Co-occurrence of Health Risk Behaviors Among Brazilian Adolescent Victims of Family Violence

Abstract

Although recent studies have related the occurrence of violence in childhood and adolescence with the adoption of health risk behaviors, there are no studies that quantify this co-occurrence among adolescent victims of family violence. Our objective was, therefore, to investigate the co-occurrence of health risk behaviors in these adolescent victims. Data from the National School Health Survey, collected in 2015, were used. Co-occurrence of risk behaviors—involvement in fights, substance use (alcohol, drugs, and tobacco), not wearing seat belts and helmets, inadequate food consumption—was analyzed using Venn diagrams, according to the victim’s status and sex. The association between the four risk behaviors and victimization was investigated using multiple logistic regression. All the analyses were performed using Stata®13. We found an excess of risk behaviors among victims of family violence in both sexes. The co-occurrence of the four risk behaviors analyzed was higher among male and female adolescents, who were victims of family violence than in nonvictims. Family violence was associated with the adoption of risk behaviors, regardless of sex. This association was stronger as the number of risk behaviors adopted increased. The chance of engaging in one risk behavior was 1.32 (95% confidence interval (CI) = [0.88, 1.98]) and 1.24 (95% CI = [0.90, 1.72]) higher for boys and girls, respectively, who had suffered family violence. This increased to 7.76 (95% CI = [5.33, 11.29]) and 7.28 (95% CI = [5.20, 10.20]) when considering engagement in four risk behaviors. Identifying the prevalence of co-occurrence of health risk behaviors in vulnerable subgroups (such as victims of domestic violence) could help target broader interventions focusing on multiple risk behaviors.

Keywords

domestic violence child abuse alcohol and drugs

Introduction

Family violence against adolescents comprises physical, psychological, sexual abuse, neglect and/or exploitation, perpetrated by parents, guardians, or other family member (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). It is one of the most pervasive public health problems globally (Xia, Li, & Liu, 2018), particularly in Central Asia and Latin America countries (Patton et al., 2016), including Brazil (Pinheiro, 2006). Family violence tends to occur at home (63.1%), to be perpetrated by parents in 39.1% of cases and mostly affects adolescents between 10 and 14 years old (40%; Waiselfiz, 2012). Physical abuse, specifically, is defined as use of physical force (hitting, beating, kicking, shaking among others) that results in, or has a high likelihood of resulting in, harm for the health, development or dignity of adolescents (World Health Organization [WHO], 2006). According to Ending Violence in Childhood: Global Report 2017, 68.3% of Brazilian children and adolescents suffered physical violence at home in 2015 (Know Violence in Childhood [KVC], 2017).

Studies on the relationship between child abuse and risk behavior began in the 1990s (Coble et al., 1993; Felitti, 1991, 1993; Gould et al., 1994; McCauley et al., 1997; Springs & Friedrich, 1992) and it has since been recognized that violence in childhood and adolescence are associated with risk factors that are important causes of morbidity and mortality in adulthood (Felitti et al., 1998; WHO, 2014). There is evidence regarding violence in childhood and adolescence associated with adoption of risky sexual behavior (Anda, Butchart, Felitti, & Brown, 2010; Coble et al., 1993; Currie & Widom, 2010; Felitti et al., 1998), misuse of alcohol, licit and illicit drugs (Felitti et al., 1998; Fergusson, Boden, & Horwood, 2008; Kendall-Tackett, 2002), and violent behaviors (Kendall-Tackett, 2002; Leeb, Lewis, & Zolotor, 2011; Taylor, Lee, Guterman, & Rice, 2010).

