Prevalence of Violent Victimization and Associated Factors Among Psychiatric Outpatients

doi:10.21203/rs.3.rs-871138/v1

Background: Victimizations, coupled with the existing political and socioeconomic instability in East Africa, poses unbearable burden on people with mental illness.

Methods: Six hundred twenty nine psychiatric patients were interviewed by trained psychiatry clinicians consecutively to study prevalence, and associated factors of victimization by using interviewer administered standard international crime victim survey questions. Analysis was done by using SPSS version 20. Adjusted odds ratio with 95% confidence interval and p-value =<0.05 were used to declare the statistical significance.

Results: Lifetime and past year prevalence of victimization were 57.4% and 27.4% respectively. Majority of men were perpetrated by Strangers and acquaintances where as majority of women by near family members. In Binary Logistic Regression analysis: factors such as being female; history of psychiatric admission, suicidal attempt, previously cigarette smoking, khat chewing; criminal history and violent perpetration had significant association with victimization.

Conclusion: The study identified high prevalence of victimization on people with mental illness which is potential for the formation of stress strain reaction as well as violation of legal rights of that population. Cooperation between law enforcers and mental health clinicians is needed.

Victimization

Ethiopian Police University

Forensic Psychiatry

Specialize Hospital

People with severe mental illness (SMI) have unachieved needs towards the healthcare system and criminal justice system. They need a special legal protection and medical care. The unprotected legal rights leads them to be a victims of physical, sexual or property violence [1]. By the Ethiopian context, the legal system guarantees the rights of people with disabilities including people with mental illness. The law clearly stipulated their right to equal recognition before the law, access to justice, adequate standard of living and social protection, freedom from torture or cruel, inhuman or degrading treatment or punishment however, practices shows in the contrary [2, 3].

Minor assaults such as pushing and shoving that result in no physical harm; aggravated assaults including intentionally stabbed, punched, kicked, pushed, jostled; sexual injuries such as being raped or attempted to be raped and property crimes such as personal theft, robbery, vandalisms of properties and burglary with entry are commonly offending incidents among the society and among People with SMI too [5, 6], however People with SMI have been victim of crime more than general population[1, 7, 8]. Victimization Leads the development of higher distress [8], decreasing life satisfaction [9], precipitates, exacerbates, and perpetuates mental illness[10-12], damages fundamental rights of citizens[2], increases healthcare costs, service utilization and scarcity of hospital bed to the victim and the public at large[13].

Experimental and longitudinal Studies showed the association between stressful life events and change in brain structures [14] and high stress had an increased adjusted risk of developing metabolic syndrome and abnormal elevation of Triglyceride Cholesterol which is a risk factor for cardiovascular disease [15]. Another Italian study also identified the association between psychiatric symptoms and prolonged stress [16, 17].

Prevalence of victimization among People with mental disorder has been higher in low & middle income countries. In Africa from general population, it ranges from 34%-63% Mozambique 58%, Zambia 46%, Tanzania 63%, Nigeria 42%, Uganda 47%, Zimbabwe 63%, Lesotho 34%, Swaziland 63%, Botswana 34%, Namibia 48%, Egypt 36%, South Africa 48%, Tunisia 54% and in Ethiopia among people with mental disorder was 61% [7].

Previous studies had identified some of the factors that predispose to be a victim of violence in general population as well as in people with mental illness. In low and middle income countries, Poor socioeconomic status, immature legal system, political unrest and uneven distribution of wealth were identified [18, 19]. According to testimonies by eye witness, from areas where civil war was ongoing in Ethiopia; people with mental disorders are being killed as a result of suspecting them as spy of Government.Female by sex, homelessness [20], lifetime history of alcohol and other substance abuse[21], history of arrest, poorer social and occupational function, severity of mental illness [22] and young age at the onset of illness were factors that had association with victimization of people with mental illness [23, 24].

Victimization is a preventable, universally disseminated and affecting all humans everywhere, problem. Epidemiological study models like Crime Victim Surveys have been developed by criminologists to produce comprehensive, reliable, and timely information on magnitude, distribution and determinants of crimes among every segment of population. Survey results have been used to develop, manage, and evaluate criminal justice policies; crime reduction strategies; to forecast future developments and trends of crime; to facilitate research; to inform the public and to create and develop efficient, effective, and equitable administration of justice [11, 25, 26]

The aim of this study was to assess the prevalence of violent victimization, where it occurs, frequency of being a victim, victim’s relationship with perpetrator, and practice of reporting incidents and associated factors among people with severe mental disorders in a mental specialized Hospital in Ethiopia.

Study Area and Setting

The study was conducted at Amanuel Mental Specialized Hospital in Addis Ababa city, Ethiopia. It is a Tertiary Mental Health care center that renders comprehensive outpatient, inpatient and specialized psychiatry services such as neurology, old age, and rehabilitation from substance addiction. The hospital was organized by 8 case teams. Two of them were dedicated to serve patients with schizophrenia and other related psychotic disorders, bipolar and related disorder or depressive disorders that were the theme of this study by categorizing under severe mental illness.

