Sage Journals: Discover world-class research

Abstract

This article examines the relationship between maternal exposure to adverse childhood experiences (ACEs), intimate partner violence (IPV), and two aspects of maternal mental well-being—stress and depressive symptoms in the context of Tirana, Albania. Data were obtained from a representative sample of 328 mothers of 2–3-year-old children, who were registered in Tirana's public nurseries. Findings show that maternal ACEs are positively associated with stress levels (β = .210, z = 4.03, p < .001) and depressive symptoms (β = .129, z = 2.62, p < .01). In addition, IPV partially mediates the effect of ACEs on maternal stress (β = .081, z = 3.75, p < .001) and fully mediates the effect of ACEs on depressive symptoms (β = .054, z = 2.87, p < .01). These results suggest that among mothers of toddlers in Tirana, ACEs influence stress levels both directly and via IPV, while they influence depressive symptoms only via IPV. The findings demonstrate long-term effects of maternal exposure to interpersonal violence on mental well-being.

Keywords

mental well-being violence mothers Tirana Albania

Introduction

The impact of interpersonal violence on a woman's mental well-being is well-documented, with experiences of victimization and interpersonal trauma rendering women vulnerable to a range of psychological disorders, such as anxiety, depression, and post-traumatic stress disorders (Pico-Alfonso et al., 2006; Satyanarayana et al., 2015). While compromised mental well-being is detrimental for women themselves, psychological depletion among women who are mothers has been further linked to poor parenting, including a detached mother–child interaction, a lack of affection/warmth, neglect, and the use of harsh, abusive, or otherwise ineffective discipline (Bornstein, 2015; Kim et al., 2010; Prendergast & MacPhee, 2020). Poor mental health in mothers has been demonstrated to have adverse consequences on their children's health and development (Liu et al., 2017; Maggi et al., 2010). While rates of maternal mental disorders in low- and middle-income countries (LMICs) are estimated to be higher than in high-income countries (HICs) (Hussain et al., 2020; Walker et al., 2007), prevalence rates on parental mental health in Albania specifically are currently lacking (UNICEF & Countdown to 2030 Women's, Children's and Adolescent's Health, 2021). Maternal care in Albania is mainly focused on medical care, and little has been done to address the psychosocial needs of mothers (Gori et al., 2010; Meçe, 2021).

Experiences of intimate partner violence (IPV) (DeVries et al., 2013; Gustafsson & Cox, 2012) and a history of childhood abuse and neglect (Guedes et al., 2016; Heidinger & Willson, 2019) have individually been identified as sources of poor mental well-being among mothers, including experiences of psychological stress and depressive symptoms. Nevertheless, the cumulative effects of different forms of interpersonal violence across the mother's lifespan on her mental well-being have been rarely investigated (Guedes et al., 2016; Kennedy et al., 2014). Researchers have been continuously calling for more efforts to bridge this divide, arguing that studies focused on one form of violence in isolation from others may overlook important risks, vulnerabilities, and consequences of multiple forms of violence within the family and across the lifespan (Lessar & Alvarez-Lizotte, 2015; Mercy et al., 2013). Moreover, while previous studies have found that women who experience adverse childhood experiences (ACEs) are more likely to encounter IPV during adulthood (Patel et al., 2012) and that health risks are particularly high among women who have experienced both ACEs and IPV (Becker et al., 2010), the underlying mechanisms between violence exposure during the life course and mental well-being outcomes remain rather unexplored (see Seon et al., 2022).

This article aims to address three issues. First, it presents novel data on maternal mental well-being and maternal exposure to interpersonal violence within the context of Tirana, Albania. Second, it examines the links between maternal ACEs and mental well-being, as measured by stress and depressive symptoms. Third, it examines IPV as a mediator of the effect of ACEs on stress and depressive symptoms among mothers of 2–3-year-old children in Tirana. The current study was guided by the following research questions: (a) How are ACEs associated with maternal levels of stress and depressive symptoms?; and (b) How does IPV mediate the relationship between ACEs and maternal levels of stress and depressive symptoms? The study hypothesized that: (a) ACEs will be positively associated with levels of maternal stress and depressive symptoms, and (b) IPV will mediate the relationship between ACEs and stress and depressive symptoms. Presenting novel evidence on the link between maternal exposure to interpersonal violence and maternal mental well-being in Albania's capital, Tirana, will help address the current gap in knowledge and has the potential to contribute to shaping policies that favor maternal, child, and family well-being in Albania. The article further contributes to the growing literature that attempts to increase international perspectives in the study of violence against women in LMICs.

Methods

Study Design and Sample

The questionnaire design of this study has been partly informed by the Evidence for Better Lives Study (EBLS), a comparative birth-cohort study led by the Violence Research Centre at the University of Cambridge (see Valdebenito et al., 2020). However, the present study is focused on mothers of toddlers rather than the period of pregnancy, as is the case in EBLS. This is a cross-sectional study that took place in Tirana, the capital and most populous city in Albania (INSTAT, 2018). With an area of 41.8 square kilometers, it is located in the center of the country, and it is the leading economic and political center in Albania. Its population in 2020 amounted to 850,530 inhabitants (Bashkia Tiranë, 2020). Tirana has 11 administrative units, which Dumani et al. (2018) have grouped into four main clusters based on these units’ socio-economic development, and 34 public nurseries. Public nurseries were the location of participant recruitment. Eight out of the 34 public nurseries in Tirana were selected to participate in the study. The sample consists of a representative sample of 328 mothers of 2–3-year-old toddlers, who were registered in Tirana's public nurseries.

