectional study
Self-Theory Scale, KAR-YA Aggression
Scale (KAR-YA AS), Beck Depression
Inventory, UCLA Loneliness Scale
(UCLA)
depression,
aggression
Conclusions and
findings
Loneliness leads to the development (exacerbation) of depression. Depression is a
positive predictor of aggressivity in young adults.
Table 3
Analysis of studies that researched both psychological factors and risky behaviors
References Sample Methodology
Psychologic
al factors
Behaviors
approached
through the
risk
dimension
1. Davis et al.,
(2012).
225 young men, 21-
35 years old, single,
volunteers,
Cross-sectional, quantitative study
Eligibility conditions, laboratory,
male operator, consent, computer
application: drinking calendar and
history questionnaire, Modified
Sexual Experiences Survey
(MSES), aggressivity
alcohol
consumption,
sexual
activity
Findings
(psychological
factors)
Very consistent association between alcohol consumption and lack of condoms in sexual
assault. Men who have high expectations about the effect of alcohol on risky sex and
aggressivity are most likely to commit sexual assault without a condom under the influence
of alcohol.
Findings
(behaviors)
Alcohol consumption considerably reduces condom use. Incapacitated rapes are positively
associated with alcohol consumption by the aggressor. 51.5% of penetrating sexual assaults
involved alcohol consumption and lack of condoms. Very consistent association between
alcohol consumption and lack of condoms in sexual assault.
2. Garthe et
al., (2018).
1087 young people
(51% M), 7th grade,
ethnic and racial
diversity,
disadvantaged
communities, USA
Secondary data analysis + cross-
sectional study (computer-assisted
interview + teachers’ reports on
anxiety and depression in
adolescents. The Problem
Behavior Frequency Scale,
anxiety,
depression,
aggressivity
sexual
activity
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
152
References Sample Methodology
Psychologic
al factors
Behaviors
approached
through the
risk
dimension
adapted Safe Dates aggression
scale, Behavioral Assessment
System for Children (BASC)
Findings
(psychological
factors)
Teenagers in the category violence against their peers and couples had higher levels of
anxiety than those in the class minor violence. The coincidence of violent relationships (eg:
colleagues aggressivity and victimization, violence against colleagues and peers),
substantially increase the risk of depressive symptoms in young adolescents.
Findings
(behaviors) Not relevant.
3.McDougall,
et al., (2019).
6939 female students
under 30, Maritime
Canada
Online cross-sectional study, 20-
25 minutes, 44 multiple-choice
items, + Center for Epidemiologic
Studies Depression (CES-D12),
reminders and incentives,
informed consent depression
alcohol
consumption,
sexual
activity
Findings
(psychological
factors) A percentage of 36.7% of the participating female students reveled a risk of depression.
Findings
(behaviors)
Risk behaviors and substance abuse have been associated with an increased risk of
depression. A percentage of 6.8% were victims of non-consensual sex during university
courses. The risk of depression was found to be 2.1 times higher than in non-victims.
4. Ngo et al.,
(2018).
735 young people
(18-25 years, average
21.5) 270F and
465M
Cross-sectional, quantitative study
Ahimsa Project, Revised Conflict
Tactics Scales (CTS-2), Alcohol
Use Disorders Identification Test
– Consumption (AUDIT-C), Five
Factor Mindfulness Questionnaire
- Short Form, Brief Symptom
Inventory
anxiety,
aggressivity
alcohol
consumption
Findings
(psychological
factors)
No gender differences in anxiety. 27.2% committed physical violence in a couple, 16.5%
committed sexual violence in a couple.
Findings
(behaviors)
A percentage of 58.6% of the particiapnts reported alcohol consumption. High alcohol
consumption is associated with higer aggressivity of physical violence as of sexual violence
in couple, also.
5. Shwartz et
al., (2020).
1055 women Arab
(248) and Jewish
(807) Israel, 18-48
years (6 weeks - 6
months from birth)
Cross-sectional study
female interviewers, trained,
Arabic / Hebrew, private rooms,
Edinburgh Postnatal Depression
Scale
(EPDS), + specific questions
depression,
stress
sexual
activity
Findings
(psychological
factors)
A percentage of 10.3% of participants showed postpartum depression (20.7% Arabs, 7%
Jews), 36% exercised violence against their intimate partner. Increased chronic stress
produces an indirect effect on postpartum depression.
Findings
(behaviors)
Unplanned pregnancy increases the risk of intimate partner violence and postpartum
depression.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
153
References Sample Methodology
Psychologic
al factors
Behaviors
approached
through the
risk
dimension
6. Tutino et
al., (2018).
306 men, students
Ottawa, Canada, 17-
47 years old (average
19.97) who reported
sexual activity alone
or with a partner in
the last 4 weeks
Cross-sectional online study,
online, consent, questionnaire
packet, ASI-3 Difficulties in
Emotion Regulation Scale
(DERS;) Depression Anxiety
Stress
Scales (DASS), Male Sexual
Function Index (MSFI), Sexual
Quality of Life Scale – Male
Version (SQoL-M) and Sexual
Experiences Questionnaire (SEQ),
offset by course credits,
anxiety,
stress,
emotionality
sexual
activity
Findings
(psychological
factors)
Greater sensitivity to anxiety leads to more difficulties in emotional regulation). Emotional
regulation moderates the relationship between sensitivity to anxiety and anxiety symptoms.
High mental stress (suffering) leads to poor sexual results. Men with high sensitivity to
anxiety and maladaptive emotional regulation skills: are more likely to develop symptoms
of anxiety and depression, more likely to experience sexual difficulties with functionality
and satisfaction.
Findings
(behaviors)
The same factors that make you mentally vulnerable (sensitivity to anxiety, difficulties in
emotional regulation) lead to difficulties in sexual health. Psychological risk factors were
associated with greater difficulties in sexual arousal, orgasm (F, M) and desire (M). Mental
health difficulties can have a greater impact on men’s sexual function and quality of sex
compared to frequency.
7. Vencill,
Tebbe, and
Garos, (2015).
426 heterosexual
women, over 18
years old
cross-sectional study
General Internalization subscale of
the Sociocultural Attitudes
Toward Appearance Scale
(SATAQ-3), Surveillance
subscale of the Objectified Body
Consciousness Scale (OBCS;),
Depression subscale of the
Depression Anxiety Stress Scale-
21 (DASS-21), Zung Self-Rating
Depression Scale (SRDS;), Center
for Epidemiological Studies-
Depression Scale–Revised
(CESD-R), The Body Exposure
during Sexual Activities
Questionnaire (BESAQ), Sexual
Quality of Life Questionnaire-
Female (SQoL-F)
anxiety,
depression
sedentary
lifestyle/
physical
activity
Findings
(psychological
factors)
Image anxiety is a mediator in the relationship between body surveillance and sexual well-
being. Depression is a mediator in: the relationship between body surveillance and sexual
well-being, between self-objectification and sexual functionality.
Findings
(behaviors)
Image anxiety during sexual activity is negatively associated with sexual physical
functionality. Participants more involved in body monitoring had a higher tendency to
experience depression and image anxiety specific to sexual activity.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
154
References Sample Methodology
Psychologic
al factors
Behaviors
approached
through the
risk
dimension
8. Agardh et
al., (2012a).
980 students (80% of
the total university),
Uganda
Cross-sectional, quantitative study
self-administered questionnaire
(132 items) + Hopkins Symptoms
Checklist-25 and Symptom
Checklist-90
anxiety,
depression,
anger
alcohol
consumption,
sexual
activity
Findings
(psychological
factors)
High anxiety scores associated with large number of partners (M) and inconsistent
condom use (M). High scores in depression (15% M, 16% F) were associated with a large
number of sexual partners (F, M). Sexual activity has been linked to anger, a strong
element in men with depression.
Findings
(behaviors)
Strong effect of the high frequency of episodes of excessive drinking, as a measure of
mental health control in terms of sexual activity and the large number of partners. High
scores in anxiety associated with large number of partners (M) and inconsistent use of
condom.
9. Agardh et
al., (2012b).