Study Design and Period

The study was intended to describe the frequency and distribution of victimization by time, place and person so an institution based quantitative, Cross-sectional descriptive study design was chosen. Data were collected from May 16, 2018, to June 22, 2018.

Population

Source population

The source population was psychiatric patients who were attending treatment in Amanuel Mental Specialized Hospital outpatient departments.

Study population

The study population was psychiatric patients who were attending treatment in Amanuel Mental Specialized Hospital outpatient departments during the study period.

Inclusion and Exclusion Criteria

Psychiatric patients on follow up with full symptom remission, age greater than or equal to 18 years, who themselves appeared on the appointment date and who had two or more follow up dates were included. Patients with first visit and those who deemed to have difficulties in memory, concentration, and abnormal behavior at the time of the interview and those who suspected to provide irrelevant information were excluded as per the judgment of data collectors.

Sample Size Determination

The minimum sample size required for this study was determined by using single population proportion formulas with the assumption of 61% prevalence of victimization in Ethiopia (found from previous study [7], confidence level (Z)= 95%, margin of error (a)= 5%, precision (d)= 0.04 and 10% of the calculated sample size was added for the anticipated non- response rate as shown below

Participant selection and Sampling Technique

A total of 7045 patients with severe illness were attended during a one month data collection period. Among them 3475 were actual patients and the rest 3570 visits were by representative family members. From the 3475 actual patients two thousand seven hundred patients had at least one previous visit and 775 of the patients were first visit for the Hospital.

Participants were selected at waiting areas of Card room and physician office. Patients who were available at the time of calling and having at least one previous visit were guided to data collectors at card room and OPD for selection to be interviewed. A systematic sampling technique was employed for the selection of the sampling units from available participants. Every 3^rd patient, were requested for interview consecutively until the required sample size was reached. The first participant was selected from the first three patients by lottery method at each data collection sites.

As shown in Figure 1 below, 629 patients were selected from 2160 patients for the interview. Seven (1.1%) of them were excluded due to difficulties in memory, concentration or abnormal behavior at the time of the interview. Only 622 were eligible for the study. Of those eligible participants12 (1.93%) refused to be interviewed. Data was collected from 610 participants.

Variables and Measurement

Outcome variable

Victimization status was determined when participants respond at least one “yes” for questions that asked if they had suffered from Simple assault, aggravated assault, kidnapping, rape or attempted rape, attempted robbery, personal theft or vandalism of property. Standard International Crime Victim Survey (ICVS) questions and proposed Indicators of Violence questions were used to explore the occurrence of those sufferings within the participant’s life. The ICVS questions were designed to assess circumstances surrounding the incident such as time frame for the incident, (life time or previous 12 months), frequency of incidence, the offender who performed the incident, the place where the incident was happened, whether the sufferer reported and for whom reported the incident; and how much she/he satisfied by the response of reported body, likelihoods of future victimization and perception of safety and security [25-27].

Certain modifications were done to make the questions acceptable, understandable by people with mental disorder and relevant to time frame of their mental illness status. For example, under “Perceptions of Safety and Violence” participants had found in difficult to forecast future likelihood of being a victim in the next 12 months and the feeling of safety while they are walking down the street after dark in the area where they live. So, those questions were omitted during the actual data collection. “Life time prevalence” was modified into “since you become mentally ill” to exclude incidents of victimization before the illness (telescoping). The phrase “in health care institution” was added under place of incidence and “health professional” under perpetrator of victimization to explore the presence of violent acts against people with mental disorders in the health care settings by heath care professional.

Predictor Variables

Demographic related variables such as participants’ sex, current age, residence, marital status, religious affiliations, educational level, occupational status and housing ownership were assessedin order to determine their association with victimization. Mental illness related variables such as type of Mental illness, Number of Hospital Admissions, duration of mental illness and age at first onset of mental illness were assessed. And behavior related variables such as current & life time use of alcoholic beverages; chewing khat (a green leaf containing amphetamine like substance); smocking cigarette; violent acts; criminal history and suicidal behaviors were also assessed.

Data collectors directly diagnosed and/or searched medical records to ascertain type of Mental illness. Participants who started treatment with antipsychotic, antidepressant and or mood stabilizer at least one month prior to data collection were considered as people with severe mental disorder. And Substance use was assessed using questions adapted from the Alcohol, Smoking and Substance Involvement Screening Test” questions [28]. Participants were considered violent perpetrators if they had caused property damage, physical injury or sexual assaults [29] and criminal history was assessed by asking if they have had accused by police, arrested or jailed. Psychological distress following suffering from violence was assessed by asking the following question adapted from Greek study. “How much did this incident affect your mood or change your life? And they were requested to rate their feeling (mood) as High, Moderate or Low [8]. Suicidal behavior such as suicidal thought, plan and attempt were assessed by the following questions adapted from “Screening Tool for Assessing Risk of Suicide (STARS) [30]. Have you thought about suicide/ending your life? Have you ever made a plan in the past? Have you tried to end your life?