The nurseries were the unit of randomization, and they were randomly selected based on the socio-economic status of the geographical area in which they were located. Three main steps were followed to select the final target sample of eight nurseries. First, all the 34 public nurseries in Tirana were grouped by administrative units. Second, the nurseries were allocated the cluster score of the unit they were located in. Each developmental cluster was given a number from one to four. Third, two nurseries per cluster were selected through systematic random sampling, with the sampling fraction per cluster being calculated by dividing two with the total number of nurseries in each respective cluster. Mothers of 2–3-year-old children were contacted in each of the chosen nurseries based on convenience and availability, with the number of participants per nursery ranging from 38 to 45. Four inclusion criteria guided the recruitment of mothers: (a) They had to live in the same administrative unit as the nursery at hand; (b) They had to have at least one child aged 2–3 years old; (c) Their toddler had to be registered in the nursery at hand; (d) The mother had to be older than 18 years of age. The overall participation rate was 84%.

Instruments and Measures

Dependent Variables

Stress. The level of maternal stress in the past month was measured by the Perceived Stress Scale (PSS) (Cohen, 1994; Cohen et al., 1983; Cohen & Williamson, 1988). This scale consists of 10 items that measure how stressful certain life situations are rated by respondents during the last month, via a 5-point Likert scale. Nevertheless, for the purposes of this study, the scale was adapted to a 4-point Likert scale: Not at all = 1; Several days = 2; More than half the days = 3; and Nearly every day = 4. Mean scores were calculated to build the stress composite measure with four items being reverse-coded (α = .78). Possible scores range from 1 to 4 with higher scores indicating higher levels of stress. A recent study conducted by Katus et al. (2022) has established the psychometric utility of PSS in assessing stress across eight culturally diverse LMICs.

Depressive Symptoms. The Patient Health Questionnaire (PHQ-9) was used to measure the severity of depressive symptoms experienced by the mother in the last month (Kroenke et al., 2001). Questions measure anhedonia, dysphoria, sleep disturbances, fatigue, changes in eating, low self-esteem, concentration difficulties, hypo- or hyperactive behaviors, and thoughts of suicide in the past month. Each item is rated on a 4-point Likert scale: Not at all = 0; Several days = 1; More than half the days = 2; and Nearly every day = 3. Mean scores were calculated to build the depression composite measure (α = .77). Possible scores range from 0 to 3 with higher scores indicating more severe depressive symptoms. A recent study examining the psychometric comparability of PHQ-9 in antenatal samples across eight LMICs found that PHQ-9 yielded internally consistent scores (Murray et al., 2022).

Independent Variables

ACEs. Maternal adverse experiences before the age of 18 were measured via 18 adapted items out of 31 items of the ACE-International questionnaire (World Health Organization, 2011). The 18 items included in the current study belonged to the following nine domains: (a) living with substance abusers; (b) living with household members who were mentally ill or suicidal; (c) living with household members who were imprisoned; (d) parental separation or divorce, one or no parents; (e) violence against household members; (f) emotional abuse; (g) physical abuse; (h) sexual abuse; and (i) physical neglect. The first four domains, which consist of five items, ask yes/no questions, while the items in the rest of the domains are rated on a 4-point Likert scale: Never = 1; Once = 2; A few times = 3; and Many times = 4. The ACEs composite measure consists of the sum scores of the first five items and the dichotomized versions of the rest of the 13 items.

IPV. Exposure to IPV during the mother's lifetime was measured using an adapted scale extracted from the World Health Organization's (2005) Multi-country Study on Women's Health and Domestic Violence Against Women (also see Garcia-Moreno et al., 2006). Seven items measure controlling behavior by the current partner, six items measure physical IPV, four items measure emotional IPV, and three items measure sexual IPV (No = 0; Yes = 1). The composite measure of lifetime IPV was calculated by summing up the yes/no items on controlling behavior as well as the items on physical, emotional, and sexual IPV. Possible scores range from 1 to 20 with higher scores indicating higher exposure to IPV.

Control Variables

Control variables included in the mediation models involved the following: mother's age (open answer, continuous), mother's educational level (0 = below undergraduate degree; 1 = undergraduate degree or above), mother's birthplace by Albanian prefectures (0 = all prefectures other than Tirana; 1 = Tirana), mother's employment status (0 = not employed; 1 = employed), mother's marital status (0 = not married; 1 = married), whether the mother had suffered from postnatal depression (0 = no; 1 = yes), mother's ethnicity (0 = not Albanian; 1 = Albanian), mother's number of children (ordinal, but treated as continuous), household income (ordinal, but treated as continuous), whether the biological father of the target toddler ever abused with alcohol or drugs (0 = no; 1 = yes), whether the biological father of the target toddler was ever criminally convicted (0 = no; 1 = yes), and the mode of questionnaire delivery (measured by two dummy variables: the first variable was coded as 0 = self-completed, 1 = face-to-face interview; the second variable was coded as 0 = self-completed, 1 = online interview).

Translation and Data Collection

The instruments were translated in whole by four individuals, who were native Albanian speakers, proficient in English, and who were familiar with psychometrics as well as the health sector. Three modes of questionnaire delivery were employed to collect the data: face-to-face interview (N = 170), self-completed (N = 116), and online interview (N = 42).¹ While the initial plan was to only conduct face-to-face interviews, adaptations had to be made due to the COVID-19 pandemic as well as the participants’ availability. The data collection process was carried out single-handedly by the first author and lasted from September 2020 to May 2021.

The influence that the delivery mode of the questionnaires (face-to-face vs. self-completed vs. online interview) could have had on the validity of the collected data was explored for the following constructs: maternal depression, perceived stress, ACEs, IPV, developmental level of the neighborhood in which the mother resides, mother's age, mother's birthplace (as coded by Albanian regions), mother's education, and her employment status. For the purposes of these analyses, the coding of the “mode” variable was done as follows: Face-to-face interview = 1; Self-completed = 2; Online interview (phone and WhatsApp) = 3.