1220 students,
University of
Mbarara, Uganda
(under 23 years and
over), average 23
years, 64.6% M,
35.4% F
Cross-sectional, quantitative study
self-administered questionnaire
(132 items), English language +
Hopkins Symptom
Checklist (HSCL-25) and
Symptom Checklist-90 (SCL-90)
anxiety,
depression,
aggression
sexual
activity
Findings
(psychological
factors)
Poor mental health (anxiety and depression) has been associated with women with threats,
and in men with actual physical violence. Women have higher scores in depression, but the
relationship between depression and violence is similar (F, M). Sexual coercion was
significantly associated with poor mental health (F, M).
Findings
(behaviors)
A percentage of 31.1% of respondents experienced sexual coercion (regardless of gender),
a significant association between experiencing sexual coercion and exposure to violence.
10. Breet et al.,
(2019).
210, South Africa,
peri-urban,
HIV/AIDS survivors
Cross-sectional, quantitative study
self-report questionnaire, Conflict
Tactics Scale – Revised (CTS2),
Beck Depression Inventory –
Second Edition (BDI-II), PTSD
Symptom Scale – Self-Report
(PSS-SR), English / Afrikaans /
isiX-hosa language, rewarded
with voucher to the supermarket,
depression,
stress,
aggression
sexual
activity
Findings
(psychological
factors)
A percentage of 48% manifested moderate-severe depression (M, F). Women who reported
symptoms of moderate-severe depression tended to report 4 times more physical
aggressivity (committed). Men who reported more severe symptoms of post-traumatic
stress reported 3 times more sexual coercion (committed). Women who reported more
severe PTSD symptoms were more than 3 times more likely to commit psychological
aggressivity. 44.4% M and 39.3% F committed physical aggressivity, 52.4% M and 46.4%
F committed psychological aggressivity
Findings
(behaviors) A percentage of 42.9% male and 23.8% female committed sexual coercion.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
155
References Sample Methodology
Psychologic
al factors
Behaviors
approached
through the
risk
dimension
11. Carney et
al., (2019).
662 active soldiers
(over 18 years old)
infected with HIV,
USA
Longitudinal study informed
consent, self-reported multiple
measurements Center for
Epidemiological Studies
Depression (CES-D 2006-2010) +
Sexual risk behavior surveys
(RBS 2015) depression
alcohol
consumption,
sexual
activity
Findings
(psychological
factors)
A percentage of 57% of the participants reported mild symptoms of depression, 26% recent
onset, 17% severe depression (90% undiagnosed). Participants with clinically diagnosed
depression (10%) reported fewer condom use with new sexual partners than undiagnosed
ones. Those with newly onset depression and severe depression use fewer condoms with
new sexual partners (and more than 2 in the last 3 months) than those with reduced
depressive tendencies.
Findings
(behaviors)
A linear relationship was found between daily alcohol consumption and increased risk of
engaging in harmful sexual behaviors. Respondents with severe depression and those with
recent onset were more likely to engage in risky sexual behaviors than those with mild
depression.
12. Choudhary
et al., (2012).
61187 adults USA,
(over 18 years old),
48.75% M, 51.25%
F,
Cross-sectional, quantitative study
Behavioral Risk Factor
Surveillance System (BRFSS)
questionnaire
anxiety,
depression
sexual
activity
Findings
(psychological
factors)
A percentage of 5% were victims of sexual assault, of which: 8.37% manifested anxiety
disorder, 18.82% diagnosed depression, 28.28% diagnosed depression and anxiety.
Findings
(behaviors)
A percentage of 5.3% stated that they were victims of sexual abuse (88.84% F). Anxiety
and depression had significantly higher values in victims of sexual assault.
13. Kalina et
al., 92011).
3725 (limited to
2318) students, 13-
16 years (51% F),
schools – towns in
Slovakia
Cross-sectional, quantitative
study, questionnaires addressed in
2 consecutive hours (90 minutes).
Self-esteem (Rosenberg);
Psychological well-being (GHQ-
12)
anxiety,
depression
alcohol
consumption,
sexual
activity
Findings
(psychological
factors)
Older boys who reported having more frequent sex had higher levels of positive self-esteem,
higher levels of psychological well-being (for those who reported low numbers: higher
scores were reported in depression/anxiety, social functioning problems)
Findings
(behaviors)
A percentage of 48.2% (108) reported sexual activity after drinking alcohol, 37.5% without
a condom at the last report, sometimes followed by unwanted pregnancy. Of total
respondents, 33.9% (224) had first sexual intercourse, after at least one month of
relationship, 19.6% had> 4 partners; Reported effects: sexually transmitted diseases,
unwanted pregnancy.
14. Maina et
al., (2020).
606 girls, 10-14
years old, Nairobi,
Kenya
Longitudinal study (secondary
stage)
face-to-face interview with
trained operators, women,
parental consent depression
sexual
activity
Findings
(psychological
factors)
A percentage of 60% of girls have reported at least one symptom of depression in the last
12 months. Girls with depressive symptoms were more likely to have sexuality in the pattern
“experienced”.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
156
References Sample Methodology
Psychologic
al factors
Behaviors
approached
through the
risk
dimension
Findings
(behaviors)
A percentage of 13% out of the participants reported naive or experienced sexual
experience.
15. Rada,
(2020).
601 geriatric patients
in a institute, 55-93
years old (average
67.32)
Cross-sectional study
informed consent, The Geriatric
Depression Scale long form
(GDS), ++ depression
sexual
activity
Findings
(psychological
factors) Association between those who report sedentary lifestyle and depression were found.
Findings
(behaviors) Not relevant.
Table 4
Analysis of studies that researched psychological factors unrelated to risky behaviors
References Sample Methodology
Psychological
factors
1. Bryan et al.,
(2017).
537 US volunteer
students, (18-60),
average 21.75 years,
74.7% women,
managed online (extra
course credits).
Cross-sectional, quantitative study
Brief Symptom Inventory-18 (BSI-
18;
Derogatis, 2000), The Daily Drinking
Questionnaire, The Rutgers Alcohol
Problem Index (RAPI), The
Authenticity Inventory-3 (AI-3), The
Three-Item Loneliness Scale (TILS) anxiety, depression
Findings
(psychological
factors) Loneliness positively correlates with poor mental health, anxiety and depression.
2. Dobson,
Ahnberg
Hopkins, Fata,
Scherrer, and
Allan, (2010).
High-risk adolescents
(high score on severe
depression but no major
depressive disorder or
current or past manic
episode), Calgary,
Alberta, and Canada.
25- “Coping with
stress”, 21- “Let’s talk”
Cross-sectional, quantitative study
Center for Epidemiological
Studies–Depression Scale (CES-D),
Computerized Diagnostic Interview for
Children and Adolescents for DSM-IV,
Mood and Anxiety Symptom Questionnaire
(MASQ), Rosenberg Self-Esteem Scale
(RSES)
anxiety,
depression
Findings
(psychological
factors)
The CBT protocol as well as the “Let’s talk” protocol reduce the severity of depressive
and anxiety symptoms in high-risk adolescents and increase self-esteem.
3. Bonsaksen
and Lerdal,
(2012).
18 (12M, 6F)
hospitalized psychiatric
patients (average 7-8
months of treatment),
Oslo, Norway, average
age 43.7 years.
Cross-sectional, quantitative study
The Global Assessment of Functioning Scale
(GAF), International Physical Activity
Questionnaire (IPAQ), The World Health
Organization Quality of Life – BREF
anxiety,
depression
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
157
References Sample Methodology
Psychological
factors
(WHOQOL-BREF), The Hospital Anxiety
and Depression Scale (HADS)
Findings
(psychological
factors)
Patients with different diagnoses of schizophrenia reported higher levels of depression
and anxiety.
General levels of physical activity were low and did not seem to relate to quality of life.
Patients with different diagnoses of schizophrenia were more physically active and
reported a lower quality of life.
4. Lloyd et al.,
(2017).