Data Collection Procedure

Data was collected by treating psychiatry clinicians by using semi structured interviewer administered questionnaire at card room and examination room. Questions were read and explained to every participant after their consent was obtained. Data collectors were strictly following psychiatry risk assessment procedure throughout the interview and they had recorded all responses provided by each participant.

All questions were pretested in 29 patients at Amanuel Mental Specialized Hospital one week prior to actual data collection. One day training was given to data collectors about the questions and the whole purpose of the research work. Overall activities during data collection were supervised by senior psychiatry professional with Master’s Degree in Integrated Clinical and Community Mental health and principal investigator.

Method of Data Analysis

Data were collected from 610 participants and analyzed using SPSS statistical packages version 20 for Windows. Descriptive analyses were carried out to explore the socio-demographic characteristics of participants and prevalence of violent victimization. A new data set was created from the main data set based on participants’ victimization status to examine circumstances surrounding violent incidents. Multi variable Binary logistic regression model was used to examine associated factors while odds ratio was used to measure the strength of the association between overall victimization and independent variables and 95%CI and p-value= 0.05 test were taken to determine the significance of the association.

Socio-Demographic Characteristics of Participants

From a total of 622 eligible participants 610 (98%) had responded to the questionnaire. However, there are number of missing values at individual question level. The mean age of participants was 36 (±10.8) years and 59.3% were male by sex. Based on Occupation 45.8% were jobless and 36.8% had income through employment, trade or farming. Nearly 20% joined tertiary level education and majority (58.9%) were “never married” based on their marital status. See table 1.

Table 1: Socio-demographic and victimization status distribution of participants

Variables	Category	Number	Percent (%)
Sex	Male	362	59.3
Sex	Female	248	40.7
Residence	Urban	477	78.3
Residence	Rural	132	21.7
Regional State	Addis Ababa	306	50.2
	Oromia	171	28.0
	Southern Ethiopia	79	13.0
	Amhara	44	7.2
	Other Regions	10	1.6
Religion	Orthodox	328	53.8
	Muslim	179	29.3
	Protestant	93	15.2
	Others	10	1.6
Occupation	Jobless	279	45.8
	Daily Worker & House Maid	82	13.5
	Student	24	3.9
	Employee, Merchant Or Farmer	224	36.8
Education	No Formal Education	84	13.8
	Elementary	194	32.0
	Secondary	209	34.4
	Post-Secondary	120	19.8
Marital Status	Never Married	359	58.9
	Married	156	25.6
	Separated/Divorced/ Widowed	94	15.41
Housing Arrangement	Homeless (Cohabit Or Street)	307	50.3
	In Institution or Employer House	14	2.3
	Has Own House	289	47.4
Note: *the inconsistency in number of respondents between items was due to missing value*

Prevalence of Victimization

By aggregating all violent incidents into a new variable [any victimization] the overall score of life time and previous year victimization were 350(57.4%) and 168 (27.5%) respectively. Table 2 below presents the number and proportions of patients exposed to victimization resulted from different categories of violent acts. Of the 350 victimized, 201; (33%) suffered from property crimes such as attempted or complete theft of Property and vandalism of property other than car vandalism; 231 (37.9%) inflicted by physical violence such as being kidnapped, kicked or bitten with stick, severely injured those resulted bone fracture tooth loss and 57 (9.3%) suffered from sexual violence such as rape.

Table 2: Prevalence of violent incidents by category and time frame distribution

Victimization status by category		Time Frame
Victimization status by category		12 month		Illness (Life) time
Any victimization		Number	%	Number	%
	Yes	168	27.5	350	57.4
	No	442	72.5	260	42.6
Any property violence	Yes	92	15.1	201	33.0
Any property violence	No	518	84.9	409	67.0
physical violence (Serious + minor injury)	Yes	116	19.0	231	37.9
physical violence (Serious + minor injury)	No	494	81	379	62.1
Robbery	Yes	22	3.6	42	6.9
Robbery	No	588	96.4	568	93.1
Vandalism of property	Yes	14	2.3	24	3.9
Vandalism of property	No	596	97.7	586	96.1
Property stolen	Yes	76	12.5%	178	29.2
Property stolen	No	534	87.5	432	70.8
Minor Physical injury	Yes	107	17.5	213	34.9
Minor Physical injury	No	503	82.5	397	65.1
Seriously physical injury	Yes	25	4.1%	47	7.7
Seriously physical injury	No	585	95.9	563	92.3
Kidnap	Yes	7	1.1%	11	1.8
Kidnap	No	603	98.9	599	98.2
Rape	yes	23	3.8	57	9.3
Rape	No	587	96.2	553	90.7

Life time prevalence of victimization was higher in comparison to two USA studies 25% and35.0% [1, 31]; three UK studies 40%, 23% and 16% [23, 32, 33]; a Dutch multisite epidemiological survey 47% [34]; an Australian study 17.9% [24] and a Taiwan study 16.8% [21]. It was also higher compared to studies done by using designs other than cross sectional [22, 35,36]. But it was lower than two remote studies done using samples from inpatients settings [11, 37]; and a study done in rural areas of Ethiopia (61%) [7]. The difference could be emanated from differences in definition of crime, sample size, area & settings of data collection and measurement tool. Studies shows that People with little or no close relation may motivate to beat, insult, cheat, harass, degrade, or sexually abuses due to wrong perception about mental illness and perceiving people with mental illness as dangerous, worthless and numb[11] .