One-way ANOVAs were conducted to determine if the means of the continuous constructs differed depending on the modes of administration. Statistically significant differences between groups at the 1% and 0.1% level were found for stress [F(2, 322) = 4.74; p < .01], depressive symptoms [F(2, 324) = 31.56; p < .001], ACEs [F(2, 324) = 7.08; p < .01], and IPV [F(2, 319) = 4.70; p < .01]. Tukey post-hoc tests revealed that all continuous constructs were in general significantly higher in the “Face-to-face interview” group and the “Online interview” group when compared to the “Self-completed” group (see Table 1). These results suggest that mothers were less likely to disclose undesirable outcomes such as exposure to violence and poor mental well-being when the mode of administration of the questionnaire was self-completed.

Table 1.

Means, Standard Deviations, and One-Way Analyses of Variance of Key Continuous Constructs According to the Mode of Delivery.

	Face-to-face interview (1)		Self-completed (2)		Online interview (3)			Post-hoc test (Tukey)
Measure	M	SD	M	SD	M	SD	One-way ANOVA	Group comp.	Mean diff.	p
Depressive symptoms	.74	.43	.38	.30	.76	.51	F(2, 324) = 31.56 p < .001	2 vs 1	−.36	<.001
								3 vs 1	.02	.959
								3 vs 2	.38	<.001
Stress	1.90	.48	1.75	.44	1.96	.49	F(2, 322) = 4.74 p < .01	2 vs 1	−.15	.022
								3 vs 1	.06	.074
								3 vs 2	.21	.035
ACEs	3.27	2.27	2.40	2.05	3.57	2.23	F(2, 324) = 7.08 p < .01	2 vs 1	−.87	<.01
								3 vs 1	.31	.698
								3 vs 2	1.17	<.01
IPV	.98	1.83	.52	.99	1.27	1.61	F(2, 319) = 4.70 p < .01	2 vs 1	−.46	<.05
								3 vs 1	.29	.541
								3 vs 2	.75	<.05

Note: Between-group comparisons (Tukey post-hoc test): significant at p < .05; p < .01 and p < .001. Non-significant between-group comparison presented in bold.

Chi-square tests of independence were run to check if the counts and percentages of the categorical constructs differed depending on the different modes of administration. Significant associations at the 1% and 0.1% level were found between the mode of delivery and neighborhood socio-economics status [χ² (6, N = 328) = 17.37, p < .01] and between the mode of delivery and mothers’ employment status [χ² (2, N = 328) = 16.19, p < .001]. Mothers from a high SES neighborhood were more likely to be interviewed face-to-face, while mothers from a low and medium (1) SES neighborhood were more likely to opt out for self-completion. Mothers who were unemployed were more likely to be interviewed face-to-face (83.33%) as compared to mothers who were working (47.95%). This might be explained by the fact that mothers who were unemployed were more available and had less commitments than employed mothers.

The face-to-face interviews were carried out in the form of structured paper-and-pen interviews (PAPI). Despite the advantages of Computer-Assisted Personal Interviews (CAPI), the use of PAPI still persist in developing countries given the limitations in technology and internet access (Campbell et al., 2014). Even on its own, PAPI has several advantages, such as being less costly and/or allowing for a shorter period of data collection when compared to CAPI (Caeyers et al., 2010; Lavrakas, 2008).

Data Analysis

Characteristics of the study population were described using counts and percentages for categorical variables, and means (SD) for continuous variables. Two path analyses models were conducted to examine whether IPV mediated the effect of ACEs on stress and depressive symptoms, respectively. The effects that these three main constructs have on each other should be interpreted with caution given that the data are cross-sectional. The estimation method of the path analyses in this study was done with maximum likelihood parameters. Full information maximum likelihood estimation was used to handle missing data by preserving all available data that would most likely produce the estimates from the study sample (Acock, 2005). All analyses were conducted using STATA IC Release16. Materials and analysis code for this study are available by emailing the corresponding author.

Ethical Considerations

Ethical approval and institutional access were obtained from the Institute of Criminology, University of Cambridge and the General Directory of Nurseries and Kindergartens at the Municipality of Tirana. Permission to conduct the study was also obtained by each director of the eight nurseries selected to participate in the study. Before starting the data collection process, all participating mothers were given information sheets and asked to sign an informed consent form.

Results

Table 2 presents the characteristics of the study population, based on the constructs that are included in the mediation models. The mothers’ mean age was 32.3 years (SD = 4.24), with a range between 22 and 46 years. Most mothers were Albanian (95.4%), were married (87.50%), had one child (50.91%), had worked in the last 12 months (89.02), had not suffered from postnatal depression (71.34%), and had finished undergraduate studies or above (83.54%). The majority of mothers had a monthly household income of 60,000–100,000 ALL² (34.15%). Concerning fathers’ characteristics, most had never been criminally convicted (96.65%) and had never abused with substances (96.95%). The majority of mothers had experienced at least one type of ACE (89%), with 20.18% of mothers having experienced four ACEs or more. In total, 51.24% had experienced at least one type of IPV (controlling behavior, emotional, physical, or sexual violence) in their lifetime, with 28.57% of mothers enduring controlling behavior from their partners, 40.06% having experienced emotional IPV, 13.35% physical abuse, and 0.93% sexual abuse.

Table 2.

Descriptive Statistics of the Key Variables.