53 F, 21-25 years
(average 22.7),
outpatient
psychotherapy clinic,
Sweden
Multi-modal study, predominantly
qualitative, semi-structured interview.
Quantitative: Karolinska Scales of
Personality (KSP), Multidimensional
Measurement of Religiousness/Spirituality
for Use in Health Research, Structural
Analysis of Social Behaviour-Self-Concept
(SASB),
anxiety,
depression,
aggressivity
Findings
(psychological
factors)
High anxiety. Tendency to depression. Participants with high scores in depression had
a negative conception of themselves and a lack or inability to use existential resources.
Inhibition of aggressivity.
5. Wolff and
Baglivio,
(2017).
27720, (21% of
juvenile delinquents
who completed
Community sanction
service), Florida
Data analysis,
centralized community sanction service
database, Full Community Positive
Achievement Change Tool (C-PACT)
anxiety,
depression,
emotionality
Findings
(psychological
factors)
(Anxiety and depression were included in the negative emotionality). About 50% of the
observed effects of adverse childhood experiences are indirectly activated by negative
emotionality. Children with a more negative perception of others and the environment
and those whose (negative) emotions are easier to activate are more likely to engage in
antisocial behaviors.
6. Cazan and
Truța, (2015).
341 (260F, 81 M)
Romanian students,
different faculties
(average age 20.65)
The Adolescent Resilience Scale, The
Student-life Stress Inventory (SSI); The
Satisfaction with Life Scale
stress,
emotionality
Findings
(psychological
factors)
Stressors acted as mediators between resilience, reaction to stress, and life satisfaction.
Emotional regulation has a mediating effect on stress reactions.
7. Masters et
al., (2019).
391 students (56% F),
Australia, grades 6-8
(monitored up to 9-11)
Longitudinal, quantitative study
parental consent, questionnaire applied 4
times, kept 3 (for each year) last year was
completed online. The Social Anxiety Scale
for Adolescents (SAS-A), The Short Mood
and Feelings Questionnaire (SMFQ), The
Difficulty in Emotion Regulation Scale
(DERS),
anxiety,
depression,
emotionality
Findings
(psychological
factors)
Early emotional disorders associated with symptoms of anxiety and subsequent
depression, instead associated with emotional disorders. There is a process of emotional
problems in adolescents, in the transition from early to middle adolescence. Lack of
emotional clarity, non-acceptance of emotional responses, difficulties in controlling
impulses, limited access to emotional regulation strategies, and difficulties in engaging
in goal-oriented behaviors
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
158
References Sample Methodology
Psychological
factors
8. Mutalik, et al.
(2016), May
118 students (42% M)
in the first year, 18-25
years (average 21)
Informed consent, Depression, Anxiety and
Stress Scale (DASS 21), General Health
Questionnaire 28 (GHQ 28),
anxiety,
depression,
stress
Findings
(psychological
factors)
The level of anxiety was found to be higher than that of depression, followed by stress
(DASS 21). Female respondents had higher levels of emotional distress than male
respondents (GHQ 28).
9. Soleimani et
al., (2017).
October-
November 2015
399 teenagers (14-19
years old), Qazvin, Iran
Cross-sectional, descriptive study, Revised
Child Anxiety and Depression Scale
(RCADS), Iranian Adolescents Risk-taking
Scale (IARS),
anxiety,
depression
Findings
(psychological
factors)
Anxiety and depression significantly predict the occurrence of risky behaviors, along
with: having smoking friends, suicidal ideation, and strong suicidal ideation.
10. ul Haq et al.,
(2018).
361 students, Punjab
University, Lahore,
Pakistan
Cross-sectional study
self-administered questionnaire:
demographic data + DASS-21
anxiety,
depression,
stress
Findings
(psychological
factors)
Male participants had higher levels of anxiety, depression and stress compared to female
participants. Students with educated parents had fewer symptoms. Symptoms of
depression and stress have higher values in students living with family than those living
alone or with friends (anxiety is no different). The illiterate mother correlates with high
levels of anxiety, depression, stress. The level of depression is higher where the father
is illiterate. The level of anxiety is higher where the father is educated below the level
of high school graduation.
11. Yavuzer et
al., (2019).
904 students (average
25 years) volunteers,
different specializations
Anatolia (Turkey)
65.7% F, 34.3% M
Transverse sturgeon
Self-Theory Scale, KAR-YA Aggression
Scale (KAR-YA AS), Beck Depression
Inventory, UCLA Loneliness Scale (UCLA)
depression,
aggression
Findings
(psychological
factors)
Loneliness leads to the development (exacerbation) of depression. Depression is a
positive predictor of aggressivity in young adults. Loneliness and depression were found
to be positive predictors for aggressivity in young adults, while self-conception was
found to be a negative predictor.
12. Yuan and
Hesketh,
(2019). July-
September 2018 2987 women, China
Partly Conflict Tactics Scale-2 (CTS-2),
partly Composite Abuse Scale, The Center
for Epidemiologic Studies Depression
Scales (CES-D) (paper and electronic) depression
Findings
(psychological
factors)
Prevalence of depression: 65.8% experienced psychological violence, 69.5% physical
violence, 75.8% sexual violence.
13. Pelletier et
al., (2016).
2011 - 2012
441 students under 35
(index of 20- 35kg/m2),
community colleges
Minnesota, USA
Cross-sectional, quantitative study
Shorr height boards (Irwin Shorr, Olney,
MD) and Tanita scales (Tanita TBF-300A
Body Composition Analyzer, Arlington
Heights, Cohen Perceived Stress Scale stress
Findings
(psychological
factors)
High levels of stress have been associated with a high prevalence of overweight and
obesity.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
159
Table 5
Analysis of studies that researched only risky behaviors in students
References Sample Methodology Behaviors
approached
through the risk
dimension
1.
Choudhry
et al.,
(2014).
2010
1954 students, under 22,
over 22, University of
Mbarara, Uganda
Cross-sectional study
self-administered questionnaire, 132
items, English language
alcohol
consumption,
sexual activity
Findings
(behaviors)
Alcohol consumption has been associated with 2 or more sexual partners in the last year (M, F).
Significant associations between: alcohol consumption in general, alcohol consumption in
relation to sexual activity and alcohol consumption at the last sexual intercourse with having
multiple sexual partners. Inconsistency in condom use with new sexual partners was significant
for men who consumed alcohol in connection with sexual activity. For women who drank
alcohol frequently in connection with sexual activity, the risk of inconsistency in condom use
was 2 times higher.
2. Kilwein
and Looby,
(2018).
108 students, 18-24 years
old (average 19.9),
Midwestern US, 90 female
(83.3%)
Cross-sectional study
Daily Drinking Questionaire (DDQ);
Drinking Motives Questionnaire -
Revised (DMQ-R); Cognitice Appraisal
of Risky Events Revised (CARE-R) -
Risky sexual Activity Scale
alcohol
consumption,
sexual activity
Findings
(behaviors)
Risky sexual behavior more often when consuming alcohol. Reported risky sexual activities:
unprotected sex, sexual coercion, sex with unknown partners. The trend towards risky sexual
behavior increases by 10.4% with each unit of social reasons. Individuals with strong reasons
for strengthening/intensifying (validation) were prone to risky sex (regardless of alcohol level).
3. Looby et
al., (2019).
