Journal of Public Health | Vol. 31, No. 1, pp. 39 46 | doi:10.

1093/pubmed/fdn100 | Advance Access Publication 3 December 2008

Violent behavior among adolescents in post-war Lebanon: the role of personal factors and correlation with other problem behaviors
Tarek Sibai1, Rania A. Tohme2, Hind A. Beydoun3, Nabil Kanaan4, Abla Mehio Sibai2
Boston University Medical Center, Boston, MA 02118, USA Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon 3 Graduate Program in Public Health, Eastern Virginia Medical School, Norfolk, V A, USA 4 Department of Family Medicine, American University of Beirut, Beirut, Lebanon Address correspondence to Abla Mehio-Sibai, E-mail: ansibai@aub.edu.lb
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A B S T R AC T
Background Adolescent violence is a signicant public health problem. The primary objective of this study is to assess the prevalence and correlates of violent behavior among adolescent students in Lebanon. Methods A cross-sectional study was conducted among a representative sample of 827 secondary students enrolled in public and private schools in Beirut. Using a series of multiple logistic regression techniques, socio-demographic variables which signicantly associated with violent behavior were included as potential confounders in building the models for risk behavior. Results Nearly 42 and 17% of adolescents reported being involved in physical ghts and weapon carrying, respectively. Boys were signicantly more likely to use violence than girls. Whereas associations with physical ghts were stronger for socio-economic variables and perceived rank in class, weapon carrying was signicantly associated with problem behaviors, such as unintentional injury, substance abuse and sexual activity, with effect measures being stronger than those estimated for physical ghting. Conclusion Compared with other countries, the rates of violent behavior in Lebanon are relatively high. The results from this study are discussed in light of the political ecology of Lebanon which may contribute to a culture that perpetrates violent behavior and may have inuenced the clustering pattern of risk behaviors. Keywords Lebanon, physical ght, risk behaviors, violence, war, weapon carrying, youth

Introduction
Although traditionally viewed as a time of optimal health, adolescence is also a period of transition from childhood to adulthood, whereby individuals are susceptible to a wide range of behavioral risk factors affecting their immediate and future physical and mental health.1 Among these behaviors, adolescent violence, as a social and public health problem, has been given considerable attention in both scientic and lay publications and in media reports since the early 1990s.1 5 Several studies conducted in developed and developing countries have attempted to examine the epidemiology of violent behaviors occurring inside and outside school properties, with a focus particularly on two indicators, weapon carrying and physical ghts.6 19 Data derived from the

Youth Risk Behavior Survey (YRBS) in the United States reveal a decreasing trend in physical ghts and weapon carrying from 42.5 and 26% in 1991, respectively, to 35.9 and 18.5% in 2005.6,20 Almost all studies concur that boys are more likely to engage in violent behavior than girls, even after adjusting for confounding variables.9,10,21 Also, the experience of negative life events such as parental divorce, expulsion from school and academic failure appears to be

Tarek Sibai, Orthopedic Surgery Intern Rania A. Tohme, Research Associate Hind A. Beydoun, Assistant Professor of Epidemiology Nabil Kanaan, Associate Clinical Professor of Family Medicine Abla Mehio Sibai, Associate Professor of Epidemiology