Circumstances Surrounding Violent Incidents

Participants with positive history of any form of victimization were selected by using ²select” menu and a filter variable from main data set in Spss data sheet to analyze circumstances surrounding violent events; a data set containing 350 participants was created. Missing value analysis was done to evaluate the participants’ response to those specific questions. The smallest and highest percentage of missing value was observed on variable Psychological disturbance following the incident (6.3%) and satisfaction by the response of incident reported body (63.1%) respectively. Female participants reported their perpetrator, place of incident and frequency of violent incident more than male, whereas male have reported violent Incidents to relevant body and satisfied by the response of report receiving body more than female, see table 3.

Table 3: Participants’ response to questions related to circumstance surrounding violent incidents

Circumstances	Participant’s action on questions	Total n (%)	Sex
Circumstances	Participant’s action on questions	Total n (%)	Male n(%)	Female n(%)
Perpetrator	Responded	319 (91.1)	181(88.3)	138 (95.2)
Perpetrator	Missing	31(8.9)	11.7	4.8
Place of incident	Responded	323(92.3)	185(90.2)	138(95.2)
Place of incident	Missing	27(7.7)	9.8	4.8
Frequency of incidents	Responded	325(92.9)	85(90.2)	140(96.6)
Frequency of incidents	Missing	25 (7.1)	9.8	3.4
Incident report to relevant body	Responded	136(38.9)	81(39.5)	55(37.9)
Incident report to relevant body	Missing	214 (61.1)	60.5	62.1
Satisfaction by the response of reported body	Responded	129(36.9)	78(38)	51(35.2)
Satisfaction by the response of reported body	Missing	221(63.1)	62.0	64.8
Psychological disturbance following the incident	Responded	328 (93.7)	190(92.7)	138(95.2)
Psychological disturbance following the incident	Missing	22(6.3)	7.3	(4.8)

Out of 350 victimized SMI patients 119(34%) had suffered from at least two categories of violent incidents, 191(56%) of them had victimized at least two times in their illness time, 32.6% were perpetrated at their home, 31.14% were victimized by their near family and 69.9% reported high psychological distress during the incident. In most cultures of Ethiopia, beating with stick, slapping, insulting and degrading in the form of punishment by parents and elder siblings towards minors are normative (not be deemed as violence). By this scenario patients who were victimized by their family members hided their sufferings of violent acts during data collection.

The study also revealed 1.8% and 1.71% of violent acts were experienced in health care institution and place of worship respectively. It shouldn’t be over-look since those places expected to be peaceful and safe. Of those violently victimized participants 38.6% reported their case to police or other relevant body which is lower compared to England and Wallace study (45%). The lower rate of reporting violent incidents was observed. in the current study might be due to incomparable socio economic status of Ethiopia and England which can affect quality of police service in terms of accessibility and infrastructure and this might also be due to low sample size in England and Wallace (350) compared to the current study (610)[41].

Table 4: circumstances surrounding violent incident by sex association with sex difference

Circumstances		Total		Sex		Sig.	OR		95% C.I. for OR
Circumstances		N =350	%	Male	Female	Sig.	OR		Lower	Upper
No of violent acts by category	Three categories	16	4.6	3	13	0.03	6.530		1.195	35.674
	Two categories	103	29.4	60	43	0.61	1.260		.513	3.097
	Only one category	231	66.0	142	89		Reference
Frequency of incident	3 times &above	125	35.7	73	52	0.15	0.466		0.164	1.323
	Two times	66	18.9	45	21	0.05	0.314		.098	1.012
	Once	159	45.4	87	72		Reference
Place of incidence	At home	114	32.6	40	74	0.00	8.309		2.852	24.207
	Work site & school	43	12.3	32	11	0.34	1.776		0.548	5.753
	Health facility, worship	11	3.1	8	3	0.39	2.831		.268	29.923
	On travel	155	44.3	105	50		Reference
Victim’s relation with perpetrator	Family member	109	31.1	43	66	0.003	3.18		1.48	6.83
	Health worker	18	5.1	11	7	0.272	2.146		0.550	8.380
	Stranger & acquaintance	192	54.9	127	65	Reference Adjusted for female
	Health worker	18	5.1	11	7	0.037		3.070	1.071		8.795
	Stranger & acquaintance	192	54.9	127	65	0.00		2.999	1.843		4.879
	Family member	109	31.1	43	66	Reference Adjusted for male
Reporting violent incident	Not reported	188	53.7	106	82	0.14	3.133		0.684	14.357
	To other bodies	33	9.4	17	16	0.34	1.666		0.586	4.737
	To police	102	29.1	63	39		Reference
Satisfaction by reportedbody	Satisfied	58	16.6	32	26
	Not satisfied	59	16.9	39	20
	Don’t know	29	8.3	16	13
Psychological distress	Highly distressed	228		128	100	0.68	1.272		0.406	3.984
	Moderate	48		28	20	0.93	1.067		0.24	4.801
	Low distress	52		34	18		Reference
Note: *categories of violent incidents- (1) against property (robbery, theft, and vandalism) (2) sexual: rape or attempted rape (3) physical violence: simple assault or rigorous assault. Eg. 3 categories = property + sexual+ physical violence, 2 categories= physical + sexual or against property