2039 (out of 7307)
students, 18-24 years old
(average 19.79, at 10
universities in 10 US
states, 1485 female
(72.83%)
Cross-sectional study
online questionnaire; informed consent,
credit for participation in scientific
research, M-DMQ-R, Protective
Behavioral Strategies Scale-20 (PBSS-
20); DDQ; CARE-R-FOI;
alcohol
consumption,
sexual activity
Findings
(behaviors)
Alcohol consumption mediates the association between social reasons and risky sexual behavior,
between reasons for reinforcement and risky sexual behavior. Risky sexual activities:
unprotected sex, sexually transmitted diseases, multiple sexual partners, risky sexual partners,
sexual coercion. Reduction of serious harm (negative effects) mediates the association between
social reasons and risky sexual behavior; Reduction of serious harm mediates the association
between reasons for reinforcement and risky sexual behavior;
Acknowledgements
This study is part of the doctoral research project entitled "Psychological factors involved in
risk behaviors in Romanian students", PhD. Student LUNGU Mihaela, coordinated by PhD. Cornelia
Rada, at the School of Advanced Studies of the Romanian Academy, "Constantin Rădulescu-Motru"
Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy, Bucharest,
Romania.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
160
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ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
165
ASSESSMENT OF THE QUALITY OF LIFE OF A GROUP OF SUBJECTS AGED 65 AND
OVER (MOROCCO)
Abdellatif BAALI (1), Hakima AMOR (1), Raja ZAKARIA (1), Noureddine EL KHOUDRI (2),
Nadia FATHI (3), Nadia EL KADMIRI (3)
DOI: http://doi.org/10.26758/11.1.11
(1) Laboratory of Human Ecology, Faculty of Sciences Semlalia, "Cadi Ayyad" University,
Marrakesh, Morocco; E-mails: abdellatifbaali@hotmail.com; amor@uca.ac.ma;
rajazakaria1@gmail.com
(2) Higher Institute of Health Sciences, "Hassan I" University, Settat, Morocco; E-mail:
noureddinebio@hotmail.com
(3) Molecular engineering, valuation and environment team, Multidisciplinary Faculty, "Ibn Zohr"
University, Taroudant, Morocco; E-mails: nadia.fathi@edu.uiz.ac.ma; n.elkadmiri@uiz.ac.ma
Address correspondence to: Abdellatif Baali, Laboratory of Human Ecology, Faculty of Sciences
Semlalia, Cadi Ayyad University, Bd. My Abdallah, BP 2390, Marrakesh, Morocco. Ph.:
212661613396; E-mail: abdellatifbaali@hotmail.com
Abstract
Objective. The aim of this study was to assess the health related quality of life of elderly Moroccans
living at home as well as determining the factors that influence it.
Material and methods. The data was gathered through a questionnaire survey conducted between
2017 and 2018. Age, gender, level of education, socio-professional activity, morbidity and perception
of old age were chosen as variables, and the LEIPAD scale was used to evaluate the respondent’s
quality of life, French version.
Results. This study included 520 subjects aged 65 and above (277 men and 243 women). The average
age was 71.2 years, and 60.8% of them were illiterate, 22.3% employed, 25.0% retired, and 52.7%
have never worked. In addition, 57.9% of participants had at least one chronic illness and 42.9% had
a pessimistic attitude toward old age. Overall, the surveyed subjects’ quality of life was adequate and
satisfactory. The main ratings for the areas involving "taking care of oneself" and "depression-
anxiety" were the lowest (23.7 and 28.6). On the other hand, the "sexual functioning" area was the
most affected (score=73.7), thus impacting the participants’ quality of life. Furthermore, socio-
demographic characteristics proved to have a negative impact on the participants’ quality of life. The
highest average test scores were reported by women, the oldest subjects (>-75 years), subjects with
low levels of education, without professions and retirees, suffering from chronic diseases and those
who negatively perceived the old age, which showed a relatively impaired quality of life.
Conclusions. The majority of the surveyed people had a good quality of life. Nevertheless, providing
adequate treatment for the most disadvantaged elderly people could improve their quality of life and
help them reach the old age in good health.
Keywords: quality of life, elderly, test LEIPAD, Morocco.
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Introduction
Globally, the number of people aged 65 and over will reach 1.5 billion by 2050, up from 703
million in 2019. The proportion of people in this age group has increased from 6% in 1990 to 9% in
2019 and will increase further to 16% in 2050, making one in every six people 65 years or older
(United Nations, 2019). Due to the impact of the techno-cultural environment and the significant
widespread medicalization, the majority of individuals were able to reach adulthood and,
subsequently, the old age. Nevertheless, aging is associated with the deterioration of elderly health,
sensory condition, nutritional state, and changes in their perception of life (progressive or brutal
isolation, lack of social contacts, confinement at home, etc.), ranging from material, physical or
financial incapacity (fragility, risk of dependence at the end of life...) to psychophysiological
problems (anxiety, depression, etc.). However, as people grow older, all of these factors may have a
negative effect on their quality of life. As a result, as the population ages, new issues emerge, such as
the rising prevalence of chronic diseases and physical disorders, which particularly affect the elders
(Monod-Zorzi, Seematter-Bagnoud, Büla, Pellegrini, & Jaccard, 2007; Lalive d'Epinay, Guilley,
Guillet, & Spini, 2008).
Quality of life is defined as an "individuals' perception of their position in life in the context
of the culture and value systems in which they live, and in relation to their goals, expectations,
standards and concerns" (World Health Organization (WHO), 1999). It is a very broad concept
influenced in a complex way by the participant's physical health, psychological state, level of
independence, active participation, social image, social support system, social relationships as well
as his or her relationship to the essential elements of his or her environment. Furthermore, the quality
of life would depend on the gender of the individual, his or her age, living conditions, family,
entourage, socio-economic level and state of health (chronic illnesses, health behaviors, etc.)
(Compagnone, Van, & Bouisson, 2007; Rada, 2020). Standardized and validated questionnaires
would allow a precise and a reliable assessment of the quality of life linked to the health of the elderly
individuals. The LEIPAD test (acronym resulting from the universities involved in creating it: Padua
and Brescia - Italy, Leiden - the Netherlands, and Helsinki - Finland) is one of the instruments that
can be used to identify seven dimensions of the individual's state of health: the physical function,
level of independence, anxiety and depression, cognitive functioning, social life, sexual life and life
satisfaction.
In addition, Morocco’s population, like the rest of the world, is rapidly aging: people aged
60 and over accounted for 8% in 2004, 10.5% in 2018, and 11.5% in 2020. In addition, by 2030, the
ratio will reach 15.4%, and almost a quarter of Moroccans (23.2%) will belong to this age group.
Furthermore, life expectancy at birth is expected to increase from 76.1 years in 2017 (71 years in
2004) to 80.4 years in 2050 (Haut-Commissariat au Plan (HCP) 2006; 2017) [High Commission for
Planning. In the face of these positive trends, improving the quality of life of the elderly is an
increasingly important challenge for the Moroccan country as well as for the responsible political and
health services, especially from this age group when the social security system is still fragile and
remote. In addition, in most cases, part or all of the care of the elderly is still mainly the responsibility
of the family, especially the children. Thus, the objective of this study was to evaluate the quality of
life of a group of individuals aged over 65 years old and living at home in Morocco using a specific
and validated self-administered scale, in order to detect the dimensions of the LEIPAD test that
affected the quality of life of these subjects and finally, to grasp the associated socio-demographic
factors.
Material and methods
The data for this study came from a survey conducted at the Marrakesh City Health Center
from 2017 to 2018, and the subjects were 520 elderly people over 65 years old. The subjects under
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investigation were randomly selected during their visits to these health centers for consultation,
medical treatment or accompanying their family members. The data was obtained through direct
interviews and questionnaires on the subject. This information was collected anonymously,
respecting the confidentiality; the interviews were conducted only with the subjects who had
approved it in advance. The selected variables were: gender, age, education level, social professional
activities, health status (chronic diseases) and perceptions of old age, and were evaluated by the
following questions: "For you, what is like getting old?" to which there were two types of answer
(Yes/No). The quality of life of these subjects was assessed by the LEIPAD test (De Leo et al., 1998),
French version (Jalenques et al., 2013). This is a multi-dimensional instrument composed of 31 items,
each of them containing 2 to 6 items: physical function (understand the physical condition of the
elderly), self-care (the ability to carry out daily activities by oneself), depression-anxiety (right
anxiety assessment and perception of depression), cognitive function (attention, confusion, memory
problems), social function (individual integration and satisfaction in society), sexual function (interest
and sexual ability/activities) and life satisfaction (satisfaction with the standard of living and the
financial situation). The score for each item is divided into a 4-point Likert scale, ranging from 0
(better quality of life) to 3 (very poor quality of life) (Table 1). Therefore, high scores reflect changes
in the personal quality of life. A single total score is obtained by adding the scores of different items,
and the total score of each of the seven categories is converted linearly on a scale from 0 to 100.
