Higher Risk of Violence Exposure in Men and Women With Physical or Sensory Disabilities

Abstract

The World Health Organization has declared that violence is a global public health problem. The prevalence of violence exposure among adults with intellectual and unspecific disabilities has been demonstrated in several studies, whereas only a few articles on people with sensory disabilities have been published. The aim of this study was to investigate the prevalence and risk for exposure to physical violence, psychological offence, or threats of violence in people with physical and/or sensory disabilities, compared with people with no such disabilities, controlling for socioeconomic data. Data from a public health survey were analyzed. A nationally representative sample of women and men aged 16 to 84 years had answered a questionnaire. In the present study, the whole sample, comprised of 25,461 women and 21,545 men, was used. Women with auditory disabilities were generally more often violence exposed than non-disabled women, whereas men with physical disabilities were more often violence exposed than non-impaired men. Some age groups among both women and men with visual disabilities had higher prevalence rates than women and men without disabilities. The adjusted odds ratios (ORs) were significantly higher among the auditory impairment group for exposure to physical (OR = 1.4, confidence interval [CI] = [1.1, 1.9]) and psychological (OR = 1.4, CI = [1.1, 1.8]) violence among women. Men with physical disabilities had raised odds ratios for physical violence (OR = 1.7, CI = [1.2, 2.4]) and psychological violence (OR = 1.4, CI = [1.0, 2.0]) compared with the non-disabled group. Both men and women with a physical or sensory disability showed higher odds of being exposed to violence than men and women without a disability. The results indicated that socioeconomic situation, smoking, and hazardous drinking strengthened the association between impairment and violence.

Keywords

disability sensory impairments violence men women

Introduction

In the World report on disability from 2011, it was reported that around 15% of adults live with some sort of disability. Women and older people have a higher prevalence of disability, and people with disability have poorer general health outcomes, lower education, and higher rates of poverty (WHO, 2011). Another great challenge is that both men and women with various forms of disabilities also seem to be at higher risks of being exposed to violence (Hughes et al., 2012; World Health Organization [WHO], 2011). In the WHO report on disability, Professor Stephen Hawking states that the barriers that people with disabilities face are attitudinal, physical, and financial, but also that addressing these barriers is within reach (WHO, 2011).

The WHO has declared that violence is a global public health problem, including physical, sexual, and psychological violence (Krug, Mercy, Dahlberg, & Zwi, 2002; WHO, 2002). The magnitude of violence is immense for both men and women, and many thousands of people all around the world suffer from both fatal and non-fatal health consequences every day (Krug et al., 2002). It is well-known that exposure to violence has substantial effects on health, even for those who do not receive physical injuries (Campbell, 2002; Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008; Krug et al., 2002; Olofsson, Lindqvist, Gadin, & Danielsson, 2009; Olofsson, Lindqvist, Shaw, & Danielsson, 2012). The multi-country study on women’s health and domestic violence demonstrated that the prevalence and attitude toward violence varied highly between different regions and countries (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Krug et al., 2002).

A systematic review of prevalence and risk of violence among adults with disabilities was published by Hughes et al. (2012) in The Lancet in 2012, with the conclusion that violence is a major problem in adults with disabilities. The pooled prevalence rates varied across studies and disability: highest for mental illnesses, less for intellectual impairments, and least for non-specific impairments. People with disabilities had an increased risk of experiencing violence, compared with those without disabilities, with pooled crude odds ratios (ORs) ranging from 1.3 (confidence interval [CI] = [0.9, 1.8]) for non-specific impairments and 1.6 (CI = [1.1, 2.5]) for intellectual impairments. In a recently published study from the United Kingdom, the increased risks for violence in people with disabilities, compared with non-disabled, were even higher, with adjusted OR of 1.8 (CI = [1.5, 2.2]) for those with non-mental disability and 3.0 (CI = [2.3, 3.8]) for mental illnesses (Khalifeh, Howard, Osborn, Moran, & Johnson, 2013). Increasing rates of domestic violence against people with disability were demonstrated in a study from Taiwan, which also showed that the increasing rates varied strongly between different types of disability (Olofsson et al., 2012).