Health risk behaviors may not occur in isolation (MacArthur et al., 2012) and consideration of their co-occurrence has gained ground in scientific literature (Hofstetter, Dusseldorp, van Empelen, & Paulussen, 2014). A systematic review and meta-analysis by Hughes et al. (2017) synthesized evidence of association between multiple adverse childhood experiences (ACE), such as family violence, and different health outcomes. The authors found a moderate association with smoking and heavy alcohol use; a strong association with sexual risk taking and problematic alcohol use; and a stronger association with problematic drug use and interpersonal violence, reinforcing the importance of ACE for the co-occurrence of detrimental health outcomes.

However, there are no studies that quantify this co-occurrence among adolescent victims of family violence. Therefore, we tested the hypothesis that adolescent victims of physical abuse engage in more health risk behaviors. Assessing the magnitude of the joint occurrence of risk behaviors in adolescence, the life cycle in which they normally begin, could contribute to the development of strategies to combat violence and reduce multiple risk behaviors. The objectives of this study were to investigate the co-occurrence of health risk behaviors in adolescent victims of family violence and to identify whether these adolescents are more likely to adopt these behaviors than those who were not victims.

Method

Study-Design and Participants

We used cross-sectional data from the Brazilian National Survey of School Health (Pesquisa Nacional da Saúde do Escolar, PeNSE) carried out from April to September 2015. PeNSE gathered data from a sample of adolescents attending ninth grade at public and private schools representative of Brazil. Detailed information about PeNSE has been published elsewhere (Instituto Brasileiro de Geografia e Estatística [IBGE], 2016). Briefly, the PeNSE sampling strategy included stratification per cluster and multistage selection. The sampling strata were each of the 26 state capitals, the Federal District, and each of the five regions of Brazil. The primary sampling units were schools, and the secondary sampling units were classrooms. School selection was proportional to the total number of ninth-grade classes, while the classes in each school were chosen by simple random selection. All students enrolled in the selected classrooms were invited to participate in the study (IBGE, 2016). Participants were not included in the study if they did not attend school during data collection, refused to participate, or did not report their age and sex. Of 3,160 selected schools, 120 were not assessed due to lack of ninth-grade classrooms, strikes at the time of data collection, or the school board’s refusal to participate. On the data collection days, 96.7% (120,122) of the total number of students attended school, 18,050 refused to participate or did not report their gender or age and were excluded from the analysis (response rate of 82.2%, n = 102,072; IBGE, 2016). The sample of the present study included all 102,072 adolescents interviewed for the background study.

Students completed a self-administered questionnaire on a smartphone in their school classrooms during regular school hours. The questionnaire was based on the Global School-Based Student Health Survey (WHO, 2009), and the Youth Risk Behavior Surveillance System (Brener et al., 2013), with adaptations to the Brazilian setting.

Study Variables

Family violence was identified through the question, “in the last 30 days, how many times have you been physically assaulted by an adult of your family.” Adolescents who reported being physically assaulted at least once in the last 30 days were considered victims of family violence.

The risk behaviors assessed were involvement in fights using guns, involvement in fights using other weapons, and having bullied others at least once in the last 30 days; substance use (alcohol, drugs and tobacco) in the last 30 days; having not used seat belts and helmets in the last 30 days; having regularly consumed (five or more times per week) soft drinks, sweets, and processed meat in the last week (Levy et al., 2010).

Statistical Analyses

All the analyses were performed by sex. The differences between sexes regarding risk behavior distribution were analyzed using a chi-squared test. We used Venn diagrams to graphically represent the co-occurrence of groups of four risk behaviors among victims and nonvictims of family violence, by sex. These graphs show the overlap of risk behaviors.

The association among the four risk behaviors was investigated separately using logistic regression analysis. The association between family violence and the number of risk behaviors adopted was investigated using multinomial logistic regression analysis. Both analyses were adjusted for age (<15 years, ≥15 years), self-reported skin color/race (White, Black, brown/mixed, Asian, native Brazilian Indian), mother’s educational level (incomplete middle school, complete middle school, complete high school, complete higher education), type of school (public, private) and familial arrangement, considering the variables living with the mother (yes/no) and living with the father (yes/no).