The data was collected and statistically processed through SPSS PC 18. Qualitative variables
were expressed in quantity and percentage, while the quantitative variables were expressed in means
and standard deviation. The comparison between groups was performed by a Chi-square test for
qualitative variables, and the non-parametric test, Mann-Whitney and Kruskal-Wallis test for
quantitative variables. The significance threshold was set to 5%.
Results
Socio-demographic profile of the studied group
The results are shown in Table 1. The sample studied included 520 elderly people aged 65
and over living at home, including 277 men (53.3%) and 243 women (46.7%). The average age was
71.2 years (=6.5; range: 65-96 years), of which 65-74 years old accounted for the highest proportion,
75.8%, while older people or those over 4 years old (>=80 years old) represented only 6.3%. At the
time of the survey, more than half of the participants (58.5%) lived with their partners, while 6.5%
were single, 6.7% were divorced and 28.3% were widowed. In terms of education level, 60.8% of the
people in this sample were illiterate, 17.9% were in elementary schools, 14.2% were in middle
schools, and 7.1% were in higher education. As far as the social professional activities were
concerned during the survey, only 22.3% of the participants reported that they were still working at
the time of the survey, 25.0% had retired, and 52.7% had never worked or had no occupation. Among
retirees, only 19.0% received pensions. In addition, 57.9% of participants reported having at least one
chronic disease. Among them, 33.7% were suffering from one disease, 13.3% were suffering from 2
diseases, 9.0% were suffering from 3 diseases, and 1.9% suffering from 4 diseases. Diabetes and
hypertension were the two most common chronic diseases, at 26.3% and 24.4%, respectively,
followed by rheumatic diseases (12.9%), cardiovascular diseases (8.1%) and respiratory diseases
(4.2%). The prevalence of other reported diseases was relatively low (frequency between 0.2% and
2.5%). After medical diagnosis, these diseases were identified in 97.7% of cases. The proportion of
individuals enjoying medical insurance was 56.3%, of which 28.6% of the Medical Assistance Plan
(RAMed) in Morocco covering individuals socially disadvantaged. Finally, among the 326
participants who answered to the questionnaire on feelings of old age, 57.1% of them had positive
feelings about old age.
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Table 1
Socio-demographic profile of the study group
Variables Modalities Frequency %
Gender Men 277 53.3
Women 243 46.7
Age groups (in years)
65 – 74 394 75.8
75–84 93 17.9
>=85 33 6.3
Level of study No 316 60.8
Primary 93 17.9
Secondary and
more 111 21.3
Socio-professional activity Without profession 274 52.7
Active 116 22.3
Retired 130 25.0
Chronic diseases
Yes 301 57.9
No 219 42.1
Old age perception
Positive 186 57.1
Negative 140 42.9
Quality of life
The average LEIPAD test score of the elderly participants in the study was 33.7 (= 17.1).
Cronbach’s alpha value was 0.94. In order of importance, the average scores on each dimension of
the test were as follows: sexual function (73.7±27.1), physical (43.9±25.3), social (37.6±20.9), life
satisfaction (36.7±22.1), and cognitive function (33.1±24.1), depression and anxiety (28.6±24.8) and
finally self-care (23.7±25.1). The propositions of the scores of the responses to different test items
are given in Table 2. For the sexual function that had the greatest impact on the quality of life of the
study subjects, the ratio of individuals who were not interested in sex and completely abstain from
sexual relations range between 46.7% and 46.5%. In terms of function, the perception of the subject’s
health status seemed to affect the score of this dimension. Among the participants, 52.1% considered
their physical condition not good (17.1 is extremely poor), and other items were related to sleep
problems, feeling tired, etc., more than half of the participants were in a positive state. As for other
categories, regardless of the category, the percentage of individuals in good condition was very high.
In fact, participants usually had a positive view of their social life. They were satisfied with their
social relationships with their families and within the communities, their financial situation, current
living conditions, very optimistic for their future, mnemonic, attentive, neither anxious, nor depressed
and feeling that they had no difficulty in carrying out their daily tasks independently (climbing stairs,
eating, getting dressed, bathing).
Quality of life and profile of the studied group
Table 3 shows the results of the study on the relationship between the average score of the
LEIPAD exam and its components, as well as the socio-demographic characteristics of the
participants. The quality of life of the participants was statistically calculated, sorted by importance,
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incidence, age, gender, literacy and awareness of old age. The participants suffering from chronic
diseases were the oldest ones, while also having a low level of education and a negative perception
of old age, thus having the highest average scores, i.e. their quality of life was relatively impaired.
For other variables, there was no correlation between the "Social Functioning" scale and the
satisfaction with life between men and women, as well as social professional activities, feelings of
old age and the "Depression and Anxiety" scale. Finally, the scales of "social function" and "sexual
function" seemed to had no connection with feelings of old age.
Table 2
Scores (in %) of the subjects' responses to the different items of the LEIPAD test
Scales and items Scores
0 1 2 3
Physical functioning
1–How would you rate your overall physical health? 8.9 38.9 36.5 15.8
6–Do you have sleep problems? 29.8 39.0 23.1 8.0 7–Do you feel tired‚ without energy? 16.3 41.4 28.9 13.4 9–Are you able to accomplish your usual tasks either at home‚ at work‚ or elsewhere? 31.5 26.4 25.9 16.3 12–How much do your physical health problems (if any) stand in the way of doing the
things you want to do? 32.9 35.8 17.1 14.2
Self-care
2–Are you able to get up and down the stairs without help? 46.9 33.7 12.5 6.8 3–Are you able to dress all by yourself? 69.2 19.7 7.5 3.6 4–Are you able to eat by yourself? 81.5 12.5 4.1 1.9 5–Are you able to bathe or take a shower by yourself? 56.3 22.1 16.8 4.8 10–Can you shop all by yourself? 46.1 23.6 10.6 19.7 11–Can you travel by public transportation? 45.4 21.7 13.7 19.2 Cognitive functioning
8–Do you have difficulties concentrating? 33.4 39.4 20.9 6.3 13–How often‚ would you say‚ does it happen that you are not able to think clearly or that
you are confused? 29.8 35.6 25.7 8.9
14–How much do your problems with thinking (if any) stand in the way of doing the things
you want to do? 38.7 38.2 15.8 7.4
15–How good is your memory? 19.7 50.0 19.5 10.8 16–How much do your memory problems (if any) stand in the way of doing the things you
want to do? 56.5 28.1 11.1 4.3
Depression and anxiety
17–Taking everything in consideration‚ how anxious do you feel? 26.5 41.8 21.1 10.6 18–How much do your feelings of anxiety (if any) stand in the way of doing the things you
want to do? 42.5 34.8 17.6 5.1
19–Taking everything in consideration‚ how depressed (blue) do you feel at present? 47.8 34.8 14.2 3.3 20–How much do your depressed feelings (if any) stand in the way of doing the things you
want to do? 54.6 31.0 11.1 3.3
Social functioning
