Polyvictimization and the Associations Between Poor Self-Perceived Health, Dissatisfaction With Life, and Sexual Dysfunction Among Women in Estonia.

The severe impact of different forms of violence on health has been demonstrated in a substantial number of studies. At the same time, it has been acknowledged that different forms of violence tend to co-occur, such that many survivors of violence have been exposed to more than one violent event and/or more than one form of violence. Despite mounting evidence concerning the associations between polyvictimization and health, there are still important gaps in this knowledge concerning adult female population's sexual health, including both physical and mental aspects associated with it. The aim of this study was to evaluate the exposure to emotional, physical, and sexual violence among women and associations with poor self-perceived health, dissatisfaction with life, stress, and worry due to sex life and sexual dysfunction. The term polyvictimization is used in this article to express the exposure to more than one form of violence. We used data from a cross-sectional study carried out in Estonia in 2014 among women aged 16 to 44 years. Responses of 2,333 women were analyzed for this article. Of all the respondents, 27.9% were polyvictimized. Women who had been exposed to all three forms of violence had, after adjusting for confounding factors, the highest risk of reporting poor self-perceived health, limited daily activities due to chronic health problems, feelings of depression, dissatisfaction with life, stress, and worry due to sex life and sexual dysfunction. The results of this study demonstrate that exposure to violence is associated with poorer health outcomes and that the association is stronger among those who have been polyvictimized.

What do we know about the impact of sexual violence on health and health behaviour of women in Estonia?

BACKGROUND: Sexual violence against women is a major public health issue and a breach of human rights. Although various consequences of sexual violence on health have been described in a large number of scientific publications, very little is known about this topic in Estonia. The aim of this study was to examine the prevalence of sexual violence and associations between exposure to sexual violence and risky health and sexual behaviours among women in Estonia. METHODS: A population-based cross-sectional study was carried out in Estonia in 2014. Self-reported data regarding selected indicators of risky health and sexual behaviours were collected from 1670 women, aged 18-44 years, via a self-administered questionnaire. To measure the prevalence of sexual violence, questions from the NorVold Abuse Questionnaire were included. Chi-square and multivariate logistic regression were used to analyse the data. RESULTS: Of the respondents, 22.7% (n = 379) reported being exposed to sexual violence during their lifetime, and over half of these women had had these experiences before the age of 18. Statistically significant associations were found between sexual violence and smoking (adjusted odds ratio (AOR) 1.32, 95% CI 1.03-1.70), alcohol consumption (AOR 1.52, 95% CI 1.18-1.95), illicit drug use (AOR 2.21, 95% CI 1.70-2.89), sexual intercourse for money or other material reward (AOR 3.51, 95% CI 1.62-7.61), concurrent sexual relationships (AOR 2.64; 95% CI 1.80-3.86), and being diagnosed with sexually transmitted infections (AOR 1.48, 95% CI 1.09-2.01). CONCLUSIONS: In Estonia, sexual violence against women is widespread and is associated with several risky health and sexual behaviours. Efforts should be made, both among the general public and professionals, to raise awareness regarding the prevalence and negative impact of sexual violence. Women who have been exposed to sexual violence are in need of professional medical, legal and psychological help free from prejudice to help them recover from such traumatic events.

The prevalence and patterns of exposure to interpersonal violence among men and women in Estonia.