The variable “mother’s educational level” had 25% missing values (n = 25,434). Our missing rate was largely due to the number of Brazilian adolescents who did not know their mother’s educational level (24.7% out of the 25% answered “I do not know,” and only 0.3% did not answer to this question). To have a complete data set and test for selection bias, we performed multiple imputation by chained equations, as described elsewhere (Azeredo et al., 2015). The imputed data exhibited satisfactory statistical reproducibility according to the Monte Carlo error analysis (Royston & White, 2011). Comparing analysis using the imputed data set and the complete data set, we found similar results, and therefore, we present results from the complete data set, following the parsimony principle.

All the analyses were performed using Stata Statistical Software 13.0, considering the complex sample design.

Ethics

The PeNSE was approved by the National Commission for Research Ethics (Brazilian Ethics Committee; CONEP record no = 1.006.467), according to the Declaration of Helsinki, and all participants gave informed consent through a self-administered questionnaire (using smartphones). Informed consent from the parents, carers, or guardians was not obtained on behalf of the participants because the Brazilian Statute of Children and Adolescents (Law no 8.069; 13 July, 1990) gives adolescents autonomy to takes initiatives, such as answering questionnaires, that offer no risk to health and which have the clear purpose of supporting health policies for this age group. All these consent procedures were approved by the National Commission for Research Ethics. Access to the study database is freely available through the Brazilian Institute of Geography and Statistics website with no identifying information on the participants (data are anonymized).

Results

As shown in Table 1, most adolescents interviewed were below the age of 15 years and lived with their parents. Most of the teenagers described themselves as brown. About 15% had been physically assaulted by an adult in their family in the 30 days prior to the interview. Boys showed greater frequencies of drug use, involvement in fights, nonuse of seat belts and helmets, and consumption of processed meat and soft drinks than girls. Girls reported more alcohol use and consumption of sweets.

Table 1.

Profile of the Study Population by Sex — Brazil, 2015.