21–How satisfied are you with your social ties or relationships? 40.4 48.3 9.8 1.5 22–Do you feel emotionally satisfied in your relationships with other people? 13.9 42.8 26.4 17.0 23–Is there someone to talk to about personal affairs when you want to? 39.2 25.2 21.2 14.4 Sexual functioning
24–Are you interested in sex? 5.8 15.6 31.2 47.4 25–How often do you have sexual contact? 3.3 16.3 31.5 49.0 Life satisfaction
26–How satisfied are you with your ability to manage your hobbies or recreational
activities? 21.4 41.3 25.2 12.2
27–How satisfied are you with your financial situation? 22.4 40.8 27.4 9.4 28–Do you feel you cannot afford the standard of living you would like? 39.7 34.6 18.0 7.7
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Scales and items Scores
0 1 2 3
29–How satisfied are you with your life at present when compared to the past? 22.6 33.9 28.3 15.2 30–Taking everything in consideration‚ how would you expect things will go in the future? 19.9 57.5 18.0 4.6 31–How much do your expectations of the future stand in the way of doing or initiating the
things you want to do (want)? 54.8 31.7 10.6 2.9
Table 3
Average scores of the LEIPAD test and each of its scales and socio-demographic profile of the
studied group
Variables Modalities LEIPAD PF SC DA CF SF XF LV
Gender Men 29.8±15.5 39.5±24.4 18.3±22.3 24.8±22.6 28.6±22.3 36.8±20.3 62.4±27.0 34.9±21.1 Women 38.1±17.8 48.9±25.6 29.9±26.8 33.1±26.4 38.2±25.0 38.6±21.5 86.6±20.8 38.7±23.0 U test 5.4*** 4.2*** 5.4*** 3.5*** 4.4*** 1.0 ns 10.5*** 1.7 ns
Age
groups (in years)
65 – 74 30.3±15.3 38.4±22.1 18.1±21.1 27.1±24.1 30.0±21.7 35.5±21.0 69.2±27.4 34.6±21.7 75–84 43.5±18.2 60.5±27.7 39.2±28.0 34.1±26.5 42.0±29.2 44.8±20.0 86.4±22.1 43.0±22.9 >=85 45.9±18.2 63.8±24.9 46.8±30.3 32.3±25.7 45.1±25.9 42.8±16.9 90.9±16.7 44.3±19.6
H test 52.8*** 67.5*** 67.2*** 6.6* 19.2*** 15.9*** 49.9*** 15.4***
Level of
study
No 36.8±17.9 47.6±26.4 27.6±26.4 30.3±25.3 36.6±25.2 39.3±20.6 80.6±23.9 39.9±22.5 Primary 32.7±15.7 41.7±24.9 19.1±24.4 30.6±26.7 28.5±22.0 43.8±20.4 65.9±28.0 39.5±19.8 Secondary
and more 25.7±12.5 35.3±19.8 16.6±19.4 22.2±20.1 27.1±20.6 27.6±18.8 60.4±28.5 25.2±18.6
H test 30.2*** 17.2*** 20.5*** 8.0* 14.7*** 37.3*** 53.8*** 38.0***
Socio-
professional
activity
Without
profession 37.0±17.7 47.0±26.2 27.3±26.8 30.9±26.5 35.7±25.0 40.3±21.3 84.2±22.0 40.2±22.0
Active 31.5±17.8 41.4±25.3 18.6±23.8 28.5±24.2 32.5±24.2 36.0±21.6 61.4±28.5 37.2±23.2 Retirees 28.7±13.4 39.7±22.7 20.7±21.3 24.1±20.6 28.1±21.1 33.5±18.7 62.4±26.8 28.8±19.1 H test 19.6*** 7.7* 12.5** 4.0 ns 7.7* 10.6** 91.4*** 24.6***
Chronic
diseases
Yes 40.5±16.8 56.0±23.6 33.1±26.8 36.4±24.7 40.8±24.1 40.3±19.1 77.9±26.1 41.0±22.4 No 24.3±12.4 27.4±17.0 10.9±15.3 18.0±20.5 22.5±19.6 33.9±22.7 67.9±27.5 30.7±20.1
U test 10.9*** 13.0*** 10.5*** 9.0*** 8.6*** 3.3*** 4.4*** 5.1*** Old age
perception
Positive 34.0±16.6 45.1±25.4 23.6±24.9 31.3±25.2 33.9±22.7 39.8±20.8 72.0±28.3 34.6±21.2 Negative 41.0±19.2 53.2±27.4 32.1±28.8 36.0±27.5 44.0±25.2 41.5±20.6 75.2±27.6 44.9±24.5 U test 3.4*** 2.7*** 2.6** 1.5 ns 3.5*** 0.8 ns 1.1 ns 3.9***
PF=Physical functioning, SC=Self-care, DA=Depression and anxiety, CF=Cognitive functioning,
SF=Social functioning, SxF=Sexual functioning, LF=Life satisfaction. U and H test=Mann-Withney
and Kruskal-Wallis test, respectively;
*=p<0.05; **=p< 0.01; ***= p<0.001.
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Discussions
The study included 520 Moroccans 65 years and older, including 277 men and 243 women.
The average age was 72.2 years, and there were very few subjects (6.3%) aged 80 years and over,
while the number of subjects in the 65-74 age group is 75.8%. This fact can be attributed to the
difference in mortality and the decrease in life expectancy with age; nationwide, the life expectancy
at birth in 2018 was 76.1 years (HCP, 2017). Most of the study subjects lived with their families
(92.3%), and more than half (58.5%) lived with their husbands and wives. Family life enables social
connections and solidarity and mutual assistance between family members, thereby helping to
improve the quality of life of the elderly. Compared with the national level of 2012, the literacy rate
of the surveyed samples (37.7%) was very high, i.e. 28% (Observatoire National du Développemet
Humain (ONDH), 2015) National Observatory for Human Development. This significant
improvement is the result of the progress made by the Moroccan country to improve the educational
level of all generations, and it is also the result of the large number of respondents in the sample
belonging to the 50s generation (65-69 years old) when the population gradually began to go to school
during the independence period. As for social professional activities, only 22% of the participants
were active at the time of the survey, which was relatively low compared to the 2012 study conducted
by Baali et al. (2012) in the city of Marrakesh. However, this study included participants of 60 years
and older. On the other hand, 25% of the participants retired and more than half (52.7%) had no social
activities. In fact, a large number of the surveyed elderly people have a low percentage of participation
in social and professional activities, which guarantees their retirement pensions. This is due to the
high percentage of women who have never participated in social and professional activities, 87.7%,
as opposed to men, who account for only 22%. Therefore, the proportion of people receiving pensions
was only 19.0%, a rate that was relatively low in 2017, among people aged 60 and over, i.e. (24.5%)
(Autorité de Contrôle des Assurances et de la Prévoyance Sociale (ACAPS), 2017) [Insurance and
Social Welfare Control Authority.
In addition, like all elderly people, the percentage of individuals with chronic diseases was
very high, and 57.9% of the surveyed participants reported having at least one chronic disease.
Diabetes and hypertension both accounted for 50.7% of the recorded chronic diseases; these diseases
were the most common diseases observed in a group of Moroccan participants, accounting for 34.1%
(the average age of the group was 64.3±21.6 years) (Elkafssaoui et al., 2017). The proportion of
individuals with chronic diseases recorded in our sample has increased along with the age; for the
three surveyed age groups, 50.2%, 61.3% and 77.6% of people had at least one chronic disease. This
result is consistent with research showing that aging increases the risk of chronic diseases (Monod-
Zorzi et al., 2007; Lalive d'Epinay et al., 2008). This will require treatment of affected individuals
because the treatment of these diseases is time-consuming and expensive. In addition, medical
insurance covers only a small part of the population, accounting for 60% (Agence Nationale de
l’Assurance Maladie (ANAM), 2016) [National Agency for Health Insurance. This rate has
increased since 2005 (25%), thanks to the generalization of the medical assistant scheme (RAMED)
since 2012. The surveyed sample with medical coverage rate (56.3%) was relatively close to the
national level, but the RAMED system sample accounts for more than half (27.7%). Finally, 42.9%
of the participants expressed negative opinions about old age; compared with 37.5% in 2012, this
proportion is relatively high (Baali et al., 2012). This feeling does not seem to be related to age or
incidence, but to the gender and education level of the participants. In fact, there were the women and
those with a low level of education who had a negative perception of ageism. Perception of aging is
considered one of the indicators of health and vulnerability: the more negative people’s perceptions
of aging, the easier it is for them to reach a worrying state of vulnerability (Bruin, Picavet, Nossikov,
& WHO Regional Office for Europe, 1996).