Factors Associated with victimization

In Bivariate and multivariable binary logistic regression analysis: factors such as being female, age at the onset of mental illness 26 years and below; previously hospitalized, suicidal attempt, substance use such as alcohol, cigarette and or khat (a green leaf containing amphetamine like substance); criminal history and history of perpetrating violence had significant association with any victimization compared to their counter parts such as; male sex, first onset of mental illness 36 years and above, no hospital admission, no suicidal attempt, no history of using alcohol ,cigarette or khat, having no history of violent act against others, and no police record see table 5.

Table:5 shows that Participants who had accused by police, arrested or jailed were nearly three times more likely than those no police record to have victimized with any category of offences (AOR: 2.59095%CI=1.493, 4.494). Those individuals who smoked cigarette but never chewed khat or drink alcohol had 4.277 times (AOR: 4.27795%CI= 1.213, 15.085) and those who were Chewing Khat at any situation(khat alone or associated with drinking and smoking, called “chebsi” in Ethiopia”) 1.881 times AOR:1.88195%CI= 1.144, 3.090) victimized than who never used any substances in their life But there was no significant relation between victimization and life time use of smoking cigarette &alcohol (p=.310), alcohol only and illegal drugs use.

The association between substance use and victimization has been identified by different researchers and different research designs. For example, In USA among 99 women with severe mental illness, substance abuse had contributed a unique predictive power(b=0.25) [46]. In another study by the same author, recent victimization among women and men with severe mental illness who had comorbid alcohol and drug use disorders was nearly 3 times more than without[31]. In Australian study, victimization amongst people with psychosis was nearly 3 times more among substance users than non-users [24]. In a Taiwan study victimization among patients with history of alcohol abuse was almost 4 times more than no history of alcohol use [21] and in Finland among schizophrenia patients the likelihood of victimization among those who used alcohol was 5.44 times more than non-users[22].Suicidal attempt was 2.126 times more among victimized patients than non-victimized patients AOR: 2.126 95%CI= (1.366, 3.311).

Table 5: Multi Variable Binary Logistic Regression Analysis to identify Factors Associated with any category of victimization

Variable	Category	N	sig.	OR (95%C.I. for OR)	Sig.	AOR	95% C.I. for AOR
Variable	Category	N	sig.	OR (95%C.I. for OR)	Sig.	AOR	Lower	Upper
Illness (Life) time substance use	Chewed Khat at any situation	136	.000	2.103(1.387, 3.19)	0.013	1.881	1.144	3.090
	Cigarette only	19	.024	3.65(1.19, 11.20)	0.024	4.277	1.213	15.085
	Alcoholic only	70	.023	1.864(1.092, 3.18)	0.050	1.826	0.999	3.340
	Alcohol+ cigarette	4	.356	2.92(.301, 28.314)	0.310	3.610	0.303	43.072
	Illegal drugs	22	.949	.973 (.411, 2.300)	0.422	0.678	0.262	1.751
	Never used	359				Reference
Occupation	Jobless	280	.096	.739(.518, 1.055)	0.031	0.610	0.389		0.956
	Daily work	82	.911	1.030(.614,1.729)	0.453	0.797	0.441		1.440
	Student	24	.316	1.601(.638,4.017)	0.670	1.253	0.444		3.534
	Permanent income	224	.002	1.517	0.000	Reference
Housing arrangement	Homeless & dependent	307	.522	1.112(.804, 1.538)	0.477	1.168	0.761		1.792
	In Institution or employer house	14	.255	1.988(.609, 6.485)	0.464	1.626	0.443		5.972
	Privately own	289	.053	1.258		Reference
Onset at age of illness	26 years and below	379	.000	2.51(1.518, 4.133)	0.012	2.102	1.175		3.762
	26-35 years	154	.078	1.646(.946, 2.867)	0.288	1.394	0.756		2.570
	36 years and above	77	.089	.674		Reference
Inpatient care	Impatient care	236	.000	2.101(1.494, 2.96)	0.003	2.025	1.262		3.250
Inpatient care	No admission	374	.836	1.022
Criminal history	Yes	144	.000	3.70 (2.382, 5.758)	0.001	2.590	1.493		4.494
Criminal history	No	466	.781	1.026		Reference
Violent behavior	Yes	187	.000	2.80(1.922, 4.089)	0.052	1.595	.996		2.554
Violent behavior	No	423	.961	1.005	0.000	Reference
Suicidal Attempt	Yes	153	.000	2.622(1.75, 3.93 )	0.001	2.126	1.366		3.311
Suicidal Attempt	No	457	.427	1.077
Sex	Female	248	.652	1.078(777, 1.495	0.003	1.871	1.245		2.811
Sex	Male	362	.012	1.306)		Reference
Duration	Duration of illness		.734	.997(.978, 1.016)		0.329	0.965		1.012
Hospitalizations	Number of hospital admissions					0.752	0.849		1.125