# The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

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associated with violent behavior in adolescents.11,13,21 Moreover, adolescents with poor self-rated health and psychological distress are more likely to engage in violent behavior than their better-off counterparts.21,22 Findings regarding the correlation of socio-economic status with violent behavior among youth have not been consistent.13,21 25 Whereas low parental education and income were found to be signicant predictors of violence among children in Egypt and Korea,21,23 reports from other populations failed to nd a signicant association after controlling for confounding.13,22,24,25 Other behavioral problems such as substance abuse and sexual activity at an early age have also been shown to be related to violent behavior.6,14 16 In Sweden, for example, involvement in physical ghts was strongly associated with smoking, alcohol and drug abuse and sexual intercourse.15 In South Korea, 40% of adolescents were involved in more than one problem behavior, with violence showing signicant association with other risk behaviors among boys.23 Jessors problem behavior theory states that high-risk behaviors such as violence, alcohol and drug abuse and early sexual activity are inter-related and share many common risk factors.26 Problem behaviors tend to cluster because different risk behaviors serve the same social or psychological developmental function, such as afrming individuation from parents, trying to achieve adult status and seeking acceptance from peers, or alternatively, because they are the manifestations of similar underlying factors.18 In spite of the many similarities in the literature regarding correlates of violent behavior, ndings from a growing number of studies, in both developed and developing countries, underscore the considerable variation in its prevalence between and within countries.14,17,18 For example, rates for weapon carrying among adolescents varied widely (between 4 and 38%) across studies in the United States and Canada, with almost a 10-fold difference.9,19,27 Halliday-Boykins argues that although key determinants of antisocial behavior may be similar across studies, it should not be generally assumed that the magnitude of associations generated from one setting can be extrapolated to another and that variations in prevalence rates should continue to be explored in different cultures.28 To a large extent, the opportunity for violence is contingent on social contextual factors,29,30 and thus ndings can mostly be generalized to the setting where the study is conducted. Nowhere is this comprehension of disparities in violent behavior better served than in a country such as Lebanon, a small middle-income country that has been ravaged by a multitude of wars, civil strife and atrocities for a period of over three decades. To date, there are no studies focusing only on

adolescent violence in Lebanon. Violence has been addressed within a discussion of other behavioral risk factors or within the context of injuries.31,32 The aim of this paper is to report the prevalence of violent behavior, specically physical ghting and weapon carrying, among secondary school adolescents in Lebanon, and to examine its association with personal factors and other high-risk behaviors.

Methods
Participants

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Data in this study are derived from the risk behavior survey initiated by the WHO in collaboration with UNICEF, UNAIDS and the Ministry of Higher Education, Youth and Sports in Lebanon, among adolescent students in schools located in Greater Beirut, Lebanon in 1997. The design and conduct of the survey are presented in detail elsewhere.33 Briey, a two-stage sampling design was implemented, with schools being rst selected on the basis of a probability sample proportionate to student population size. This was followed by a sample of three classrooms drawn randomly from within each school representing the 10th, 11th and 12th grades. The sampling frame consisted of a total of 887 students attending 12 schools. The study protocol was approved by the institutional review board at the American University of Beirut, and consent to participate in the survey was obtained from school ofcials and teachers. Parents committees in the schools also approved the study and all the students approached provided assent. However, with one school refusing to participate (number of students 42), 10 students being absent on the day of data collection, and 8 questionnaires being discarded because of inconsistent response patterns or mostly blank or missing answers, the nal study sample yielded a total of 827 completed questionnaires from 11 schools with a 93% response rate. The survey questionnaire was adapted, with minor modications from the Centers for Disease Control and Prevention YRBS in the United States.34 In comparison to the YRBS questionnaire, ltering methods were introduced when eliciting such culturally sensitive subjects as sexual activity, alcohol and drug abuse. Other issues, such as waterpipe smoking and the extent of television watching were added. The questionnaires were self-administered during regular school hours, anonymous and took less than an hour for completion.
Measures

The level of engagement with violence, the outcome of the study, was dened using two dichotomous variables: (i)