Characteristics		Mean scores/sum scores/count	Percentage (%)
Dependent Variables
Maternal depression	Mean (SD)	0.62 (0.44)
Maternal depression	Possible scale range	0–3
Maternal perceived stress	Mean (SD)	1.86 (0.48)
Maternal perceived stress	Possible scale range	1–4
Independent Variables
Mother's adverse childhood experiences	Mean (SD)	2.99 (2.23)
	Possible scale range	0–18
	At least one type	291	89.00
	<4	261	79.82
	≥4	66	20.18
Mother's lifetime intimate partner violence	Mean (SD)	1.37 (2.45)
	Median [Min, Max]	0 [0, 17]
	Possible score range	0–20
	At least one type	165	51.24
	Controlling behavior	92	28.57
	Emotional IPV	129	40.06
	Physical IPV	43	13.35
	Sexual IPV	3	0.93
Control Variables
Age (years)	Mean (SD)	32.3 (4.24)
Age (years)	Median [Min, Max]	32 [22, 46]
Ethnicity	Albanian	313	95.4
Ethnicity	Not Albanian	15	4.6
Birthplace (prefectures)	Tirana	121	36.89
Birthplace (prefectures)	Not Tirana	205	62.50
Marital status	Married	287	87.50
Marital status	Not married	41	12.50
Number of children	1	167	50.91
	2	130	39.63
	3	28	8.54
	4+	3	0.91
Education	Below undergraduate degree	54	16.46
Education	Undergraduate degree or above	274	83.54
Mother postnatal depression	Yes	93	28.35
Mother postnatal depression	No	234	71.34
Paid work in the last 12 months	Yes	292	89.02
Paid work in the last 12 months	No	36	10.98
Household monthly income (ALL)	<30,000	16	4.88
	30,000–60,000	71	21.65
	60,000–100,000	112	34.15
	100,000–200,000	77	23.48
	>200,000	15	4.57
Father's lifetime substance abuse	Yes	8	2.44
Father's lifetime substance abuse	No	318	96.95
Father's lifetime criminal conviction	Yes	10	3.05
Father's lifetime criminal conviction	No	317	96.65
Mode of delivery	Face-to-face interview	170	51.83
	Self-completed	116	35.37
	Online interview	42	12.80

A path analysis was estimated to test the mediating effect of IPV in the relationship between maternal ACEs and stress, while holding the control variables constant (see Table 3). The fitted model (χ² = 227, p < .001; CFI = 1.0; RMSEA = .00, p = 1.0; CD = .455) used all 328 observations. The results show that maternal ACEs are positively associated with stress levels (β = .210, z = 4.03, p < .001). Analyzing the indirect effects, results reveal that IPV significantly mediates the relationship between ACEs and stress (β = .081, z = 3.75, p < .001). Nevertheless, the results also suggest that even after accounting for the mediating role of IPV, ACEs still have an effect on stress (β = .129, z = 2.42, p < .05). Results indicate that the proportion of total effect mediated by IPV is 38.6%, thus suggesting that IPV partially mediates the effect of ACEs on stress, while holding the control variables constant. It is assumed that ACEs temporally precede current stress and/ or IPV by the retrospectively reported adverse experiences before 18 years of age. While this directionality is less clear when it comes to IPV and stress, the temporal directionality from IPV to stress is assumed by the fact that IPV was measured during the mothers’ lifetime, while stress was captured only for the past month. Nevertheless, the fact that the data were gathered cross-sectionally should be kept in mind when interpreting the path analyses.

Table 3.

IPV as a Mediator of ACEs and Stress.

Effect	β	SE	Z	p-value
Direct (ACEs)	.129	.011	2.42	<.05
Indirect	.081	.004	3.75	<.001
Total	.210	.011	4.03	<.001

A further path analysis was estimated to test the mediating effect of IPV in the relationship between ACEs and depressive symptoms, while holding the control variables constant (see Table 4). The fitted model (χ² = 254, p < .001; CFI = 1.0; RMSEA = .00, p = 1.0; CD = .514) used all 328 observations. The results show that ACEs are positively associated with depressive symptoms (β = .129, z = 2.62, p < .01). Analyzing the indirect effects, results reveal that IPV significantly mediates the relationship between ACEs and depressive symptoms (β = .054, z = 2.87, p < .01). The results also suggest that after accounting for the mediating role of IPV, ACEs does not have an effect on depressive symptoms, thus suggesting that IPV fully mediates the effect of ACEs on depressive symptoms, while holding the control variables constant. It is assumed that ACEs temporally precede depressive symptoms and/or IPV by the retrospectively reported adverse experiences before 18 years of age. While this directionality is less clear when it comes to IPV and depressive symptoms, the temporal directionality from IPV to depressive symptoms is assumed by the fact that IPV was measured during the mothers’ lifetime, while stress was captured only for the past month. Nevertheless, the fact that the data were gathered cross-sectionally should be kept in mind when interpreting the path analyses.

Table 4.

IPV as a Mediator of ACEs and Depressive Symptoms.

Effect	β	SE	Z	p-value
Direct (ACEs)	.088	.075	1.46	.143
Indirect	.054	.004	2.87	<.01
Total	.129	.009	2.62	<.01

Discussion

This study revealed that almost 90% of the mothers of 2–3-year-old children in Tirana had been exposed to at least one type of ACE (89%). This percentage is higher than the existing studies on adults’ ACEs in Albania. For example, a study conducted by Qirjako et al. (2013) on the prevalence of ACEs found that 72.4% of Albanian young adults—representatively selected from public universities in major cities (N = 1,437)—had experienced at least one ACE. Compared to other countries in the region, the findings of the current study also report a higher prevalence of adults’ exposure to ACEs, with 70% of adults having experienced at least one form of ACE in Serbia (Kostić et al., 2019) and 64.5% of young adults having experienced at least one form of ACE in Romania (Baban et al., 2013). The disparities in percentages of ACEs across these studies might be attributed to the different target populations, with the participants of the current study being women only and generally born during a period of socio-economic and political turmoil in Albania.