Women were 1.871 times more likely victimized than male AOR: 1.871 95%CI= 1.245, 2.811) (table 5). On a logistic regression analysis of separated victimized patients, Women were 6.53 times more likely than men to experience multiple types of violent acts such as simple to rigorous assaults, sexual assault and property violence (AOR: 6.53095%CI=1.195, 35.674) experiences violent traumas at their homeOR (8.309: 95%CI 2.52, 24.207) and perpetrated by their near family membersOR (3.177:95%CI= 1.478, 6.832) (See table 4).On the other hand male were nearly thiree times more likely victimized than female OR: 2.99995%CI= 1.843, 4.879) see table 4.

Scientific information about prevalence of victimization, place of incident, relationship with the offender, frequency and concurrence of violent incidents, whether the victim reported crimes to police and contributing factors for occurrence of victimization; are vital to prevent crimes as well as mental health sequel resulted from violent traumas. It is also vital in planning rehabilitation program to crime victims. Victimization creates adverse emotional reactions which are potential to worsening of psychiatric symptoms, decrease life satisfaction which leads to poor health outcomes, poor physical and psychosocial functioning, those can affect cognition and judgment [50].

Impairments in areas of cognition, emotion regulation, behavioral control, and judgment and communication ability might lead them to perpetrate violence and engagement in criminal activities that might result in reverse attacks in response to their actions. Police officers might cause victimization in response to disagreement during seizure, search or interrogation whenever the police have little awareness about mental illness [43, 44]. The association between patients with criminal history and being a victim might be due to their mental illness status. A study in South Africa people with mental illness had more contact with police than non-mental illness [42].

Previous researchers also noted that people with mental illness use substances more than non-mentally ill and associated with victimization. Psychoactive substance use coupled with mental illness might led them to maladaptive behaviors such as begging, deceiving or steeling and increase the risk of victimization or decreasing one’s ability to perceive risk or avoid victimization as a result of impaired decision making. Some of the reasons mentioned were using a substance as a coping mechanism or a self-medication for their physical or emotional discomfort and pain that result from mental illness or traumatic life events, to relieve feelings of intense cravings for an addictive substance. [43, 45].

Suicide has been a major public health problem which is mainly associated with mental illness [47, 48]. Victimization fuels up suicidal behavior due to two reasons. Victimization creates adverse emotional reactions which are potential to suicide by worsening psychiatric symptoms, decrease life satisfaction which leads to poor health outcomes, poor physical and psychosocial functioning, those can affect cognition and judgment [50]. On the other hand, those who are violent towards themselves may also be violent towards to others. In this scenario, they may be victimized in response to their action [4].

Reporting violent incidents to the police or other concerned bodies such as religious leaders, elders, family head, and governmental offices or women associations have been universally accepted normsin order to get relief from psychological pain resulted from victimization. On the other hand, failing to report sufferings resulted from violent traumas was high (56.6%) in the current study. Some of the reasons for failure to report might be to protect the perpetrator, reluctance to discuss unpleasant memories and fear of future violence [32, 38]. Other factors for non-reporting could also be fear of a negative response from the police; a blame for causing the incident, not being believed or taken seriously, feelings of shame or embarrassment or feeling too overwhelmed, distressed or being confused in the aftermath of the crime [26, 41].

Limitations

The research is limited by its cross-sectional design which restricts the researcher to indicate direction of causal relationship. The study measured only contact (personal) crimes experienced by participants. But there are other categories of offenses such as burglary, consumer fraud, corruption related and emotional abuses by those the respondents of this study might be Suffered.

The study identified higher prevalence of victimization which indicates the presence of unmated needs of legal protection among persons with mental disorders. The main factors associated with victimization were being female, young age, life time cigarette smoking, chewing khat, taking alcoholic drinks, previous hospitalization, history of perpetration of violence, engagement in criminal activity and suicidal attempt those are potential to precipitate & perpetuate mental illness to patient, pose burden on police activities and mental healthcare facilities. Systematic Collaborative relationship is recommended between those public bodies. Nationwide crime victim surveys are recommended to compare victimization rate among special population with general population as well as to use it as a warning alarm to prevent crimes.