BACKGROUND: To understand better the total burden of interpersonal violence on society, it is useful to assess the prevalence of interpersonal violence among both, men and women. Exposure to multiple forms of interpersonal violence, referred to as polyvictimization, has been associated with more severe health consequences than exposure to any form separately. The aims of this study were to assess the prevalence of emotional, physical and sexual interpersonal violence in childhood, adulthood and at both childhood and adulthood among men and women in Estonia, analyze the patterns of interpersonal violence and socio-demographic correlates of polyvictimization in adulthood by gender. METHODS: The analysis was based on two population-based, cross-sectional, self-administered surveys carried out among men and women in Estonia in 2014. In both surveys, the NorVold Abuse questionnaire was used to measure exposure to interpersonal violence. Men and women aged 18-44 were included to the analysis. RESULTS: Among men 66.6% and among women 54.2% had been exposed to at least one form of interpersonal violence during lifetime. Men had been more often exposed to isolated physical interpersonal violence, among women the distribution of different forms of interpersonal violence was more even and exposure to sexual violence was more common. The prevalence of polyvictimization in adulthood was two times higher among women compared to men and more socio-demographic correlates, were associated with it. Exposure to violence in childhood was associated with polyvictimization in adulthood across gender. CONCLUSIONS: The prevalence of interpersonal violence in Estonia is high among men and women. The most prevalent forms and patterns of interpersonal violence, however, differ by gender, as do the socio-demographic correlates. Screening for interpersonal violence, in childhood and adulthood, and gender-specific interventions are needed, especially for high-risk groups identified in this study. Primary prevention of childhood violence should be a priority, as it was associated with higher risk for exposure to violence later in life across gender.

Contraceptive use among young women in Estonia: Association with contraceptive services.

OBJECTIVES: Our study aimed to explore the association between the use of effective contraceptive methods and access to different contraceptive services, as well as to describe accessibility-related obstacles when using contraceptive services and satisfaction with those services. METHODS: From a population-based cross-sectional study carried out in 2004 (response rate 53.8%), the data of 16- to 24-year-old women requiring contraception (N = 868) were analysed. Factors associated with the use of effective contraceptive methods and, specifically, hormonal methods, were explored using multiple logistic regression analysis. RESULTS: Effective contraception was used by 75.1% of the respondents. The use of effective contraceptive methods was associated with school-based sexuality education (adjusted prevalence odds ratio 2.69; 95% confidence interval 1.32 - 5.50), visiting a youth-friendly clinic (YFC) (1.82; 1.03-3.23) or a private gynaecologist (2.08; 1.11-3.92). The use of hormonal methods was additionally associated with being a native Estonian speaker and visiting a family doctor. More than half of the respondents reported some obstacle in accessing contraceptive services. The highest satisfaction ratings were given to YFCs. CONCLUSIONS: Steps to promote the use of services that are youth-friendly and associated with better uptake of effective contraceptive methods are needed among all 16- to 24-year-old women.

Abortion trends from 1996 to 2011 in Estonia: special emphasis on repeat abortion.

BACKGROUND: The study aimed to describe the overall and age-specific trends of induced abortions from 1996 to 2011 with an emphasis on socio-demographic characteristics and contraceptive use of women having had repeat abortions in Estonia. METHODS: Data were retrieved from the Estonian Medical Birth and Abortion Registry and Statistics Estonia. Total induced abortion numbers, rates, ratios and age-specific rates are presented for 1996-2011. The percentage change in the number of repeat abortions within selected socio-demographic subgroups, contraception use and distribution of induced abortions among Estonians and non-Estonians for the first, second, third, fourth and subsequent abortions were calculated for the periods 1996-2003 and 2004-2011. RESULTS: Observed trends over the 16-year study period indicated a considerable decline in induced abortions with a reduction in abortion rate of 57.1%, which was mainly attributed to younger cohorts. The percentage of women undergoing repeat abortions fell steadily from 63.8% during 1996-2003 to 58.0% during 2004-2011. The percentage of women undergoing repeat abortions significantly decreased over the 16 years within all selected socio-demographic subgroups except among women with low educational attainment and students. Within each time period, a greater percentage of non-Estonians than Estonians underwent repeat abortions and obtained third and subsequent abortions. Most women did not use any contraceptive method prior to their first or subsequent abortion. CONCLUSION: A high percentage of women obtaining repeat abortions reflects a high historical abortion rate. If current trends continue, a rapid decline in repeat abortions may be predicted. To decrease the burden of sexual ill health, routine contraceptive counselling, as standard care in the abortion process, should be seriously addressed with an emphasis on those groups--non-Estonians, women with lower educational attainment, students and women with children--vulnerable with respect to repeat abortion.

Teenage pregnancies in the European Union in the context of legislation and youth sexual and reproductive health services.