The prevalence of lifetime IPV among mothers of toddlers in Tirana (51.24%) however seems to be similar to the ones reported in previous studies on violence against women by intimate partners conducted in Albania (one in two women; UNDP, 2018) and in Kosovo (54% of women; OSCE, 2019a), but higher than the percentages reported in Bulgaria (28%; Gender Equality Index, 2017) and Bosnia and Hercegovina (36%; OSCE, 2019b). It is of worth to note however that the lifetime IPV composite measure in the current study includes “controlling behavior” in addition to physical, emotional, and sexual violence, while that is not always the case for other similar studies. Another interesting finding was the fact that the majority of mothers in the current study (83.54%) held an undergraduate degree, while the OECD estimate of 25–34-year-olds with tertiary education is 45.6% (OECD, 2022). This might be related to the fact that the study took place in the capital, to the low quality and increased access to higher education in Albania (Latifi, 2010; Mora et al., 2015), or to the potential reluctance of mothers with lower levels of education to participate in the study.

Regarding maternal ACEs, we see that it is significantly associated with both stress and depressive symptoms while holding the control variables constant, which supports the study hypothesis (a). This finding is in line with previous studies that have found a link between ACEs and adult mental health issues (Hughes et al., 2017; Karatekin, 2018; Watt et al., 2020). The standardized coefficient of total effects of ACEs on stress levels was higher than on depressive symptoms. One of the reasons that might explain these results can be the notion that it is stress and its biological implications that lead to depressive symptoms. Previous studies have found that consistent experiences of stress, such as the long-lasting effects of stressful experiences during childhood, can lead to neurobiological disturbances underlying depression or particular depressive symptoms (Chrousos, 2009; Guilliams & Edwards, 2010; Tafet & Nemeroff, 2016; van Praag, 2004). The finding that maternal ACEs are associated with maternal stress levels and depressive symptoms suggests the need for initiatives that take into consideration the long-term effects of ACEs on adult mental well-being. Early prevention and intervention strategies, such as parent training programs, home visitations, or building safe communities, would help ensure a healthy start for children by alleviating or preventing future harm from ACEs, including compromised mental well-being or the potential transmission of intergenerational abuse. Previous research has indeed found that the effects of ACEs, such as mental health issues, function as mediating factors for the intergenerational transmission of child maltreatment (Chang et al., 2020; Frias-Armenta, 2002; Jaffee et al., 2013).

Additionally, the results showed that IPV fully mediated the effect that ACEs had on depressive symptoms and partially mediated the effect that ACEs had on stress levels, while holding all the control variables constant. This supports the study hypothesis (b). A similar conclusion was reported by Seon et al. (2022), who found that IPV partially mediated the effect that ACEs had on perceived physical health, mental health, and depression among a sample of college students in the United States. Nevertheless, contrary to the results reported by Seon et al. (2022), the current study found partial mediation only for stress and a full mediation for depressive symptoms. It can be argued that the effect of ACEs on depressive symptoms among mothers diminishes when compared to the effect of IPV, given the threat and abuse from the partner is present, on-going, and has several current implications on an emotional, physical, and financial level both for the mother and for the child. Future research needs to look at specific developmental processes that are disrupted by ACEs and how those negative experiences are particularly related to stress levels and depressive symptoms. Overall, the result from the current study, which shows that exposure to ACEs influences mental well-being outcomes via IPV among mothers of toddlers in Tirana, suggests a pathway of cumulative effects on maternal mental well-being from a series of lifetime interpersonal violence victimizations.

Strengths and Limitations

The main strengths of this study are related to the fact that it makes use of a probabilistic rather than a convenience sampling method, to the relatively high overall participation rate (84%), to all the data being collected by the first author, and to it presenting novel data on maternal mental well-being in Albania. The limitations are concerned with the limited sample size, the delivery of the questionnaire through three different modes of data collection, the restricted possibility of generalizing the findings to all Albanian mothers, the study outcomes being self-reported, as well as with the fact that this is a cross-sectional rather than a longitudinal study, which thus prevents one from drawing causal conclusions about the data. The limitation of using cross-sectional data is particularly relevant for the interpretation of the results from the mediation analyses (see Fairchild & McDaniel, 2017; Maxwell et al., 2011; Maxwell & Cole, 2007). Even though it can be argued that temporal order is established in the collected data due to the fact that ACEs took place before IPV, the participants’ recall of ACEs could have been influenced by their current psycho-emotional state. The use of PAPI instead of CAPI could also be considered a possible limitation.

Conclusions

This study was an initial attempt at uncovering the unexplored patterns of associations between exposure to interpersonal violence and mental well-being among mothers of 2–3-year-old children in Tirana, Albania. The results showed that ACEs were positively associated both with maternal stress levels and depressive symptoms. Path analyses also found that IPV partially mediated the effect that ACEs had on maternal stress and fully mediated the effect of ACEs on depressive symptoms. Both hypotheses of the current study were confirmed. The findings suggest the promotion of initiatives in favor of maternal support, maternal psychological well-being, and gender equality, as well as the elimination of violence against women and children. Future studies should consider increasing the sample size, taking a longitudinal approach to data collection, and employing a single mode of questionnaire delivery.

Footnotes

Acknowledgments

The authors would like to thank all the mothers who participated in the study, as well as the General Directory of Nurseries and Kindergartens at the Municipality of Tirana for the great collaboration.

Declaration of Conflicting Interests

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

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Newnham College and Cambridge Trust.

ORCID iD

Klea Ramaj

Author Contributions

Klea Ramaj conducted the majority of the work for this manuscript. She planned the study, collected the data, ran the analyses, and wrote the manuscript. Manuel Eisner supervised the research process and made comments on iterative drafts of the manuscript.