The prevalence of violence exposure among adults with mental and/or intellectual disabilities and/or unspecific disabilities has been demonstrated in several studies, whereas only a few articles on people with sensory disabilities have been published (Casteel, Martin, Smith, Gurka, & Kupper, 2008; Hughes et al., 2012; Silver, Arseneault, Langley, Caspi, & Moffitt, 2005; Teplin, McClelland, Abram, & Weiner, 2005). Also, very little is known about gender differences in adult men and women with disabilities, except for sexual violence, where a few studies are published (Haydon, McRee, & Tucker Halpern, 2011; Mitra, Mouradian, & Diamond, 2011). In an American study on adult men and women, higher prevalence rates for lifetime sexual violence victimization were found for disabled women compared with disabled men. Both disabled men and women had higher odds for victimization compared with the non-disabled men and women, but the odds for victimization were greater for the women. (Mitra et al., 2011).

To be able to step forward and reach the barriers for violence-exposed disabled people, more knowledge and studies are needed. Research has demonstrated a highly varied prevalence and attitude toward violence between countries with different political and welfare systems (Garcia-Moreno et al., 2006). This raises expectations that the prevalence and attitude toward disability also varies accordingly and existing data demonstrates that violence among disabled people varies according to different studies and different countries (Hughes et al., 2012; Olofsson et al., 2012). Previous studies come from a small number of countries, and few studies are controlled for confounding factors, that is, mainly socio-demographic factors (Hughes et al., 2012). Socio-demographic factors are known to differ between people with and without disabilities (Khalifeh et al., 2013; WHO, 2011). Furthermore, there is a need for high-quality studies on violence exposure in people with a physical, sensory, or intellectual disability (Hughes et al., 2012).

The aim of this study was to investigate the prevalence and risk for exposure to physical violence, psychological offence, or threats of violence in men and women with physical and/or sensory disabilities, compared with men and women with no such impairments, controlling for socioeconomic and demographic factors, and using data emanating from the Swedish Public Health Agency from year 2010.

Method

Data from a nationwide public health survey conducted by the Swedish National Institute of Public Health in 2010 were analyzed. A nationally representative sample of nearly 100,000 (N = 87,529) women and men aged 16 to 84 years had been asked to reply to a Swedish questionnaire, called “Equal Health?” sent to them by mail. In this present study, the whole sample, comprised of 25,461 women and 21,545 men, was used. The response rate was 54%.

The questionnaire contained 77 questions, 42 of which were about physical and mental health and use of the health care system; 30 pertained to socioeconomic factors, form of housing, and work environment; and 5 dealt with cigarette smoking and use of alcohol. Seven questions were used to define persons with sensory or mobility impairments: The questions for visual and hearing impairments, respectively, were worded as follows: “Can you see and pick out normal text in a daily newspaper without difficulty?” (response alternatives: Yes, without glasses; Yes, with glasses; or No) and “Can you hear what is being said in a conversation between several people without difficulty?” (response alternatives: Yes, without a hearing aid; Yes, with hearing aid; or No). To measure mobility impairment, the following questions were used: “Can you run a fairly short distance?,” “Can you climb stairs without difficulty?,” “Can you take a fairly short walk?,” and “Do you need aids or someone’s help to move about outdoors?” The response alternatives for all four questions about mobility were “Yes” or “No.” The internal consistency of the four mobility questions, measured as Cronbach’s alpha, was .70.

Based on the questions about vision, hearing, and mobility, three impairments groups were defined as follows:

Visual impairment: Cannot read normal text without difficulty, not even with glasses

Hearing impairment: Cannot hear conversation between several people without difficulty, not even with hearing aid

Physical impairment: Cannot run a fairly short distance, cannot climb stairs/take a short walk without difficulty, and/or need aids or help of another person to move about outdoors

Another prerequisite for classification as having impairment in this study was to have answered “Yes, to a great extent” to the question: “Do these problems mean that your work capacity is diminished or hinder you in your other daily activities?” The Public Health Agency of Sweden (2010) uses the same operationalization of disability when fulfilling its national responses of monitoring “Health on equal terms.” The operationalization of disability in this study also corresponds to most other studies with definitions of disabilities, and is the same as that used in The Lancet review article on violence against adults with disabilities. (Hughes et al., 2012).