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being involved in a physical ght at least once over the past 12 months, and (ii) carrying a weapon such as a gun, knife or club on at least one day during the 30 days preceding the survey. These behaviors may have occurred inside or outside of school properties. The independent variables, which were identied from the previously published studies on adolescent violence, included two broad categories: socio-demographics9 11,13,21 23 and youth risk behaviors,6,14 16,23,26 other than violent behavior. Socio-demographic variables considered in the present analysis included gender, school type ( public versus private), grade level (10th, 11th and 12th), perceived academic rank in class (better than average, average or less than average), parental marital relations (married versus others including divorced, widowed or married with impaired parental relations) and self-perceived health (excellent, better than average and average or lower). Measures of socio-economic status relied on father and mothers education (illiterate, primary, secondary, university or higher) and students pocket money [none, , 10 000, 10 25 000 and . 25 000 Lebanese Pounds (LP) per week], with $1 being equivalent to 1500 LP. A total of 12 youth risk behaviors, identied in the literature as associated with violent behavior, were examined in this analysis. These included two injury-associated risk behaviors dened as (i) riding in a car with a drunk driver and (ii) driving after drinking alcohol, both of which were assessed with a recall period of one month. The list also included current (iii) cigarette, (iv) waterpipe (narghile, shisha), (v) alcohol, (vi) drug (hashish, cocaine, opium and other illicit substances) use and (vii) binge drinking on at least one occasion within a recall period of one month. Noteworthy here is that the legal age for alcohol drinking and acquiring a drivers license in Lebanon is 18 years. In addition, risk behaviors related to sexual activity included (viii) being sexually active, (ix) having had multiple sexual partners over the past three months prior to the survey, as well as (x) unprotected sex during the last intercourse. Finally, (xi) thoughts of or plans to commit suicide, and (xii) actual attempts were assessed with a recall period of one year.

into a series of logistic models, examining the association of violent behavior with each of the other 12 youth risk behaviors. This procedure allowed for the evaluation of the co-variation of each specic behavior problem with violent behavior while controlling for the confounding effect of personal characteristics. Unadjusted and adjusted prevalence odds ratios (ORs) and their corresponding 95% condence intervals (CIs) were calculated. The sample was self-weighted and all analyses were performed using the Statistical Package for Social Sciences (SPSS 13.0). A P-value , 0.05 was considered statistically signicant.

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Results
The study sample was evenly split among both gender groups, with the majority being enrolled in private schools. Around half of the students (49.6%) perceived their academic rank in school as better than average. Students reported higher educational attainment for fathers than mothers and the majority perceived their parental marital relations as free of conjugal problems (79.0%). Whereas 5.6% of students did not receive any weekly allowances, 23.3% reported access to over 25 000 LP of pocket money per week (equivalent to around US $17) (Table 1). Prevalence rates for physical ghts and weapon carrying were estimated at 41.5 and 17.3%, respectively. The majority of students were involved in physical ghts for one to three times during the past 12 months (27.6%), whereas 6% had been involved in physical ghts for 12 times or more. Concerning weapon carrying, 6.5% of the students carried a weapon on one day, whereas almost 8% carried a weapon on 6 days or more during the past 30 days. A total of 102 students (12.5%) were involved in both physical ghts and weapon carrying. Results of the multivariate logistic regression analysis showed that males (P , 0.001) and those perceiving their class rank less than average (P , 0.01) were signicantly more likely than their counterparts to engage in both physical ghts and weapon carrying, with associations being stronger for the former behavior than the latter (Table 2). In addition, the presence of parental marital problems (P , 0.05) and access to larger weekly allowances of pocket money (P , 0.05) signicantly increased the likelihood of being involved in a physical ght. In contrast, school type and grade level were not correlated with violent behaviors. Associations between physical ghts and weapon carrying with other risk behaviors are shown in Table 3 after controlling for the signicant confounders identied in Table 2 (for physical ghts: gender, perceived academic rank in class, perceived parental marital relations and pocket money

Statistical analyses

Multivariate logistic regression technique was used to examine the net effect of each explanatory variable on violent behavior, physical ghts and weapon carrying. Initially, associations of violent behavior were assessed with demographic and socio-economic characteristics and perceived academic achievement. Subsequently, the subset of variables identied as signicant were entered as covariates