AOR: Adjusted odds ratio; CI: Confidence Interval; OR: Odds ratio; SMI: Severe Mental Illness; UK: United Kingdom; USA: United States of America; WHO: World Health Organization

Ethics approval and consent to participate

Ethical clearance was obtained from Research approval Committee of Amanuel Mental Specialized Hospital jointly with ethical review board of the University of Gondar. Informed consent was obtained from all study participants except for the illiterate participants, after brief explanation about the purpose of the study and content of the question. Legally authorized representatives 'LARs’ of illiterate participants provided informed consent for the study' and all methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

No competing interest

Funding

This research was funded by Gondar University and Amanuel Mental Specialized Hospital as Post Graduate Student Research Grant Award. The funder had no any role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. The views expressed in this publication are the responsibility of authors and do not necessarily reflect the views of the university and or Amanuel Mental Specialized Hospital.

Availability of data and materials

All data generated or analyzed during this study are included in this published article are available from the corresponding author [initials] on request.

Authors' contributions

SE was the primary investigator of this study. SE was accountable for the study design, conceptualization and practical implementation of the study. SE performed the statistical analysis. HM supervised research development process commented on the draft and finally approved. All authors have read and approved the final manuscript.

Acknowledgements

I would like to thank University of Gondar College of Medicine and Health Science Department of Psychiatry and Amanuel Mental Specialized Hospital for arranging opportunity to carry out this research. I would also thank Ethiopian Federal Police health service for the chance gave me to join graduate school and Ethiopian Police University research institute for the chance given me to present on National Law Enforcement Symposium. I would like to thank my advisor HaregewoinMulat. And finally I would like to thank data collectors and participants for their participation

Authors' information (optional)

Solomon Eshete, (BSc in General public health, Msc in Integrated Clinical and Community Mental Health, member of Ethiopian Federal Police) and as Mscin Clinical and community mental health.