The area of violence was covered using three questions. Two that involved psychological abuse were used: “Have you been verbally offended during the past 12 months?” (with response alternatives dichotomized into “Yes” and “No”) and “Have you been exposed to any threats of violence or other threats that scared you during the past 12 months?” (with binary answer alternatives). The question regarding physical abuse was worded as follows: “Have you been exposed to physical violence during the past 12 months?” and had binary answers. Hazardous alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT), designed by the WHO in 1992 and widely used for adults (Babor, Ramon de la Fuente, Saunders, & Grant, 1992). The first three questions (AUDIT C) regarding consumption were used, and different cut-off values for women and men were chosen to discriminate for hazardous drinking (Dawson, Grant, Stinson, & Zhou, 2005). For smoking, one question was chosen, namely, “Are you a daily smoker?” Hazardous gambling was measured using a summation index built on three sub-questions originating from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994; 0 to 6 points, where 0 indicates no problem and 1 to 6 indicate hazardous gambling problems).

Questions that were relevant regarding socioeconomic factors were chosen for the analyses of this study. Immigrant status was dichotomized into (a) born in Sweden and (b) born outside Sweden, whereas civil status was dichotomized into (a) married or cohabiting and (b) single. Regarding education, the answers were trichotomized into (a) short: all levels of education less than a total of 11 years, (b) medium: education of 12 to 14 years, and (c) long: 15 years of education or more. Present occupation was dichotomized into (a) manual and (b) non-manual. Working status was dichotomized and measured as having or not having an occupation, as follows: Gainfully employed (0), Self-employed (0), Leave of absence or parental leave (0), Studying or training (0), Involved in a labor-market measure (0), Retiree (0), Unemployed (1), On sick leave/activity support (early-retirement pension, sickness pension) (1), and Long-term sick-listed (more than 3 months) (1). Economic margin and economic crisis were evaluated by use of the questions: “If you suddenly needed 15,000 kronor (approximately €1,500/US$2,500), could you manage to get it in one week?” and “Have you had difficulty managing your everyday expenses for food, rent, bills, etc. during the past 12 months?”

A thorough review of the questions used in this study could be read in “Objective and background of the questions in the national public health survey” (Swedish National Institute of Public Health, 2010).

Statistical Analyses

Prevalence, with a 95% CI, was used to describe and analyze differences in socioeconomic background, smoking, hazardous alcohol use, and hazardous gambling for those with a physical or sensory impairment exposed to violence compared with those not exposed. In general, when comparing two parameter estimates, the estimates are statistically significantly different if the CIs do not overlap (Altman, Machin, Bryant, & Gardner, 2000). Multivariate logistic regression was used to analyze possible associations between different socioeconomic factors and violence. The chi-square test was used to analyze for significant differences in frequency of violence and Student’s t test was used to analyze average age differences. The significance level was set at <.05. The statistical analyses were conducted using the SPSS program 20.

Calibration has been used in this study when producing various percentages. Calibration means that register data are used as auxiliary information to adjust for non-response bias in various groups (Särndal & Lundström, 2005).

Ethics

All participants were informed about the study in a cover letter enclosed with the questionnaire. Answering the questionnaire was judged to be consent to join the study. The Ethics Committee at the Swedish National Board of Health and Welfare approved the survey

Results

In Table 1, age and frequencies of various socioeconomic variables, along with smoking, hazardous alcohol use, and hazardous gambling, are given for disabled and non-disabled women and men exposed to violence. The violence-exposed disabled women and men are older, have a shorter education, are more often unemployed, report being born outside Sweden more frequently, have a more difficult economic situation, and have a higher percentage of daily smokers than the violence-exposed non-disabled women and men (Table 1). The violence-exposed disabled women have more often non-manual work and are more often born outside Sweden compared with the violence-exposed disabled men, who showed a higher percentage of hazardous drinking and gambling behavior (Table 1).

Table 1.

Descriptives of Socioeconomic Factors and Hazardous Behavior, Distributed Among Women and Men Exposed to Violence With or Without Physical or Sensory Impairment.