Notes

Author Biographies

Klea Ramaj is a PhD candidate in Criminology at the Institute of Criminology, University of Cambridge and a Senior Research Associate in Child Wellbeing at the Policy Evaluation and Research Unit (PERU), Manchester Metropolitan University. She holds a BA (cum laude) in Social Sciences from University College Maastricht and an MPhil in Criminological Research from the University of Cambridge. In her research, Klea employs a victim-centered approach and is particularly interested in shedding light on the voices of marginalized women and children in low- and middle-income countries. She is skilled in both qualitative and quantitative research.

Manuel Eisner is the Wolfson Professor of Criminology and Director of the Institute of Criminology, University of Cambridge. His research interests include the causes and consequences of violence, violence prevention, developmental and life course patterns of victimization and antisocial behavior, and comparative and historical macro-criminology. He is also adjunct professor at the Jacobs Center for Productive Youth Development of the University of Zurich. He is founding director and co-PI of the Zurich Study on Social Development from Childhood to Adulthood, a 20-year multi-informant longitudinal study.

References

Acock

A. C.

(2005). Working with missing values. Journal of Marriage and Family, 67(4), 1012–1028. https://doi-org.ezp.lib.cam.ac.uk/10.1111/j.1741-3737.2005.00191.x

Baban

Cosma

Balazsi

Sethi

Olsavszky

(2013). Survey of adverse childhood experiences among Romanian university students: Study report from the 2012 survey. World Health Organization. Regional Office for Europe. https://apps.who.int/iris/handle/10665/107317

Bashkia Tiranë. (2020). Popullsia e Tiranës. [The Municipality of Tirana (2020). The Population of Tirana]. https://opendata.tirana.al/?q=popullsia-e-tiranC3ABs-2020

Becker

K. D.

Stuewig

McCloskey

L. A.

(2010). Traumatic stress symptoms of women exposed to different forms of childhood victimization and intimate partner violence. Journal of Interpersonal Violence, 25(9), 1699–1715. https://doi.org/10.1177/0886260509354578

Bornstein

M. H.

(2015). Children’s parents. In Bornstein

M. H.

Leventhal

Lerner

R. M.

(Eds.), Handbook of child psychology and developmental science. Volume 4: Ecological settings and processes (7th Ed., pp. 55–132). John Wiley & Sons Inc.

Caeyers

Chalmers

De Weerdt

(2010). A comparison of CAPI and PAPI through a randomized field experiment. https://ssrn.com/abstract=1756224 or https://doi.org/10.2139/ssrn.1756224

Campbell

A. A.

Cherry

Ryerson

Jones

(2014). Better pen-and-paper surveys for transportation research in developing countries: A modified, stated preference, pivoting approach. Transportation Research Record: Journal of the Transportation Research Board, 2405(1), 42–48. https://doi.org/10.3141/2405-06

Chang

Y.-T.

Feng

J.-Y.

Chang

H.-Y.

Chang

Y.-C.

Lee

C.-K.

(2020). The impacts of maternal childhood adversity, stress, and mental health on child development at 6 months in Taiwan: A follow-up study. Development and Psychopathology, 33(3), 970–979. https://doi.org/10.1017/S0954579420000267

Chrousos

G. P.

(2009). Stress and disorders of the stress system. Nature Reviews Endocrinology, 5(7), 374–381. https://doi.org/10.1038/nrendo.2009.106

10.

Cohen

(1994). Perceived stress scale. Mindgarden, 1–5.

11.

Cohen

Kamarck

Mermelstein

(1983). A global measure of perceived stress. Journal of Health and Social Behaviour, 24(4), 385–396. https://doi.org/10.2307/2136404

12.

Cohen

Williamson

G. M.

(1988). Perceived stress in a probability sample of the United States. In Spacapan

Oskamp

(Eds.), The social psychology of health (pp. 31–67). Sage.

13.

DeVries

K. M.

Mak

J. Y. T.

García-Moreno

Petzold

Child

J. C.

Falder

Lim

Bacchus

L. J.

Engell

R. E.

Rosenfeld

Pallitto

Vos

Abrahams

Watts

C. H.

(2013). The global prevalence of intimate partner violence against women. Science, 340(6140), 1527–1528. https://doi.org/10.1126/science.1240937

14.

Dumani

Bici

Dumani

Subashi

Kondi

(2018). Dissemination of demographic and socio-economic developments in Tirana with special attention to youth education. Journal of Educational and Social Research, 8(2), 93–108. https://doi.org/10.2478/jesr-2018-0020

15.

Fairchild

A. J.

McDaniel

H. L.

(2017). Best (but oft-forgotten) practices: Mediation analysis. The American Journal of Clinical Nutrition, 105(6), 1259–1271. https://doi.org/10.3945/ajcn.117.152546

16.

Frias-Armenta

(2002). Long-term effects of child punishment on Mexican women: A structural model. Child Abuse & Neglect, 26(4), 371–386. https://doi.org/10.1016/S0145-2134(02)00314-9

17.

Garcia-Moreno

Jansen

H. A. F. M.

Ellsberg

Heise

Watts

C. H.

(2006). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence. Lancet, 368, 1260–1269. https://doi.org/10.1016/S0140-6736(06)69523-8

18.

Gender Equality Index. (2017). Violence indicators in Bulgaria. https://eige.europa.eu/gender-equality-index/2017/domain/violence/BG

19.

Gori

Pivetta

Tamburlini

(2010). Assessment of maternal and child health consulting services in Albania. https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.638.5008&rep=rep1&type=pdf

20.

Guedes

Bott

Garcia-Moreno

Colombini

(2016). Bridging the gaps: A global review of intersections of violence against women and violence against children. Global Health Action, 9(1), 1–15. https://doi.org/10.3402/gha.v9.31516

21.

Guilliams

T. G.

Edwards

(2010). Chronic stress and the HPA axis. The Standard, 9(2), 1–12.

22.