Variables	Boys		Girls		Both		p value^b
Variables	n	%^a	n	%^a	n	%^a	p value^b
Age
below or equal to 15 years	42,096	86.9 [86.2, 87.6]	47,639	91.1 [90.4, 91.7]	89,735	89.0 [88.4, 89.6]	—
Greater than 15 years	7,194	13.1 [12.4, 13.8]	5.143	8.9 [8.3, 9.6]	12,337	11.0 [10.4, 11.5]
Skin color/race
White	16,996	37.4 [36.2, 38.5]	16,779	35.0 [33.8, 36.2]	33,775	36.1 [35.1, 37.2]	—
Black	7,193	15.5 [14.8, 16.2]	5,656	11.3 [10.7, 12.0]	12,849	13.4 [12.9, 13.9]
Asian	1,863	3.6 [3.3, 3.9]	2,717	4.6 [4.3, 5.0]	4,589	4.1 [3.9, 4.4]
Brown/mixed	21,156	39.9 [38.9, 41.0]	25,779	46.0 [44.9, 47.1]	46,935	43.0 [42.2, 43.9]
Native Brazilian Indian	2,021	3.6 [3.3, 3.9]	1,804	3.0 [2.7, 3.3]	3,835	3.3 [3.1, 3.5]
Living with the mother
No	5,675	10.2 [9.7, 10.7]	5,868	9.9 [9.4, 10.4]	11,543	10.1 [9.7, 10.4]	—
Yes	43,575	89.8 [89.3, 90.2]	46,883	90.1 [89.6, 90.6]	90,458	89.8 [89.6, 90.3]
Living with the father
No	17,152	33.5 [32.6, 34.4]	21,189	38.9 [38.0, 39.8]	38,341	36.3 [35.6, 37.0]	—
Yes	32,059	66.5 [65.6, 67.3]	31,541	61.09 [60.2, 62.0]	63,600	63.7 [63.0, 64.4]
Family violence against adolescent
No	42,111	84.9 [84.3, 85.5]	44,684	84.4 [83.8, 85.0]	86,795	84.7 [84.2, 85.1]	—
Yes	7,179	15.1 [14.4, 15.7]	8,098	15.6 [14.9, 16.2]	15,277	15.3 [14.8, 15.8]
Alcohol use
No	38,771	77.6 [76.8, 78.3]	40,593	74.9 [74.1, 75.7]	79,364	76.2 [75.6, 76.8]	<.0001
Yes	10,457	22.4 [21.6, 23.2]	12,140	25.1 [24.3, 25.9]	22,597	23.8 [23.1, 24.4]
Drug use
No	47,107	95.3 [94.9, 95.7]	51,008	96.3 [96.0, 96.6]	98,115	95.8 [95.6, 96.1]	.0002
Yes	2,157	4.7 [4.2, 5.1]	1,758	3.7 [3.3, 4.0]	3,915	4.1 [3.9, 4.4]
Tobacco use
No	46,420	94.2 [93.7, 96.6]	50,176	94.6 [94.1, 95.1]	96,596	94.4 [94.0, 94.7]	.1570
Yes	2,830	5.8 [5.4, 6.3]	2,587	5.4 [4.9, 5.8]	5,417	5.6 [5.2, 5.9]
Involvement in fights using guns
No	45,005	92.1 [91.5, 92.6]	50,730	96.3 [96.0, 96.7]	95,735	94.3 [93.9, 94.6]	<.0001
Yes	3,751	7.9 [7.4, 8.5]	1,832	3.7 [3.3, 4.0]	5,583	7.7 [5.4, 6.1]
Involvement in fights using other weapons
No	43,478	89.4 [88.8, 90.0]	49,588	94.6 [94.2, 95.0]	93,066	92.08 [91.7, 92.4]	<.0001
Yes	5,218	10.6 [10.0, 11.2]	2,900	5.4 [5.0, 5.8]	8,118	7.9 [7.6, 8.3]
Involvement in fights
No	34,107	68.6 [67.8, 69.5]	44,225	82.7 [82.0, 83.4]	78,332	75.9 [75.2, 76.5]	<.0001
Yes	15,183	31.4 [30.5, 32.2]	8,557	17.3 [16.5, 18.0]	23,740	24.1 [23.5, 24.7]
Wearing seat belts in front seat
No	12,877	34.6 [33.6, 35.6]	15,030	37.0 [35.8, 38.2]	27,907	35.8 [34.9, 36.8]	0.0002
Yes	25,156	65.4 [64.3, 66.4]	25,886	63.0 [61.8, 64.2]	51,042	64.1 [63.2, 65.0]
Wearing seat belts in back seat
No	19,098	49.2 [48.1, 50.3]	22,798	53.0 [51.8, 54.1]	41,896	51.1 [50.2, 52.0]	<.0001
Yes	19,819	50.8 [49.7, 51.9]	19,809	47.0 [45.9, 48.1]	39,628	49.0 [48.0, 49.8]
Wearing helmets
No	7,976	28.3 [27.1, 29.5]	8,434	30.6 [29.2, 32.0]	16,410	29.4 [28.3, 30.6]	.0003
Yes	23,226	71.7 [70.5, 72.9]	22,621	69.4 [68.0, 70.8]	45,847	70.6 [69.4, 71.7]
Having regularly consumed processed meat^c
No	44,756	91.5 [91.0, 92.0]	48,270	92.6 [92.1, 93.0]	93,026	92.1 [91.7, 92.4]	.0018
Yes	4,377	8.5 [8.0, 9.0]	4,440	7.4 [7.0, 7.9]	8,817	7.9 [7.6, 8.3]
Having regularly consumed soft drinks^c
No	30,857	61.1 [60.2, 62.0]	35,535	67.0 [66.0, 68.0]	66,392	64.1 [63.4, 64.9]	<.0001
Yes	18,320	38.9 [38.0, 39.8]	17,186	33.0 [32.0, 34.0]	35,506	35.9 [35.1, 36.6]
Having regularly consumed sweets^c
No	27,758	54.4 [53.6, 55.3]	23,919	43.5 [42.6, 44.4]	51,677	48.8 [48.2, 49.5]	<.0001
Yes	21,404	45.5 [44.7, 46.2]	28,809	56.5 [55.6, 57.4]	50,213	51.2 [50.5, 51.8]