	Women		Men
	Impairment, n = 315	Non-Impairment, n = 833	Impairment, n = 260	Non-Impairment, n = 698
Age mean year (SD)	44 (17)***	37 (15)	47 (18)***	36 (17)
Work (%)
Manual	53 [47-59]	57 [54-60]	69 [63-75]^a	67 [64-70]
Non-manual	48 [42-59]^a	43 [40-46]	31 [25-37]	33 [30-36]
Unemployed	12 [8-16]	7 [5.3-8.7]	17 [12-22]	9 [6.9-11]
Education (%)
Short	53 [47-59]	40 [37-43]	64 [58-70]	48 [44-52]
Medium	35 [30-40]	39 [36-42]	30 [24-36]	43 [39-47]
Long	12 [8-16]	21 [18-24]	6 [3-9]	9 [7-11]
Country of birth (%)
Sweden	79 [75-83]	93 [91-95]	89 [85-93]^a	93 [91-95]
Europe/World	21 [17-25] ^a	7 [5.3-8.7]	11 [7-15]	7 [5-9]
Civil status (%)
Married/cohabiting	55 [50-60]	57 [54-60]	49 [43-55]	47 [43-51]
Single	45 [40-50]	43 [40-46]	51 [45-57]	53 [49-57]
Insufficient economic margin (%)	48 [47-54]	37 [34-40]	48 [42-54]	28[25-31]
Have experienced economic crisis (%)	49 [43-55]	33 [30-36]	40 [34-46]	31 [28-34]
Hazardous gambling (%)	4 [1.8-6.2]	2 [1-3]	13 [9-17]^a	8 [6-10]
Daily smoking (%)	24 [19-29]	18 [15-21]	29 [23-35]	12 [10-14]
Hazardous drinking (%)	14 [10-18]	20 [17-23]	27 [24-32]^a	44 [40-48]

Note. Bold figures represent statistically significant higher percentages for impaired versus non-impaired (95% confidence interval).

Significantly higher percentages for impaired women versus impaired men.

***

p ≤ .0001.

The prevalence of violence exposure, physical as well as psychological, during the past 12 months is shown in Table 2. In general, a higher percentage of women with auditory disabilities are exposed to physical and psychological violence than the non-disabled women, except for the older age groups. The physically disabled men showed a higher percentage of both physical and psychological violence in some age groups compared with the non-disabled men. In the older age groups, both physical and psychological violence exposure was more frequent in several impairments groups. The overlap between the different self-reported exposures of violence is 11% to 24% in the male group and 14% to 16% in the female group. A lower percentage of overlap was observed in the older age group and a higher percentage of overlap in the younger age groups. This holds for both sexes.

Table 2.

Percentage of Auditory, Visually, or Physically Impaired and Non-Impaired Women and Men Exposed to Violence During the Past Year.

	Auditory				Visual				Physical
	Women		Men		Women		Men		Women		Men
Violence	Impaired, n = 2,649	Non-Impaired, n = 18,455	Impaired, n = 2,984	Non-Impaired, n = 14,954	Impaired, n = 1,130	Non-Impaired, n = 19,721	Impaired, n = 907	Non-Impaired, n = 16,708	Impaired, n = 3,219	Non-Impaired, n = 17,986	Impaired, n = 2,218	Non-Impaired, n = 15,625
Physical
16-29	6.9*	4.3	7.9	8.1	5.3	4.4	5.3	8.1	7.3	4.4	6.7	8.1
30-44	5.0***	2.0	3.7	3.2	3.8	2.1	3.1	3.2	3.5	2.1	4.7	3.1
45-64	1.5	1.8	1.4	1.4	3.3	1.7	3.6**	1.3	1.6	1.8	4.2***	1.1
65-84	0.5	0.4	0.7	0.7	1.2*	0.4	1.4	0.7	0.6	0.4	1.0	0.7
Psychological
16-29	10.2**	6.2	7.9	4.9	8.1	6.3	7.7	4.8	10.1	6.3	6.8	4.9
30-44	6.5*	4.3	4.5	2.8	5.5	4.4	4.6	2.7	4.7	4.4	5.4*	2.7
45-64	5.2**	3.1	3.2**	1.6	4.0	3.3	5.8***	1.6	4.8**	3.1	3.7***	1.6
65-84	0.8	0.6	1.5	1.0	1.4*	0.6	2.0	1.0	0.9	0.5	1.4	1.0

p ≤ .05, **p ≤ .001, ***p ≤ .0001 for differences between impaired and non-impaired women and men.