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Table 1 Socio-demographic characteristics of the study sample: a total of 827 secondary school students in Beirut, Lebanon Variable Gender Female Male School type Public Private Grade level 12th 11th 10th Perceived academic rank in class Better than average Average Less than average Fathers education Illiterate Primary Secondary University or higher Mothers education Illiterate Primary Secondary University or higher Perceived parental marital relations Married with no problems Othersa Pocket money per week None , 10 000 LP 10 000 25 000 LP . 25 000 LP Self-perceived health Excellent Better than average Average or less Engagement in violent behavior Physical ght Weapon carrying Both behaviors 343 143 103 41.5 17.3 12.5 452 314 51 55.3 38.4 6.2 46 228 360 193 5.6 27.6 43.5 23.3 645 171 79.0 21.0 148 335 190 123 18.6 42.1 23.9 15.5 117 284 186 186 15.1 36.7 24.1 24.1 409 280 136 49.6 33.9 16.5 225 340 261 27.2 41.2 31.6 210 617 25.4 74.6 411 412 49.9 50.1 n Percentage

carrying compared with physical ght, and a greater number of risk behaviors were signicantly associated with the former (riding with a drunk driver, driving after drinking alcohol, current cigarette smoking, waterpipe and alcohol use, binge drinking, current sexual activity and having multiple sexual partners) than the latter (riding with a drunk driver, current alcohol use and binge drinking). Both outcome measures were signicantly associated with riding with a drunk driver ( physical ghting: OR 2.60, 95% CI 1.20 5.65; weapon carrying: OR 2.77, 95% CI 1.42 5.43), current alcohol use (OR 1.78, 95% CI 1.16 2.76; OR 1.80, 95% CI 1.14 2.84, respectively) and binge drinking (OR 4.18, 95% CI 1.51 11.6; OR 3.99, 95% CI 1.79 8.92, respectively). In addition, weapon carrying was signicantly associated with driving after drinking alcohol (OR 2.92, 95% CI 1.10 7.75), current cigarette (OR 2.78, 95% CI 1.68 4.62) and waterpipe smoking (OR 2.52, 95% CI 1.66 3.83), current sexual activity (OR 3.19, 95% CI 1.88 5.39) and having multiple sexual partners (OR 3.61, 95% CI 2.13 6.14).

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Discussion
Main ndings

The present study has shown notably high prevalence rates of violent behavior among youth in Lebanon, especially for physical ght. Boys showed signicantly higher rates of violent behavior compared with girls. Study ndings also indicate that associations with socio-economic indicators and perceived rank in class were stronger for physical ghting than weapon carrying. In contrast, a greater number of problem behaviors associated signicantly with weapon carrying than physical ghts.
What is known already

Note that totals do not all add up to 827, as some of the variables have missing responses.
a

Others include divorced, widowed or married with impaired parental

relations.

per week; for weapon carrying: gender and perceived academic rank in class). Overall, ndings indicate that the adjusted effect measures (ORs) were stronger for weapon

Consistent with the literature,6,9,15,21,22,27,35,36 both physical ghts and weapon carrying were found to be predominantly male activities. Surveys conducted in different parts of the world have shown that boys are 2 3 times and 4 5 times more likely than girls to report physical ghts9,15,21,22,31,35 and weapon carrying, respectively.9,19,35 Also, violent behavior was found to be associated with perceived rank in school, corroborating ndings based on studies conducted in the West. Academic failure has been found to be a signicant predictor of multiple youth risk behaviors, including violence.12,18,24 A positive association was found between parental education and involvement in violent behavior; however, this relationship was not signicant after controlling for other

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Table 2 Associations of socio-demographic characteristics with violent behavior among secondary school students (n 827) in Beirut, Lebanon Variable Gender Female Male School type Public Private Grade level 12th 11th 10th Perceived academic rank in class Better than average Average Less than average Fathers education Illiterate Primary Secondary University or higher Mothers education Illiterate Primary Secondary University or higher Perceived Parental marital relations Married with no problems Others Pocket money per week None , 10 000 LP 10 000 25 000 LP . 25 000 LP Self-perceived health Excellent Better than average Average or less OR, odds ratio; CI, condence interval.
a