The quality of life of the participants seemed to be generally satisfying; the average LEIPAD
score was very low, at 33.7 (LEIPAD scores range from 0 to 93). In fact, 25% of participants scored
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greater than 43 (75th percentile), and only 10% of participants scored greater than 59 (90th
percentile). The results showed that participants enjoyed greater autonomy, and very few of them had
difficulties in completing daily tasks independently without the help of anyone else (climbing stairs,
eating, dressing, bathing, etc.). Similarly, they were in a good mental health (very low average score
for the "depression and anxiety" dimension was very low). However, diagnosing the elderly with
depression and anxiety is still difficult (Thomas & Hazif-Thomas, 2008). In addition, their cognitive
function (mental ability, knowledge acquisition and memory) was satisfactory: the average score of
this dimension was low, and the score was higher than 70% of the cognitive function (mental ability,
knowledge acquisition and memory). The average score of this dimension was low, and more than
70% of the participants were in a positive state. This feature can be attributed to the predominance of
the 65-74 age group in this sample (75.8%). Moreover, they were doing quite well were more likely
to reach the age of 75.
As for the two variables "life satisfaction" and "social functioning", they reflected the extent
to which the surveyed people were satisfied with the standard norms of their life in the community
and their current financial situation as well as their perception of the future, which shows that the
respect which is granted to the elderly by the community, as well as the solidarity and the socio-
culturally governed family ties are still strong and solid for them. These attitudes and behaviors will
only have a positive impact on the individual's living conditions (providing daily needs, satisfactory
living conditions, shopping and travel expenses, access to medical care, etc.) and will reduce their
psychological deterioration. Nevertheless, the quality of life of the participants was affected by
certain changes caused by the "sexual function" variable, while the changes caused by the "body
function" variable were smaller. The average scores of these two variables were 73.3 and 43.9,
respectively. As for physical function, it seemed that the self-perception regarding the health had had
the greatest influence on the score of this variable. 47.8% of the participants thought they were in
poor physical condition (including 9% in extremely poor physical condition). The actual health status
of the participants made an important contribution to this self-assessment. In fact, 76.4% of
participants with a chronic disease believed that their health was very poor (including 28.6% of people
who were in poor physical condition), while only 18.8% of the participants (including 1, 4% who
were unwell) considered themselves to be unaffected (2 to 3ddl=177.8; p<0.001). Regarding other
items in the scale (sleep problems, feelings of fatigue, completing daily tasks, health-related
obstacles), most participants (over 55%) had the lowest score (0 or 1), indicating a better quality of
life. As for the "sexual functioning" scale, it is well known that problems related to sexual activity
are frequently encountered by the elderly (Jalenques, Auclair, Rondepierre, Gerbaud, &
Tourtauchaux, 2015; Kharrat, Mersni, Guebsi, Ben Salah, & Dziri, 2017). Many variables are
believed to have an influence on the sexual life of elderly participants, such as: reproductive aging,
hormone deficiency, related pathologies and their treatments (diabetes, hypertension), menopause,
psychosocial factors, sexual desire disorders (Graziottin & Leiblum, 2005; Grafeille, 2016).
In addition, the socio-cultural background may also be the reason for this result, because
sexuality is still considered a taboo topic, especially among people of this age group, and even among
unmarried elderly participants. However, the widowhood experienced by participants who lost their
spouse had a significant impact on this ratio. Widows had an average score of 96.5, and married
participants had an average score of 62.2 (average scores for divorced and single persons were 72.4
and 79.4). The latest work of Jalenques et al. (2015) and Kharrat et al. (2017), carried out on French
and Tunisian participants aged 65 and above (Figure 1), also revealed the negative impact of the scale
on the quality of life of the respondents. Finally, the average scores of the various scales obtained in
the study are higher than those of the French counterparts (except for LS); difference which could be
attributed to the obvious difference in the living conditions and caring conditions for the elderly
participants studied compared to their French peers. There are obvious differences in living conditions
and nursing conditions. On the other hand, the score registered for this research was much lower than
that of the Tunisian group. The difference between the two groups of elderly participants with
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173
relatively similar socioeconomic levels was due to the fact that the average age of Tunisians (74.3
years) was higher than the average age of Moroccans (71.2 years), and the sample of Tunisians only
included participants who have been interviewed during their hospitalization.
Figure 1
Average scores of the dimensions of the LEIPAD scale of the studied group, compared to those of
their Tunisian and French counterparts
Furthermore, there is a clear relationship between the quality of life and its span and the
socio-demographic characteristics of the studied sample (Table 3). These results indicate that
women’s quality of life seemed to be more impaired than men’s, which could be attributed primarily
to sexual functioning. The average scores for women and men were 86.6 and 62.4, respectively. This
difference between men and women was especially likely to increase the frequency of women’s
widowhood; 48.6% compared to only 10.5% among men, as well as the response rate with "never"
to items related to sexual desire (item 24) and sexual activity (item 25) (Table 2), which were similar
to the widowhood rate of 47.4% and 49.0%. Moreover, it must be noted that the length of the marital
status is the result of women’s life expectancy at birth, which is relatively higher than that of men
(77.8 years vs. 74.5 years) (HCP, 2018). In addition to that, the age gap between spouses at the time
of marriage and the possibility of men remarrying after the death of their spouse is high. For the scales
of "social functioning" and "life satisfaction", there was no gender association, which shows the value
of this age group without any difference between men and women and the fact that the culture and
customs of the Moroccan society towards these people reinforce social ties which consequently leads
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
174
to supporting them as well as their integration into the society, as people who are wise, and
experienced, in addition to that as people who have effectively fulfilled their roles in society.
Moreover, the results showed that the quality of life of participants and all their scales
deteriorated with age. In fact, regardless of the dependent variable, the average score would
significantly increase with age. This is still the biggest differentiator of aging and has a great impact
on its quality. Similarly, the level of education, which is one of the most important factors that
determine personal living conditions and health status (better access to information related to health
education, nutrition and life hygiene), also seemed to affect the quality of life of elderly participants’
scale. The positive impact of intellectual activities on the quality of life of the elderly has been fully
demonstrated; compared with peers with a higher education level, illiterate or less educated people
suffer more damage (Martin, 2010). Consequently, education has a great influence on the cognitive
performance of older participants. This effect seems to be reflected in the lower allocation of
dedicated resources required to perform certain tasks (Guerrero-Sastoque, Bouazzaoui, Burger, &
Taconnat, 2017). However, the level of education was assumed to be closely related to the average
age of people with secondary education and above. The average age was 69.2 years (=4.4), while the
average ages of elementary school and illiterate counterparts were 70.2 years (6.3) and 72.2 years
(7.0), which showed a statistically significant difference (Kruskal-Wallis H=7.2; p<0.01). Morbidity
also greatly affected the participants’ health-related quality of life and various aspects. The physical
deterioration (high frequency of chronic pathologies) that older people are expected to face increases
with age (Monod-Zorzi et al., 2007; Lalive d'Epinay et al., 2008). Chronically ill participants were
statistically older than their unaffected counterparts (72.3±7.0 years vs. 69.7±5.4 years; Mann-
Whitney’s u-test=4.2; p<0.001). Professional activity is an essential element in an individual’s life
because it is obvious that any activity with a decent and stable salary would certainly have a positive
effect on the individual's living conditions while enabling him or her to meet their daily needs, and
to ensure a sufficient and a balanced nutrition, satisfactory living conditions, a better access to health
care and a satisfactory social life in general. Any activity in general whether it is professional or non-
professional, is associated with both physical and mental health. Socio-professional activities are
statistically related to the participants’ socioeconomic level, as well as to the participants’ quality of
life and all test scales, i.e. the Depression-Anxiety Scale (Kivits, Erpelding, & Guillemin, 2013).
Nowadays, living to old age and not being able to work exposes individuals without pensions
to severe economic insecurity this can only be addressed through special solidarity (mostly family
solidarity). There is no doubt that the family environment will have positive impact on the lifestyle,
the health state and the quality of life of the elderly, and the cohabitation will also contribute to intra-
and inter-generational family solidarity, with children providing care and kindness to their parents at
all stages of their lives and especially in old age. Therefore, the family is the most important social
institution that can meet the needs of the elderly. In fact, family members, especially children, will
provide elderly parents with all the financial means to meet their daily needs, especially for those
who cannot benefit from any type of social or medical insurance, which is the case for the majority
of elderly Moroccans. In addition, children will provide parents with psychological, emotional and
physical support, especially in vulnerable and/or dependent situations (HCP, 2006; Baali et al., 2012;
Baali et al., 2017). Similar to the education level and morbidity, age is also a confounding factor that
may affect the impact of social and professional activities on the quality of life of the studied samples.