Gustafsson

H. C.

Cox

M. J.

(2012). Relations among intimate partner violence, maternal depressive symptoms, and maternal parenting behaviors. Journal of Marriage and Family, 74(5), 1005–1020. https://doi.org/10.1111/j.1741-3737.2012.01010.x

23.

Heidinger

L. S.

Willson

A. E.

(2019). The childhood roots of adult psychological distress: Interdisciplinary perspectives toward a better understanding of exposure to cumulative childhood adversity. Child Abuse & Neglect, 97, 104–136. https://doi.org/10.1016/j.chiabu.2019.104136

24.

Hughes

Bellis

M. A.

Hardcastle

K. A.

Sethi

Butchart

Mikton

Jones

Dunne

M. P.

(2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public Health, 2(8), 356–366. https://doi.org/10.1016/S2468-2667(17)30118-4

25.

Hussain

Zahra

Hussain

(2020). Prevalence and risk factors of domestic violence and its impacts on women’s mental health in Gilgit-Baltistan, Pakistan. Pakistan Journal of Medical Sciences, 36(4), 627–631. https://doi.org/10.12669/pjms.36.4.1530

26.

INSTAT. (2018). Albanian Demographic and Health Survey 2017-18. Institute of Statistics, Institute of Public Health, and ICF Macro.

27.

Jaffee

S. R.

Bowes

Ouellet-Morin

Fisher

H. L.

Moffitt

T. E.

Merrick

M. T.

, et al. (2013). Safe, stable, nurturing relationships break the intergenerational cycle of abuse: A prospective nationally representative cohort of children in the United Kingdom. Journal of Adolescent Health, 53(4), 4–10. https://doi.org/10.1016/j.jadohealth.2013.04.007

28.

Karatekin

(2018). Adverse childhood experiences (ACEs), stress and mental health in college students. Stress and Health, 34(1), 36–45. https://doi.org/10.1002/smi.2761

29.

Katus

Foley

Murray

A. L.

Luong-Thanh

B. Y.

Taut

Baban

Madrid

Fernando

A. D.

Sikander

Ward

C. L.

Osafo

Marlow

Du Toit

Walker

Van Vo

Fearon

Valdebenito

Eisner

M. P.

Hughes

(2022). Perceived stress during the prenatal period: Assessing measurement invariance of the Perceived Stress Scale (PSS-10) across cultures and birth parity. Archives of Women's Mental Health, 25(3), 633–640. https://doi.org/10.1007/s00737-022-01229-5

30.

Kennedy

A. C.

Bybee

Greeson

M. R.

(2014). Examining cumulative victimization, community violence exposure, and stigma as contributors to PTSD symptoms among high-risk young women. American Journal of Orthopsychiatry, 84(3), 284–294. https://doi.org/10.1037/ort0000001

31.

Kim

H. K.

Pears

K. C.

Fisher

P. A.

Connelly

C. D.

Landsverk

J. A.

(2010). Trajectories of maternal harsh parenting in the first 3 years of life. Child Abuse & Neglect, 34(12), 897–906. https://doi.org/10.1016/j.chiabu.2010.06.002

32.

Kostić

Lazarević

Maravić

V. M.

Vončina

M. M.

Kirćanski

J. R.

Stojković

Videnović

(2019). Adverse childhood experiences study. UNICEF. https://www.unicef.org/serbia/media/10726/file/Adverse%20Childhood%20Experiences %20(ACE)%20Study.pdf

33.

Kroenke

Spitzer

R. L.

Williams

J. B.

(2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

34.

Latifi

(2010). Politics and procedures to fight corruption in higher education in Albania. International Journal for Education Law and Policy, 6, 61–71.

35.

Lavrakas

P. J.

(2008). Paper-and-Pencil-Interviewing (PAPI). In Lavrakas

P. J.

(Ed.), Encyclopedia of survey research methods (pp. 573–574). Sage Publications.

36.

Lessar

Alvarez-Lizotte

(2015). The exposure of children to intimate partner violence: Potential bridges between two fields in research and psychosocial intervention. Child Abuse Neglect, 48, 29–38. https://doi.org/10.1016/j.chiabu.2015.05.004

37.

Liu

Kaaya

Chai

McCoy

D. C.

Surkan

P. J.

Black

M. M.

Sutter-Dallay

A.-L.

Verdoux

Smith-Fawzi

M. C.

(2017). Maternal depressive symptoms and early childhood cognitive development: A meta-analysis. Psychological Medicine, 47(4), 680–689. https://doi.org/10.1017/S003329171600283X

38.

Maggi

Irwin

L. J.

Siddiqi

Hertzman

(2010). The social determinants of early child development: An overview. Journal of Paediatrics and Child Health, 46(11), 627–635. https://doi.org/10.1111/j.1440-1754.2010.01817.x

39.

Maxwell

S. E.

Cole

D. A.

(2007). Bias in cross-sectional analyses of longitudinal mediation. Psychological Methods, 12(1), 23–44. https://doi.org/10.1037/1082-989X.12.1.23

40.

Maxwell

S. E.

Cole

D. A.

Mitchell

M. A.

(2011). Bias in cross-sectional analyses of longitudinal mediation: Partial and complete mediation under an autoregressive model. Multivariate Behavioral Research, 46(5), 816–841. https://doi.org/10.1080/00273171.2011.606716

41.

Meçe

(2021). The importance of routine screening for postpartum depression in Albania. Food, Sustainability, Nutrition and Tourism, 323–327.

42.

Mercy

Saul

Hillis

(2013). The importance of integrating efforts to prevent violence against women and children. UNICEF Office of Research.

43.

Mora

J. G.

Ferreira

Vidal

Vieira

M. J.

(2015). Higher education in Albania: Developing third mission activities. Tertiary Education and Management, 21(1), 29–40. https://doi.org/10.1080/13583883.2014.994556

44.