Physical ght [adjusted OR (95% CI)]a

Weapon carrying [adjusted OR (95% CI)]a

1.00 9.57 (6.44 14.20)* 1.00 0.76 (0.48 1.22) 1.00 1.48 (0.92 2.36) 1.04 (0.67 1.63) 1.00 1.56 (1.08 2.26)* 3.05 (1.38 6.76)* 1.00 1.02 (0.58 1.82) 1.51 (0.79 2.88) 1.62 (0.82 3.23) 1.00 1.11 (0.65 1.91) 0.97 (0.51 1.85) 1.09 (0.53 2.25) 1.00 1.86 (1.19 2.90)* 1.00 3.76 (1.38 10.20)* 4.13 (1.55 11.00)* 4.34 (1.58 11.90)* 1.00 1.04 (0.70 1.55) 0.86 (0.51 1.47)

1.00 5.68 (3.36 9.61)* 1.00 0.93 (0.49 1.72)

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1.00 1.29 (0.74 2.28) 1.23 (0.72 2.11) 1.00 1.44 (0.92 2.25) 2.74 (1.31 5.74)* 1.00 1.05 (0.49 2.24) 1.57 (0.69 3.55) 1.48 (0.63 3.47) 1.00 0.94 (0.47 1.89) 1.03 (0.47 2.26) 1.77 (0.76 4.09) 1.00 1.03 (0.59 1.76) 1.00 1.19 (0.36 3.88) 1.35 (0.43 4.24) 2.49 (0.78 7.94) 1.00 1.54 (0.96 2.48) 1.62 (0.84 3.11)

ORs are adjusted for all socio-demographic characteristics.

*Signicant associations, P , 0.05.

confounding variables. Evidence supporting a higher socioeconomic status as facilitating the initiation of violence in adolescence remains inconclusive.13,25 Our study showed that access to economic resources through weekly pocket money was positively correlated, in a dose response relationship, with physical ghting. However, the direction of the association found may not be causal. Whether pocket money is an indicator of parents socio-economic status and

has an effect on violent behavior, or is a consequence of and a response to early recurrent violent behavior, can only be elucidated through longitudinal studies. Our ndings of a positive association between weapon carrying and various indicators of substance use and sexual activity at an early age are also consistent with previous research conducted in several countries including the United States, Japan and Korea.23,37 39 Compared with physical

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Table 3 Relationship between physical ghting and weapon carrying with other risk behaviors among secondary school students (n 827) in Beirut, Lebanon Risk behaviors a Riding with a drunk driver Driving after drinking alcohol Suicide plan (past year) Suicide attempt (past year) Current cigarette use Current waterpipe smoking Current alcohol use Binge drinking Current drug use Currently sexually active (past three months) Multiple sexual partners (past three months) Unprotected sexual activity (last intercourse) OR, odds ratio; CI, condence interval. For physical ght, ORs are adjusted for gender, perceived academic rank, parental marital relations and pocket money; for weapon carrying, ORs are adjusted for gender and perceived academic rank.
a

Physical ght [adjusted OR (95% CI)] 2.60 (1.20-5.65)* 1.96 (0.59 6.52) 1.42 (0.71 2.83) 1.25 (0.57 2.75) 1.62 (0.95 2.75) 1.41 (0.96 2.09) 1.78 (1.16 2.76)* 4.18 (1.51 11.6)* 2.36 (0.56 10.0) 1.36 (0.75 2.48) 1.72 (0.93 3.21) 0.47 (0.19 1.15)

Weapon carrying [adjusted OR (95% CI)] 2.77 (1.42 5.43)* 2.92 (1.10 7.75)* 1.94 (0.93 4.07) 1.38 (0.56 3.40) 2.78 (1.68 4.62)*

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2.52 (1.66 3.83)* 1.80 (1.14 2.84)* 3.99 (1.79 8.92)* 2.59 (0.81 8.36) 3.19 (1.88 5.39)* 3.61 (2.13 6.14)* 2.29 (0.96 5.44)

Youth risk behaviors were assessed with a recall period of one month, unless otherwise stated.