In parentheses: 95% confidence interval (CI).

Chi-squared test is used to compare the risk behavior distribution by sex.

Having regularly consumed: five or more times per week.

Figure 1 shows the Venn diagram with the prevalence of risk behaviors in female and male adolescents, victims and nonvictims of family violence. The intersection between involvement in fights, nonuse of seat belts and/or helmets, smoking and/or alcohol and drug use and inadequate food consumption was more frequent in adolescent victims of violence than nonvictims of violence. The co-occurrence of the four risk behaviors analyzed was higher among both male and female adolescents, who were victims of family violence than nonvictims. The proportion of adolescents with none of the health risk behaviors analyzed was higher in those who did not experience family violence, regardless of sex, being 10% in male and 8% in female adolescents.

Most of the risk behaviors were associated with each other (Table 2). Involvement in fights was strongly associated with substance use, among both boys (odds ratio [OR] = 2.29, 95% CI = [1.83, 2.88]) and girls (OR = 2.55, 95% CI = [2.11, 3.08]). Family violence was associated with the adoption of risk behaviors, regardless of sex. This association was stronger as the number of risk behaviors adopted increased. The chance of engaging in one risk behavior was 1.32 (95% CI = [0.88, 1.98]) and 1.24 (95% CI = [0.90, 1.72]) higher for boys and girls, respectively, who had suffered family violence. This increased to 7.76 (95% CI = [5.33, 11.29]) and 7.28 (95% CI = [5.20, 10.20]) when considering engagement in four risk behaviors (Table 3).

Table 2.

Association Between Risk Behaviors for Being Victims of Family Violence Among Brazilian Adolescents by Sex — Brazil, 2015.

Behaviors	Involvement in Fights		Not Wearing Seat belts and Helmets		Substance Use		Inadequate Food Consumption
Behaviors	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Boys
Involvement in fights	—	—	1.78	[1.27, 2.51]	2.29	[1.83, 2.88]	1.33	[1.06, 1.66]
Not wearing seat belts and helmets	1.78	[1.27, 2.51]	—	—	1.76	[1.24, 2.49]	1.38	[1.01, 1.88]
Substance use^a	2.29	[1.83, 2.88]	1.76	[1.24, 2.49]	—	—	1.24	[1.00, 1.55]
Inadequate food consumption	1.33	[1.06, 1.66]	1.38	[1.01, 1.88]	1.24	[1.00, 1.55]	—	—
Girls
Involvement in fights	—	—	1.27	[0.95, 1.69]	2.55	[2.11, 3.08]	1.54	[1.24, 1.89]
Not wearing seat belts and helmets	1.27	[0.95, 1.69]	—	—	1.41	[1.09, 1.81]	1.53	[1.13, 2.08]
Substance use	2.55	[2.11, 3.08]	1.41	[1.09, 1.81]	—	—	1.75	[1.44, 2.13]
Inadequate food consumption	1.54	[1.24, 1.89]	1.53	[1.13, 2.08]	1.75	[1.44, 2.13]	—	—

Note. Analyses adjusted for demographic, socioeconomic, and family context variables (age, skin color/race, mother’s educational level, type of school, living with the mother, and living with the father). OR = odds ratio; CI = confidence interval.

Substance use: alcohol, drugs, and tobacco.

Table 3.

Association Between Family Violence Against Adolescents and Risk Behaviors by Sex — Brazil, 2015.