Teplin et al.: Crime Victimization in Adults With Severe Mental Illness; Comparison With the National Crime Victimization Survey.Arch Gen Psychiatry 2005, 62 (8), 911-921.
Ethiopian Constitution: Prohibition against Inhuman Treatment. Article 18 1995, 1.
Mental Health Strategy: National Mental Health Strategy In. Edited by health Emo, vol. 2012/13 - 2015/16. Addis Ababa; 2011.
Krug et. al.: The world report on violence and health. PUBLIC HEALTH 2002, 360:1083-1088.
Rosenberg et al.: Interpersonal Violence. Disease Control Priorities in Developing Countries 2004, Chapter 40:754-770.
Deyessa et al: Intimate partner violence and depression among women in rural Ethiopia: a cross-sectional study. BioMedcentral 2009, 1745(0179):5-8.
Tsigebrhan R.: Violence and violent victimization in people with severe mental illness in a rural low-income country setting: a comparative cross-sectional community study. Schizophrenia Research 2013, 152 (1):275-282.
Katsikidou et al.: Victimization of the severely mentally ill in Greece: The extent of the problem. International Journal of Social Psychiatry 2012, 59(7):706 -715.
Layard et al.: Mental Illness and Unhappiness, Center for Economic Performance. CEP Discussion Paper 2013(1239).
Fittzpatrick et al.: dangerous places: expossure to violence and its mental health consequences for the homeless. American Journal of orthopsychiatry 1999, 69(4):438-447.
Kilpatrick and Acierno: Mental Health Needs of Crime Victims: Epidemiology and Outcomes Journal of Traumatic Stress 2003, 16(2):119-132.
Lurigio: People With Serious Mental Illness in the Criminal Justice System: Causes, Consequences, and Correctives. The Prison Journal Supplement to 91(3) 2011:665 -865.
Hanson et al.: The Impact of Crime Victimization on Quality of Life. J Trauma Stress 2010, 23 (2):189-197.
Papagni et al.: Effects of stressful life events on human brain structure: A longitudinal voxelbased morphometry study. Informa Healthcare USA, Inc 2011, 14(2):227–232.
Garbarino S MN: Work Stress and Metabolic Syndrome in Police Officers. A Prospective Study. PLoS ONE 2015
Garbarino S. Cuomo G. Chiorri C ea: Association of work-related stress with mental health problems in a special police force unit. BMJ Open 2013, 3.
Gaines and Jermier: Emotional Exhaustion In High Stress Organizations. Academy of Management Journal 1983, 26(4):567-586.
Volavka J.: History of violent behaviour and schizophrenia in different cultures: Analyses based on the WHO study on Determinants of Outcome of Severe Mental Disorders. British Journal of Psychiatry 1997, 171(1):9-14.
Coll CVN Ewerling F. García- Moreno c. et al.: ntimate partner violence in 46 lowincome and middle- income countries: an appraisal of the most vulnerable groups of women using national health surveys. BMJ Global Health 2019, 2020.
Lam and Rosenheck: The effect of victimization on clinical outcomes of homeless persons with serious mental illness. Psychiatric Services 1998, 49(5):678-683.
Hsu et al: Crime victimization of persons with severe mental illness in Taiwan. Australian and New Zealand Journal of Psychiatry 2009, 43:460 466.
Honkonen et al.: Violent victimization in schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2004, 39:606-612
Dean et al: Predictors of violent victimization amongst those with psychosis. . . Acta Psychiatr Scand 2007 116:345-353.
Chapple et al: Correlates of victimisation amongst people with psychosis. Soc Psychiatry Psychiatr Epidemiol 2004, 39 836-840.
Kesteren & Frate: The ICVS in the developing world. International Journal of Comparative Criminology 2002, 2(1): 57-76.
Naudé PaL: Experiences of Crime in Thirteen African Countries: Results from the International Crime Victim Survey. Electronic Publication, Turin, UNICRI-UNODC 2006.
Manual on Victimization surveys: Manual on Victimization surveys. In. Edited by Force UNT. Geneva: United Nations Office on Drugs & Crime and United Nations Economic Commission for Europe; 2010.
WHO ASSIST Working Group: The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction 2002, 97(1183-1194).
Appelbaum. Robbins and Roth: Dimensional Approach to Delusions: Comparison Across Types and Diagnoses. Am J Psychiatry 1999, 156:1938-1943.
Hawgood & De Leo: Screening Tool for Assessing Risk of Suicide STARS. Australian Institute for Suicide Research and Prevention 2017.
Goodman et al.: Recent Victimization in Women and Men With Severe Mental Illness: Prevalence and Correlates. Journal of Traumatic Stress, 2001, 14(4):615-632.
Walish et al.: Prevalence of violent victimisation in severe mental illness. British Journalof Psychiatry 2003, 183:233-239.
Khalifeh ea: Violent and non-violent crime against adults with severe mental illness. The British Journal of Psychiatry 2015, 206 275-282.
Kamperman et al: Criminal Victimisation in People with Severe Mental Illness; A Multi-Site Prevalence and Incidence Survey in the Netherlands.PLOS ONE | wwwplosoneorg 2014 9(3).
Short et al.: A case-linkage study of crime victimisation in schizophrenia-spectrum disorders over a period of deinstitutionalisation. BMC Psychiatry 2013, 13(66):1-9.
Sturup Sorman and Kristiansson: Violent victimisation of psychiatric patients: a Swedish case-control study Soc Psychiat Epidemiol 2011, 46:29-34.
Jacobson and Richardson: Assault experiences of 100 psychiatric inpatients. Am J Psychiatry 1987, 144:908-913.
Cascardi M.: Physical Aggression Against Psychiatric Inpatients by Family Members and Partners. PSYCHIATRIC SERVICES 1996 47( 5):531-533.
Bengtsson-Tops et al: Victimization in individuals suffering from psychosis:a Swedish cross-sectional study. Journal of Psychiatric and Mental Health Nursing 2012, 19:23-30.
Yegomawork et al.: Women's Health and Life Events Study in Rural Ethiopia. Ethiopian Journal of Health Development 2004, 17.
At risk yet dismissed: The criminal victimisation of people with mental health problems In. 15-19 Broadway, London, E15 4BQ, 0202 8519 2122: Victim Support; 2013.
Schumann et al: Prevalence and clinical correlates of police contact prior to a first diagnosis of schizophrenia. Criminal Behaviour and Mental Health 2017, 27:27-39.
DSM-5 Task Force: Diagnostic and Statistical Manual Of Mental Disorders -DSM- 5th ed. washington DC: American Psychiatric Association; 2013.
Peterson Manchak & Skeem: How Often and How Consistently do Symptoms Directly Precede Criminal Behavior Among Offenders With Mental Illness? . Law and Human Behavior 2014, 38 (5):439-449.
Logan. Walker. Cole and Leukefeld: Victimization and Substance Abuse Among Women: Contributing Factors, Interventions, and Implications. . Review of General Psychology 2002 6(4):325-397.
Goodman Dutton: and Harris: The Relationship Between Violence Dimensions and Symptom Severity Among Homeless, Mentally ill Women.Journal of Traumatic Stress 1997, 10(1):51-70.
Endalamaw S.: Suicidal Behaviours among People with Mental Illness at Jimma University Teaching Hospital Psychiatry Clinic, South West Ethiopia. Quality in Primary Care 2016 24 (6):246-255.
Hussien Z.: Prevalence and Associate Factors of Suicidal Ideation and Attempt among People with Schizophrenia J Psychiatry , 2015, 18(1).
Devries et al: WHO multi-country study on women’s health and domestic violence against women. Social Science & Medicine 2011, 73
Boudreaux et al.: Criminal Victimization, Posttraumatic Stress Disorder & Comorbid Psychopathology Among a Community Sample of Women. Journal of Traumatic Stress 1998, 11(4).

No competing interests reported.

Prevalence of Violent Victimization and Associated Factors Among Psychiatric Outpatients

Status:

Version 1

Abstract

Figures

INTRODUCTION

METHODS

RESULTS

Discussion

Limitations

Conclusion and Recommendations

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1