*Signicant associations, P , 0.05.

ghts, weapon carrying in our study not only tended to be associated with a larger number of problem behaviors, but the effect measures were overall much stronger, supporting the contention of clustering of risk behaviors in the same individual.23,26,38 In our study, the clusters of behavioral risk factors can be classied in the areas of unintentional injury, substance use and sexual activity.
What this study adds

Study ndings showed prevalence rates of  42 and 17% for physical ghts and weapon carrying, respectively. Comparisons of these gures with international data are difcult to interpret, and, often not without problems. Studies vary in sample characteristics (ages, private versus public schools) and types of questions used. However, drawing on several studies conducted worldwide,20,21,24,40,41 Lebanon is among the few countries where the rate of weapon carrying exceeds 10% and approaches that in the United States (18.5%).20 Although the culture of carrying weapons in the United States is associated to drug trafcking and involvement in crime,42 there is no evidence that this is the case in Lebanon. Most cases in this study revealed the possession of weapons such as a knife, switch blades or a club, and around a third of those involved in physical ghts reported weapon carrying. Violence can only be understood within the wider social context,43 and whether the observed elevated violence rates

in our study population may be attributed to the longstanding exposure to the civil strife and armed conicts in the country requires further research. Adolescents of today were raised as children in a culture that was permissive of weapon carrying, and they continue to be exposed to turmoil and military aggression. For example, at the time this paper was conceptualized, a war characterized by an unprecedented scale of destruction struck Lebanon in July 2006. More recently, political aggression erupted in May 2008, impacting on the countrys economy, its social infrastructure (including educational services), as well as its political order, possibly for years to come. Consistent with ndings from Uganda44 and Palestine,45 the prolonged exposure to armed conicts and war-related events in Lebanon may have inuenced patterns of risk behaviors and contributed to a general culture that endorses weapon carrying and physical ghts. Although the intention of this study was not to directly investigate the impact of wartime conditions on violence and adolescent behavior, the present study acknowledges that the war context, with which the social order and political order interact, does enable the expression of violent behavior.

Limitations of this study

When interpreting ndings, the studys limitations should be noted. First, the cross-sectional nature of the study

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precludes establishing a cause effect interpretation of the association between the various independent variables and violent behavior, and the regression analysis may only be viewed as showing co-variational relationships. Second, although the data were derived from a representative sample of adolescent students in an urban setting in Lebanon, results observed may not apply to students in less urban or in rural communities and more importantly to those who have dropped out of school. Furthermore, underreporting of sensitive and antisocial behaviors may have affected study results. Nevertheless, researchers have shown that adolescents tend to be reasonably truthful when measures are based on self-administered interview schedules.46 Reporting biases in this study are likely to be minimal, as the survey was not administered in the adolescents home and condentiality and anonymity of the responses were ensured. Last, although our data are not recent, they provide useful insights into adolescent violent behavior in Lebanon and set a point of reference for future studies on violent behaviors in the country.

the manuscript or the decision to submit the manuscript for publication.

References
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Conclusion
Few countries have formally recognized the problem of violent behavior, and when tackled, the issue has been addressed with a focus on such a typology as suicidal behavior, family and partner violence and abuse with no regard to its initial manifestations among youth. Among adolescent in Lebanon, a number of personal factors were identied as underlying factors for physical ght and a wide spectrum of youth risk behaviors clustered around weapon carrying. Although violence has recently become a priority concern among civic groups, non-governmental organizations and researchers in Lebanon and the region, ofcial recognition in terms of policies, intervention plans and program development has been slow to follow. For the success of intervention programs, there is a need to address the co-existence of multiple risk behaviors and not only focus on one particular behavior. The study also suggests that efforts to curb adolescent violence need to crucially address individual, personal and behavioral factors within the wider context of the youths social and political environment.

Funding
This work was supported by funds from the World Health Organization (WHO), and the United Nations Childrens Fund (UNICEF) (A/C 32502026416). The funding agencies did not interfere with the study design, analyses, write-up of

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