	One Risk Behaviors		Two Risk Behaviors		Three Risk Behaviors		Four Risk Behaviors
	Crude OR (95% CI)	Adjust OR (95% CI)	Crude OR(95% CI)	Adjust OR (95% CI)	Crude OR (95% CI)	Adjust OR (95% CI)	Crude OR (95% CI)	Adjust OR(95% CI)
Boys	1.54 [1.10, 2.18]	1.32 [0.88, 1.98]	2.57 [1.87, 3.56]	2.36 [1.61, 3.46]	5.54 [3.74, 7.12]	4.48 [3.04, 6.62]	8.71 [6.27, 12.01]	7.76 [5.33, 11.29]
Girls	1.38 [1.04, 1.83]	1.24 [0.90, 1.72]	2.06 [1.58, 2.69]	1.88 [1.39, 2.54]	3.40 [2.58, 4.48]	3.21 [2.35, 4.39]	8.15 [6.08, 10.95]	7.28 [5.20, 10.20]

Discussion

This study found that family violence against adolescents is more strongly associated with adolescent engagement in four risk behaviors, than with only one or two risk behaviors. This result is in line with the literature (Anda et al., 2010; Felitti et al., 1998; Flaherty et al., 2013; Hughes et al., 2017) that found a strong relationship between the number of ACE, such as child abuse, and the number of risk behaviors and health problems, such as alcoholism, drug abuse, smoking, sexual risk taking, and obesity. All of these behaviors are important risk factors for adult mortality. Particularly in Brazil, Zappe and Dell’Aglio (2016) noted that family violence was significantly associated with a high level of engagement in risk behaviors (substance use, risk sexual behavior, antisocial and suicidal behaviors).

The mechanisms for adopting these risk behaviors can be understood based on the context in which adolescents are inserted, such as the experience of family violence (Feijó & Oliveira, 2001). Social learning theory suggests that children and adolescents who are victims of family violence learn that violence is an acceptable way to solve problems and begin to reproduce aggressive behaviors in other social relationships (Cecconello, De Antoni, & Koller, 2003). Other health risk behaviors, such as substance use and inadequate food consumption, may be related to family violence as they are often coping devices for the psychological consequences of abuse experiences (Felitti et al., 1998).

The relationship between family violence, substance use, and adoption of violent behaviors in adolescence has been corroborated in several studies. Tonmyr Thornton, Draca, and Wekerle (2010) reviewed the literature and found an association between various types of maltreatment, including physical abuse, and nicotine, alcohol and drug use among adolescents in community and school samples. There are also literature reviews showing that exposure to family violence is a risk factor for being a bully and for violent behavior and delinquency in adolescence (Álvarez-García, García, & Núñez, 2015; Trickett, Negriff, Ji, & Peckins, 2011).

However, nonuse of seat belts and helmets and inadequate food consumption have not been studied (Foo, 2015; Norman et al., 2012). Although the focus of this article is not on the relationship of physical abuse with any particular risk behavior but with the co-occurrence of these behaviors, this is noteworthy and should be further explored by future studies. In particular, further knowledge on the association of physical abuse and consumption of unhealthy food can help better understand the relation with overweight and obesity. Moreover, a closer look at eating habits could enhance the approach of considering the role of family context in the nutritional condition of adolescents, bearing in mind that inadequate food consumption not only affects weight but can also be linked to other health problems.

Studies in different countries have observed that the adoption of risk behaviors differs between sexes, with boys adopting more aggressive behaviors (Adriano et al., 2009; Azeredo, Levy, Peres, Menezes, & Araya, 2016; Centers for Disease Control and Prevention [CDC], 2016; Inchley et al., 2016; Kann et al., 2015; Malta et al., 2014), which corroborates the results found in the present study. A possible explanation for this is the greater social acceptance of violent behaviors in males (Adriano et al., 2009; Baxendale, Cross, & Johnston, 2012).