OBJECTIVE: To study cross-country and regional variations and trends in reported teenage pregnancies in the context of legislation and youth sexual and reproductive health (SRH) services in Europe. DESIGN: Data were collected on teenage live births and induced abortions, abortion legislation and youth SRH services. SETTING: Population-based statistics from the European Union (EU) member states. POPULATION: Fifteen- to nineteen-year-old female teenagers. METHODS: Detailed statistical information for each member state about teenage live births, induced abortions, abortion legislation and youth SRH services were compiled relying on national and international data sources. MAIN OUTCOME MEASURES: The annual reported pregnancies per 1000 women aged 15-19 years. RESULTS: Teenage pregnancy rates have declined since 2001, although progress has been uneven across regions and countries. Eastern Europe has a higher average teenage pregnancy rate (41.7/1000) than Northern (30.7/1000), Western (18.2/1000) and Southern Europe (17.6/1000). While data on teenage live births are available across Europe, data on teenage abortions are unavailable or incomplete in more than one-third of EU countries. Reported teenage pregnancy rates are generally lower for countries where parental consent for abortion is not required, youth SRH services are available in all areas and contraceptives are subsidized for all minors, compared with countries where these conditions are not met. CONCLUSIONS: The collection of standardized teenage pregnancy statistics is critically needed in the EU. The remarkable variability in teenage pregnancy rates across the EU is likely to be explained, among other factors, by varying access to abortion and youth SRH services.

Intimate partner violence and sexual health outcomes: a population-based study among 16-44-year-old women in Estonia.

BACKGROUND: Violence against women as a public issue and health burden has only recently been acknowledged in Estonia. The aim of this study was to outline the prevalence and to explore the associations of intimate partner violence (IPV) and selected sexual health outcomes. METHODS: Data from the population based cross-sectional survey among representative sample of 16-44-year-old non-pregnant women (n = 1966) were analysed using multivariate logistic regression. RESULTS: Of 1966 respondents, 362 (18.4%) reported IPV during 12 months preceding the survey. Physical IPV was reported by 339 (17.2%), sexual by 80 (4.1%) and both physical and sexual by 35 (1.8%) of respondents. After controlling for significant confounding socio-demographic factors, exposure to IPV was found to be associated with contraception non-use [adjusted odds ratio (AOR) = 2.02, 95% confidence interval (CI) 1.44-2.82] or the use of unreliable contraceptive methods (AOR = 1.54, CI 1.16-2.04) during the most recent sexual intercourse, having never used a condom (AOR = 1.53, CI 1.12-2.10), repeat induced abortion (AOR = 1.72, CI 1.24-2.37), lifetime sexually transmitted infections (AOR = 2.05, CI 1.56-2.68) and dyspareunia (AOR = 2.14, CI 1.65-2.77). CONCLUSION: The exposure of IPV was an important contributor to sexual risk behaviour and adverse sexual health outcomes among women of reproductive age in Estonia. Any strategy to promote sexual health should include prevention of IPV and other forms of violence against women with the strengthening of women's sexual and reproductive rights.

Youth sexual health improvement in Estonia, 1990-2009: the role of sexuality education and youth-friendly services.

OBJECTIVES: A new school curriculum was introduced in Estonia in 1996 comprising for the first time sexuality education (SE) topics. The first youth counselling centres (YCCs) addressing sexual health matters were set up in 1991-1992. This study describes the development of school-based SE and YCCs in 1992 - 2009, and explores the concurrent changes in sexuality-related knowledge, behaviour, and sexual health indicators. METHODS: The analyses are based on 12 population-based surveys. Data on births, abortions and sexually transmitted infections, including HIV, are taken from national registers. RESULTS: By the middle of the past decade SE was well established. There has been a trend towards younger age at first sexual intercourse, and increased usage of condoms and reliable contraceptive methods. The abortion rate among 15-19-year-olds declined by 61% and their fertility rate by 59%. The annual number of registered new HIV cases among 15-19-year-olds dropped from 560 in 2001 to 25 in 2009, new syphilis cases from 116 in 1998 to two in 2009, and gonorrhoea cases from 263 in 1998 to 20 in 2009. CONCLUSIONS: This study documents considerable improvements in sexual health indicators of youths, and indicates that these run parallel to the development of school-based SE and YCCs.