Adjusted odds ratios for physical and psychological violence outcomes are given for women and men with an auditory, visual, and physical disability compared with non-disabled women and men (Table 3). All the odds ratios have been adjusted for age, country of birth, education, work status, economic stress, economic margin, hazardous alcohol usage, and daily smoking. In the auditory impairment group, significantly higher adjusted odds ratios for exposure to both physical (OR = 1.4, CI = [1.1, 1.9]) and psychological (OR = 1.4, CI = [1.1, 1.8]) violence were found among the impaired women. The visual impairment groups also showed an adjusted higher odds ratio for physical (OR = 1.6, CI = [1.1, 2.4]) violence in women compared with the non-impaired group.

Table 3.

Crude and Adjusted Odds Ratio (With 95% confidence interval [CI]) for Exposure to Physical and/or Psychological Violence in Men and Women With Physical or Sensory Impairments Compared With Men and Women With No Such Impairments.

Impairment	Sex	Violence	Crude OR	Adjusted OR	Age	Immigrant Status	Education	Work Status	Economic Stress	Economic Margin	Daily Smoking	Hazardous Drinking
Auditory imp	W	Physical violence	1.2 [1.0, 1.6]	1.4 [1.1, 1.9]	0.9 [0.9, 0.9]	1.3 [0.9, 1.9]	1.1 [0.9, 1.3]	1.2 [0.9, 1.6]	2.0 [1.5, 2.6]	1.2 [0.9, 1.6]	1.8 [1.2, 2.2]	2.1 [1.5, 2.7]
Auditory imp	M		0.7 [0.5, 0.9]	0.9 [0.7, 1.3]	0.9 [0.9, 0.9]	1.1 [0.8, 1.7]	1.2 [1.0, 1.5]	1.1 [0.8, 1.5]	2.4 [1.9, 3.1]	0.9 [0.7, 1.2]	1.9 [1.4, 2.5]	2.6 [2.1, 3.2]
Auditory imp	W	Psychological violence	1.3 [1.0,1.6]	1.4 [1.1, 1.8]	0.9 [0.9, 0.9]	1.2 [0.9, 1.6]	0.8 [0.7, 1.0]	1.2 [1.0, 1.5]	2.3 [1.9, 2.8]	1.3 [1.1, 1.6]	1.5 [1.2, 2.0]	1.6 [1.2, 2.0]
Auditory imp	M		1.3 [1.0, 1.6]	1.5 [1.1, 1.9]	0.9 [0.9, 0.9]	1.4 [1.0, 2.1]	0.9 [0.8, 1.2]	1.2 [0.9, 1.6]	2.4 [1.8, 3.1]	1.4 [1.0, 1.8]	1.6 [1.2, 2.2]	1.7 [1.4, 2.2]
Visual imp	W	Physical violence	1.5 [1.1, 2.2]	1.6 [1.1, 2.4]	0.9 [0.9, 0.9]	1.3 [0.9, 1.9]	1.1 [0.9, 1.4]	1.1 [0.9, 1.5]	2.0 [1.5, 2.6]	1.2 [1.0, 1.6]	1.6 [1.2, 2.1]	1.9 [1.5, 2.6]
Visual imp	M		1.7 [1.2, 2.4]	1.2 [0.8, 1.7]	0.9 [0.9, 0.9]	1.1 [0.8, 1.7]	1.2 [1.0, 1.5]	1.1 [0.9, 1.5]	2.4 [1.9, 3.1]	0.9 [0.7, 1.2]	1.8 [1.3, 2.4]	2.6 [2.1, 3.2]
Visual imp	W	Psychological violence	2.3 [1.7, 3.2]	1.2 [0.9, 1.7]	0.9 [0.9, 0.9]	1.24 [0.9, 2.0]	1.0 [0.8, 1.2]	1.1 [0.8, 1.5]	2.4 [1.8, 3.1]	1.4 [1.0, 1.8]	1.7 [1.2, 2.2]	1.7 [1.3, 2.2]
Visual imp	M		1.3 [1.0, 1.8]	1.9 [1.3, 2.7]	0.9 [0.9, 0.9]	1.4 [0.9, 2.0]	0.9 [0.8, 1.2]	1.1 [0.8, 1.5]	2.4 [1.8, 3.1]	1.4 [1.0, 1.8]	1.7 [1.2, 2.2]	1.7 [1.3, 2.2]
Physical imp	W	Physical violence	0.9 [0.7, 1.2]	1.2 [0.8, 1.7]	0.9 [0.9, 0.9]	1.4 [1.0, 2.0]	1.1 [0.9, 1.3]	1.1 [0.8, 1.4]	2.0 [1.6, 2.6]	1.3 [1.0, 1.7]	1.6 [1.2, 2.1]	2.0 [1.5, 2.6]
Physical imp	M		0.5 [0.5, 0.9]	1.7 [1.2, 2.4]	0.9 [0.9, 0.9]	1.2 [0.8, 1.7]	1.2 [1.0, 1.5]	1.0 [0.8, 1.4]	2.4 [1.8, 3.1]	0.9 [0.7, 1.2]	1.8 [1.4, 2.4]	2.5 [2.0, 3.1]
Physical imp	W	Psychological violence	1.1 [0.8, 1.5]	1.2 [0.9, 1.6]	0.9 [0.9, 0.9]	1.2 [0.9, 1.7]	0.8 [0.7, 1.0]	1.1 [0.9, 1.4]	2.3 [1.9, 2.9]	1.3 [1.1, 1.6]	1.6 [1.3, 2.0]	1.5 [1.2, 1.9]
Physical imp	M		0.8 [0.6, 1.0]	1.4 [1.0, 2.0]	0.9 [0.9, 0.9]	1.5 [1.1, 2.2]	0.9 [0.7, 1.2]	1.1 [0.8, 1.4]	2.5 [1.9, 3.2]	1.4 [1.1, 1.9]	1.6 [1.2, 2.1]	1.8 [1.4, 2.3]