Murray

A. L.

Hemady

C. L.

Dunne

Foley

Osafo

Sikander

Madrid

Baban

Taut

Ward

C. L.

Fernando

Thang

V. V.

Eisner

Hughes

Fearon

Valdebenito

Tomlinson

Pathmeswaran

Walker

(2022). Measuring antenatal depressive symptoms across the world: A validation and cross- country invariance analysis of the Patient Health Questionnaire-9 (PHQ-9) in eight diverse low-resource settings. Psychological Assessment, 34(11), 993–1007. https://doi.org/10.1037/pas0001154

45.

OECD. (2022). Population with tertiary education (indicator) . Retrieved August 30, 2022, from https://doi.org/10.1787/0b8f90e9-en

46.

OSCE. (2019a). Well-being and safety of women in Kosovo. https://www.osce.org/mission-in-kosovo/439781

47.

OSCE. (2019b). Well-being and safety of women in Bosnia and Hercegovina. https://www.osce.org/files/f/documents/3/5/423470_1.pdf

48.

Patel

M. N.

Bhaju

Thompson

M. P.

Kaslow

N. J.

(2012). Life stress as mediator of the childhood maltreatment–intimate partner violence link in low-income, African American women. Journal of Family Violence, 27, 1–10. https://doi.org/10.1007/s10896-011-9398-9

49.

Pico-Alfonso

M. A.

Garcia-Linares

M. I.

Celda-Navarro

Blasco-Ros

Echeburúa

Martinez

(2006). The impact of physical, psychological, and sexual intimate male partner violence on women's mental health: Depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. Journal of Women's Health, 15(5), 599–611. https://doi.org/10.1089/jwh.2006.15.599

50.

Prendergast

MacPhee

(2020). Trajectories of maternal aggression in early childhood: Associations with parenting stress, family resources, and neighborhood cohesion. Child Abuse & Neglect, 99, Article 104315. https://doi.org/10.1016/j.chiabu.2019.104315

51.

Qirjako

Burazeri

Sethi

Miho

(2013). Community survey on prevalence of adverse childhood experiences in Albania. World Health Organisation.

52.

Satyanarayana

V. A.

Chandra

P. S.

Vaddiparti

(2015). Mental health consequences of violence against women and girls. Current Opinion in Psychiatry, 28(5), 350–356. https://doi.org/10.1097/YCO.0000000000000182

53.

Seon

Cho

Choi

G. Y.

Son

Allen

Nelson

Kwon

(2022). Adverse childhood experiences, intimate partner violence victimization, and self-perceived health and depression among college students. Journal of Family Violence, 37(4), 691–706. https://doi.org/10.1007/s10896-021-00286-1

54.

Tafet

G. E.

Nemeroff

C. B.

(2016). The links between stress and depression: Psychoneuroendocrinological, genetic, and environmental interactions. The Journal of Neuropsychiatry and Clinical Neurosciences, 28(2), 77–88. https://doi.org/10.1176/appi.neuropsych.15030053

55.

UNDP. (2018). Violence against women and girls in Albania. National Population Survey.

56.

UNICEF & Countdown to 2030 Women’s, Children’s and Adolescent’s Health. (2021). Early childhood development. https://nurturing-care.org/albania-2021?fbclid=IwAR04551W4_Ha84cCF_SbWCy04bBjWmIPXbsCSgx2xEJ2HGPZh yD5eTxVHBM#

57.

Valdebenito

Murray

Hughes

Băban

Fernando

A. D.

Madrid

B. J.

Ward

Osafo

Dunne

Sikander

Walker

S. P.

Thang

V. V.

Tomlinson

Fearon

Shenderovich

Marlow

Chathurika

Taut

Eisner

(2020). Evidence for better lives study: A comparative birth-cohort study on child exposure to violence and other adversities in eight low- and middle-income countries-foundational research (study protocol). BMJ Open, 10(10), 1–11. https://doi.org/10.1136/bmjopen-2019-034986

58.

van Praag

H. M.

(2004). Can stress cause depression? Progress in Neuro- Psychopharmacology and Biological Psychiatry, 28(5), 891–907. https://doi.org/10.1016/j.pnpbp.2004.05.031

59.

Walker

S. P.

Wachs

T. D.

Meeks Gardner

Lozoff

Wasserman

G. A.

Pollitt

Carter

J. A.

(2007). Child development: Risk factors for adverse outcomes in developing countries. The Lancet, 369(9556), 145–157. https://doi.org/10.1016/S0140-6736(07)60076-2

60.

Watt

Toni

Ceballos

Natalie

Kim

Seoyoun

Pan

Sharma

Shobhit

(2020). The unique nature of depression and anxiety among college students with adverse childhood experiences. Journal of Child & Adolescent Trauma, 13(2), 163–172. https://doi.org/10.1007/s40653-019-00270-4

61.

World Health Organisation. (2005). Multi-country study on women’s health and domestic violence against women: Initial results on prevalence, health outcomes and women’s responses.

62.

World Health Organisation. (2011). Adverse Childhood Experiences International Questionnaire (ACE-IQ). http://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/global_research_network_may_2011.pdf

Adverse Childhood Experiences,Intimate Partner Violence,and Mental Well-Being Among Mothers of Toddlers in Tirana,Albania: A Cross-Sectional Mediation Analysis

Abstract

Keywords

Introduction

Methods

Study Design and Sample

Instruments and Measures

Dependent Variables

Independent Variables

Control Variables

Translation and Data Collection

Data Analysis

Ethical Considerations

Results

Discussion

Strengths and Limitations

Conclusions

Footnotes

Acknowledgments

Declaration of Conflicting Interests

Funding

ORCID iD

Author Contributions

Notes

Author Biographies

References