Therefore, the subjects who declared they had never had a socio-professional activity and the retirees
were older than the participants who are still practicing a professional activity was of 71.7 years
(=7.2), 7.9 years (=6.3) and 69.3 years respectively (=4.1) (Kruskal-Wallis H test=8.9; p<0.01).
However, this only affected the scales of "physical function", "care", "cognitive function" and "life
satisfaction". Studies have shown that negative perceptions of aging have many effects on physical
health (Levy, 2000). In addition, older participants tend to have a negative perception about the future
and tend to be unsatisfied about their life (Netuveli, Wiggins, Hildon, Montgomery, & Blane, 2006).
However, in our case, age had nothing to do with the perception of age: participants who perceived
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
175
old age negatively were on average at the same age as their counterparts who had a positive view,
which was demonstrated in the result 70.9 (=6.3), and 71.8 (=6.8) years old (Mann-Withney u-
test=1.01; p=0.29). Similarly, there were no associations between this variable, morbidity and the
level of education.
Conclusions
The overall quality of life of Moroccan people over 65 and living at home was satisfactory.
However, the results showed that variables such as "sexual function", "physical function" and the
selected socio-demographic characteristics (gender, age, education level, occupational activity,
morbidity and perception of age) have a negative effect on the quality of life of the participants. Based
on the Moroccan socio-economic and cultural background, implementing programs for this age
group, focusing on preventing the consequences and effects of chronic diseases, preventing
vulnerability and dependence, good social integration and physical and intellectual maintenance
activities, as well as the professionalization of certain occupations, the improvement of the medical
and financial care, and the assistance to the most disadvantaged families are very necessary to ensure
that the elderly could enjoy a good "quality of life" in the years to come.
Conflict of interest: None
Acknowledgments
The authors sincerely thank all those who were deliberately involved in the investigation
and, consequently, the realization of this work. Also special thanks go to the Health Authority of
Marrakesh.
Funding
The authors received no financial support for the research, authorship, and/or publication of
this article.
ANTHROPOLOGICAL RESEARCHES AND STUDIES No.11, 2021
176
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SPECIALISTS INVOLVED IN THE REVIEW OF ARTICLES AND ABSTRACTS IN THE
PERIOD 2012-2020
Specialists involved in the review of articles and abstracts published in the journals
Anthropological Researches and Studies (ARS) (ISSN 2360-3445; ISSN-L 2360-3445) and Studii și
Cercetări de Antropologie (SCA) (ISSN 2344-2824; ISSN-L 0039-3886) in the period 2012-2020.
1. Adina BACIU, "Francisc I. Rainer" Anthropology Institute of the Romanian Academy,
Bucharest, Romania.
2. Adriana ALBU, "Grigore T. Popa" University of Medicine and Pharmacy, Faculty of Medicine,
Department of Preventive Medicine and Interdisciplinarity, Iasi, Romania.
3. Albena NAKOVA, Institute of Philosophy and Sociology, Bulgarian Academy of Sciences,
Sofia, Bulgaria.
4. Alexandra COMŞA, Center of Thracology of the "Vasile Pârvan" Institute of Archaeology,
Romanian Academy, Bucharest, Romania.
5. Alexandra Elena NEAGU, "Francisc I. Rainer" Anthropology Institute of the Romanian
Academy, Bucharest, Romania.
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7. Andrei Dorian SOFICARU "Francisc I. Rainer" Anthropology Institute of the Romanian
Academy, Bucharest, Romania.
8. Andrey KOZLOV, Lomonosov Moskow State University, Anuchin Research Institute and
Museum of Anthropology, Russia.
9. Angela SIMALCSIK, "Olga Necrasov" Center of Anthropological Research, Romanian
Academy, Iași Branch.
10. Anne RYEN, University of Agder, Faculty of Social Sciences, Department of Sociology and
Social Work, Kristiansand, Norway.
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Extension, New Delhi, India.
12. Archna KUMAR, University of Delhi, Department of Development Communication &
Extension at Lady Irwin College, New Delhi, India.
13. Atanas BALTADJIEV, Medical University of Plovdiv, Faculty of Medicine, Department of
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and Sport, Iasi, Romania.
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Bucharest, Romania.
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Studies, Iasi, Romania.
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Romania.
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Bucharest, Romania.
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Bucharest, Romania.
29. Cristina FALUDI, "Babes-Bolyai University", Faculty of Sociology and Social Work, Cluj-
Napoca, Romania.
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Bulgaria.
31. Diana ȘERBAN, National Anti-Drug Agency, Bucharest, Romania.
32. Diego Oswaldo CAMACHO VEGA, Universidad Autónoma de Baja California, Faculty of
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Philosophy, Department of Sociology, Blagoevgrad, Bulgaria.
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Warsaw, Poland.
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Romania.
37. Elena-Ana PAUNCU, "Victor Babes" University of Medicine and Pharmacy Timisoara, Faculty
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38. Elena CIOBANU, Nicolae Testemitanu State University of Medicine and Pharmacy of the
Republic of Moldova, Department of General Hygiene, Chisinau, Republic of Moldova.
39. Elena GODINA, Moscow State University "M. Lomonosov", Institute of Anthropology with
Museum, Moscow, Russia.
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42. Ergyul TAIR, Institute for Population Studies at Bulgarian Academy of Sciences, Sofia,
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54. Jasminka HADŽIHALILOVIĆ, University of Tuzla, Faculty of Sciences, Tuzla, Bosnia and
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Psychology and History, Ruse, Bulgaria.
56. Luminita BEJENARU, Alexandru Ioan Cuza University of Iasi, Faculty of Biology, Iasi,
Romania.
57. Maria MARCZEWSKA-RYTKO, Maria Curie-Skłodowska University, Faculty of Political
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58. Maria Nives SALA, University of Torino, Department of Psychology, Italy.
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Kingdom.
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62. Mihaela-Camelia POPA, "Constantin. Rădulescu-Motru" Institute of Philosophy and
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Academy, Bucharest, Romania.
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Bucharest, Romania.
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81. Sedin HABIBOVIĆ, University of Zenica, Zenica, Bosnia and Herzegovina.
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Bulgaria.
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85. Stefan SIVKOV, Medical University, Department of Anatomy, Histology and Embryology,
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86. Stevo PAŠALIĆ, University of East Sarajevo, Faculty of Pedagogy, Lukavica, Bosnia and
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90. Tatiana Shopova, South-West University "Neofit Rilski", Faculty of Arts, Department of
Cultural Studies, Blagoevgrad, Bulgaria.
91. Tatjana PAVLICA, University of Novi Sad, Department of Human Biology and Ecology, Novi
Sad, Serbia.
92. Tudor B. MARINESCU, "Carol Davila" University of Medicine and Pharmacy, Anatomy
Department, Bucharest, Romania.
93. Valentina MARINESCU, University of Bucharest, Faculty of Sociology and Social Work,
Department of Sociology, Romania.
94. Valentina MILENKOVA, South-West University "Neofit Rilski", Faculty of Philosophy,
Department of Socilogy, Blagoevgrad, Bulgaria.
95. Valeria LAZA, Iuliu Hatieganu University of Medicine and Pharmacy, Division of Community
Medicine, Cluj-Napoca, Romania.
96. Vasile CREȚU, University of Bucharest, The Faculty of Orthodox Theology "Justinian the
Patriarch", Bucharest, Romania.
97. Veska SHOSHEVA, Thracian University – Stara Zagora, Medical School, Department of
Social Care Services, Stara Zagora, Bulgaria.
98. Zoran MATEVSKI D., Cyril and Methodius University, Faculty of Philosophy, Skopje,
Macedonia.
Thank you for the excellent work you have done
over these years !