Note. Adjusted odds ratio are adjusted for socioeconomic factors, sex, smoking, and hazardous drinking. Bold figures represent statistically significant odds ratios.

The men with physical disabilities had raised odds ratios for physical violence (OR = 1.7, CI = [1.2, 2.4]) and psychological violence (OR = 1.4, CI = [1.0, 2.0]) compared with the non-disabled group. Regarding auditory and visual impairment, the odd ratios for psychological violence outcomes were also significantly raised.

Age produces odds ratios that are all significantly decreased in the impaired groups compared with the non-impaired groups, which indicates that older age is related to less exposure to violence. Significantly higher odds ratios among the adjustment factors are economic stress, daily smoking, and hazardous drinking in both women and men when comparing impaired with non-impaired (Table 3).

Discussion

The most essential findings of this study are that women with auditory or visual disabilities have higher risks of being exposed to physical and psychological violence than women without such disabilities, whereas men with auditory, visual, or physical disability have higher risks of being exposed to mainly psychological and physical violence than non-disabled men. These results apply while controlling for age, sex, socioeconomic factors, hazardous drinking, and smoking. Increasing age seems to be protective in both women and men whereas poor economic situation, hazardous drinking, and smoking increase the risk of violence among the disabled. Some gender differences in the adjusted odds ratios of violence exposure between women and men with disabilities are seen, but there is no clear trend. In general, few studies are published on gender differences in disabled people probably due to the fact that many studies on violence exposure in disabled people include only women (Hughes et al., 2012; Hughes, Lund, Gabrielli, Powers, & Curry, 2011). In this study, socioeconomic factors, smoking, and hazardous drinking most often seemed to strengthen, although in a few cases weaken, the relation between impairment and violence. In general terms, these factors probably work as moderators affecting the direction and/or strength of the relation between the independent self-reported impairment and the dependent self-reported exposure to violence. The strengthening function of these factors acts together with the impairment and increases the relation between impairment and violence as a possible explaining factor for the violence. When the confounding factors weaken the relationship between impairment and exposure to violence, they are the more important explaining factors. It is probable that in socioeconomically vulnerable surroundings, with factors like living with a poor household economic situation, being born outside Sweden, or being poorly educated, different impairments might be accepted differently or adapted more or less easily. In short, having an impairment in different vulnerable situations lessens or strengthens the association to violence depending on the situation. The percentage of disabled women exposed to violence in this study is in congruence with data from another Swedish study with self-reported data on exposure to violence in women and men in different impairment groups (Swedish Research Institute for Disability Policy, 2007).

The study has some shortcomings, the main one being its design. Cross-sectional studies always present several clear shortcomings, but when it comes to the prevalence of violence and the association between impairment and violence, they are to date essentially the only method that has been used. Another possible limitation is the wording of the questions about abuse, which did not include a specification of different forms of physical violence or threats. A third problem was that the frequency of violence was not considered in the response alternatives.