Ethnic differences in factors associated with the use of contraception among 20- to 44-year-old women in Estonia and St. Petersburg, Russia.

BACKGROUND: The aim of this study was to explore factors associated with contraception among 20- to 44-year-old women in different ethnic groups in two Eastern European countries. STUDY DESIGN: Data on sexually experienced women in need of contraception taken from population-based cross-sectional surveys, conducted in Estonia (n=1680) and in St. Petersburg (n=798), were analyzed. Factors associated with contraception nonuse or the use of unreliable contraceptive methods were explored using multivariate logistic regression analysis. RESULTS: The age-standardized prevalence rate of contraception nonuse or the use of unreliable contraceptive methods was high (27.3% among Estonian-speaking women in Estonia, 39.9% and 42.5% among Russian-speaking women in Estonia and in St. Petersburg, respectively). Age, economic subsistence, high-risk sexual behavior and smoking did not correlate with contraception nonuse or the use of unreliable contraceptive methods among Russian-speaking women in Estonia and in St. Petersburg; this was in contrast to Estonian-speaking women in Estonia. Previous childbirth and abortion reduced the risk of contraception nonuse or the use of unreliable contraceptive methods among Estonian-speaking women in Estonia (adjusted odds ratio, 0.50; 95% confidence interval [CI], 0.31-0.81) but elevated the risk among Russian-speaking women in St. Petersburg (1.99; 1.17-3.40). Abortion, not previous childbirth, was associated with an increased risk among Russian-speaking women in Estonia (2.94; 1.25-6.95). CONCLUSIONS: The importance of different risk factors associated with contraceptive use varies between different ethnic groups. Cross-national comparisons are essential for the design of public health policies that decrease the burden of sexual ill health.

Gender differences in factors associated with sexual intercourse among Estonian adolescents.

AIMS: To examine factors associated with early sexual intercourse among 15 to 16-year-old adolescents by gender. METHODS: The data were collected from a random sample of Estonian basic schools' ninth grade pupils in 1999 using self-completed questionnaires. A multivariate logistic regression analysis for boys and girls was used to test for associations between sexual intercourse, and personal gender role-related attitudes, attitudes towards sexual intercourse, pubertal timing, smoking status and experience of drunkenness. RESULTS: Of the respondents, 14.6% of boys and 13.1% of girls had experienced sexual intercourse. Traditional gender role-related attitudes were associated with sexual intercourse among girls, but not among boys. Smoking and experience of drunkenness was strongly associated with sexual intercourse for both genders. CONCLUSIONS: Gender differences in the association between gender role-related attitudes and early sexual intercourse were observed among 15 to 16-year-olds in Estonia. Smoking and experience of drunkenness were strongly related to sexual intercourse for both genders.

Factors associated with Estonian adolescents' sexuality-related knowledge: Findings from the 1994 and 1999 KISS studies.

OBJECTIVE: To identify changes in factors associated with Estonian adolescents' sexuality-related knowledge. The relationship between self-reported school sexuality education and good sexuality-related knowledge is addressed. METHODS: The study is based on the results of two consecutive studies conducted in 1994 and 1999, based on anonymous self-completed questionnaires in schools, which involved 2256 respondents from random samples of primary school 9th grade pupils. Information on 16 sexual knowledge items, experience of sexual intercourse, discussions about sexuality with parents and school sexuality education was collected. A multivariate logistic regression analysis was used to account for the simultaneous effects of independent determinants on good sexuality-related knowledge. RESULTS: The results showed improvement in the respondents' level of sexuality-related knowledge between the two study years. Whereas in 1994, good sexual knowledge was positively associated solely with experience of sexual intercourse, in 1999, good sexual knowledge was also positively associated with school sexuality education. CONCLUSION: The improvement of sexuality-related knowledge and its positive association with school sexuality education in 1999 may be a result of the mandatory sexuality education introduced into the school curriculum in 1996. These findings have important implications for the further provision of school sexuality education in Estonia.