The strong association between involvement in fights and substance use found in our study corroborates the findings of previous research on alcohol and drug abuse and violence. Andrade et al. (2012) found an association of alcohol and illegal drugs use with involvement in physical violence, and a heightened effect of the combined consumption of alcohol and other drugs among adolescents aged 13 to 15 years (Andrade et al., 2012). Chalub and Telles (2006), Hernandez-Avila et al. (2000), and Dawkins (1997) verified a relationship between alcohol use, other drugs and criminality.

Also noteworthy is the high prevalence of physical family violence in the 30 days prior to the interview found in this study. Similar (Laranjeira, Madruga, Viana, Pinsky, & Mitsuhiro, 2014) and even higher (Waiselfiz, 2012) results were observed in studies among the Brazilian population. In view of the frequent co-occurrence of different types of violence (abuse, neglect, witnessing of domestic violence) during childhood and adolescence and their negative repercussions in the short, medium, and long term, early detection and development of actions for reducing the consequent health risk behaviors are fundamental to the full development of adolescents.

Some limitations of this study need to be considered. The first is its cross-sectional design, which prevents a temporal relationship between family abuse and co-occurrence of risk behaviors. However, although family violence does not necessarily precede the adoption of multiple risk behaviors, recognizing that victims are vulnerable to other health risk factors is relevant to public health. Another limitation is that the identification of both family violence and health risk behaviors was based on single questions, which could result in information bias (non-differential measurement error) with underestimation of the associations found.

Despite the limitations, our results are important not only for Brazil, but also for the broader literature in other middle-income countries. The Lancet commission on adolescent health and well-being recently classified Brazil and other 27 countries, mainly from Latin America and Central Asia, in the “injury excess” group according to burden of disease. This group is characterized by high, persistent levels of unintentional injury or violence and high adolescent birth rates (Patton et al., 2016). Despite the relevance of this subject in countries that represent 12% of global population, co-ocurrence of risk behaviors among victims of violence is under explored in these settings (Hughes et al., 2017), and our results contribute to filling an important gap in the literature.

In addition, these analyses have important implications for public health because they enable assessment of the prevalence of co-occurrence of health risk behaviors in a clear and simple way. Such information is essential for planning and implementation of disease prevention strategies based on the reduction of such behaviors. Understanding that risk behaviors do not occur in isolation, which behaviors co-occur, and the prevalence of their co-occurrence in the general population and among vulnerable groups (e.g., victims of family violence) may help in the design of interventions, both in primary health care and in schools. Finally, designing a political agenda to promote adolescent health should be a priority as it has potential to bring benefits into present and future adult life and to the next generation of children (Patton et al., 2016).

Future research is needed to explore the temporal relationship between family abuse and the adoption of multiple risk behaviors. New studies would also be helpful to investigate the role of other forms of family violence beyond physical abuse, such as neglect, emotional, and sexual abuse. In addition, prevention and intervention strategies for adoption of risk behaviors in adolescence that take into account family violence experiences should be proposed and evaluated in forthcoming studies.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Emanuele Souza Marques

Author Biographies

Emanuele Souza Marques is a professor in the Department of Epidemiology at the Rio de Janeiro State University, holds a doctoral degree, and is a registered clinical and research psychologist. His areas of expertise include epidemiology, family violence, household food security, and nutritional epidemiology.

Catarina Machado Azeredo is a professor in the Department of Nutrition at Federal University of Uberlandia, holds a doctoral degree, and is a registered clinical and research psychologist. His areas of expertise include epidemiology, violence, bullying, adolescent, and nutritional epidemiology.

Aline Gaudard e Silva de Oliveira is a professor at Arthur Sá Earp Neto Faculty, holds a doctoral degree, and is a registered clinical and research psychologist. His areas of expertise include epidemiology, family violence, and nutritional epidemiology.

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