Another shortcoming was the high non-response. The problem of non-response is general in all population-based surveys. The major problem is whether the non-responding individuals would have answered similarly to the ones who did answer. A Swedish study, using data from the Swedish National Survey of Public Health as the basis for its analyses, has put forward that the non-responders would have answered fairly similarly to those who did answer, and by using calibration weightings, possible differences can be reduced, allowing for the use of health surveys with low response rates (Lindén-Boström & Persson, 2013). Calibration made by the National Institute of Public Health for this study was used. Lee, Brown, Grant, Belin, and Brick (2009) have also demonstrated, by using an American large-scale population-based survey, that non-response did not affect the representativeness or usefulness of the results.

However, the strength of this study compared with earlier studies is the large population-representative sample, with both sexes reporting from different stages of life and with a comprehensive list of socioeconomic and individual variables. These variables gave the researchers the possibility to control for several possible confounders and to isolate the potential association between impairment and violence. The men and women answering the questions about different socioeconomic conditions or their individual situation did not do so because they had specifically been exposed to violence or because they had an impairment, but because they were answering a questionnaire about their general living conditions. In studies where specifically violence-exposed individuals with an impairment have been interviewed, the situation may have created a greater bias.

Hughes et al. (2012) presented a methodologically rigorous meta-analysis that shed light on the increased prevalence of the victimization of women and men with disabilities. Some areas were pointed out as inadequately researched, specifically people with sensory impairments. Even in high-income countries, data on prevalence and odds ratios for violence exposure for people with disabilities are lacking. Also, few studies have controlled for confounding factors. This study has filled some of those gaps.

The most important message emerging from this study is that attention should be called to violence in the group of people with physical or sensory disabilities, as they have a higher risk of being exposed to violence. In general, people with disabilities are a vulnerable population; they are older, have low income, low education, and high unemployment; and there is a higher disability prevalence in low income countries (WHO, 2011). In our study, from a high-income country with high social welfare, we have demonstrated a strong association between violence exposure in disabled men and women and socioeconomic factors as well as hazardous drinking. As this is a cross-sectional study, we cannot specify the direction of the effects, the disability, or the vulnerability.

Undivided attention should be given to the socioeconomic situation of people with different forms of disabilities, as it usually strengthened the association between disability and violence. Our study indicates that patterns of violence exposure and their association to disability among women and men in different age groups vary, thereby suggesting that different causes, histories, and dynamics are at play for different forms of associations between violence and impairment. The prevalence of violence, as well as the form of violence, varies throughout the age groups. It is a great challenge working in the social and health sector, to be aware of the increased risks of violence exposure in people with impairments and especially to take action against it. Interest should be focused on research and evaluation of the effects of screening disabled adults for violence exposure as the magnitude of positive effects have so far not been established in physically or mentally dysfunctional groups (Moyer & U.S. Preventive Services Task Force, 2013).

We believe that there are insights to be gained by addressing these issues from a Swedish perspective. Sweden has been a special case in discussions about welfare states and welfare regimes and has been referred to in the discussion about size of health inequalities, and the possibilities to battle health inequalities with social policies; still, the impact of socioeconomic factors on violence exposure among impaired men and women is unclear (Fritzell & Lundberg, 2007).

Conclusion

This study has provided representative results addressing a group of hitherto largely forgotten victims of violence that is men and women with different impairments. As a group, higher odds ratios for violence exposure were found for men and women with both sensory and physical impairments compared with those without impairments. Especially men with physical impairments and women with auditory impairments showed higher odds ratios of self-reported violence compared to non-disabled. These patterns of the association between impairment and violence were present even when controlling for age, country of birth, education, work status, economic situation, smoking, and hazardous drinking in both men and women.

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.

Author Biographies

Niclas Olofsson works as a statistican at the department of Research and Development in the County Council of Västernorrland. He also works as a senior lecturer at the Midsweden Univeristy.

Kent Lindqvist is a Professor in public health at the University of Linköping. He is also leading researcher at the university injury prevention team. WHO collaborating researcher.

Ingela Danielsson is a medical doctor and works as a senior lecturer at at the department of Research and Development in the County Council of Västernorrland. She also works as a senior lecturer at the University of Umeå.

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