Introduction: Violence has become a public health problem worldwide and Cuba is not exempt, there are few studies but the associated variables are not explored. In Cuba, there are no validated instruments to explore exposure to violence in adolescents in different scenarios and types of violence.

Goal: To design and validate an instrument for the identification of exposure to violence in adolescents.

Method: Technology development research, with the participation of 130 adolescents from Secondary Education, Pre-university Education, Technical and Professional Education and Special Behavioral Schools Categories 1 and 2, who answered the questionnaire in test-retest mode with 30 days between them; content validity was evaluated by a group of experts using Moriyama's criteria; construct validity by confirmatory factor analysis; Internal consistency by Cronbach's alpha coefficient and temporal stability by comparison test of mean ranks with Wilcoxon signs and associated p value.

Results: Validated instrument for the study of exposure to violence as victims and observers of violence with the variables: physical violence, psychological violence, sexual violence, economic violence and violence due to neglect and/or abandonment in the following scenarios: home, school and community; all items met Moriyama's criteria and the construct structure was justified. The dimensions achieved acceptable to good coefficients of internal consistency (0.70<= α <= 0.93), temporal stability was met (p > 0.05).

Conclusion: The instrument designed and validated to explore exposure to violence in adolescents as victims and observers in the home, school and community settings in the variables physical, psychological, sexual, economic and neglect violence fulfilled the objectives for which it was designed.

Keywords: exposure to violence, violence and adolescence, adolescents victims of violence, cyberbullying and adolescence, instrument construction and validation

Exposure to violence has been broadly defined, including both direct exposure, where an individual is a victim of violence, and indirect exposure, where an individual witnesses such violence.¹ Exposure to violence, in its various forms, has long been considered to be a powerful factor through which children and adolescents learn aggressive behavior through imitation of aggressive role models, direct operant reinforcement of aggressive acts and vicarious reinforcement through observational learning.² This is supported by the numerous studies that have found a positive association between exposure to violence in different contexts (school, neighborhood, Exposure to violence, in its various forms, is a powerful factor through which children and adolescents learn aggressive behavior through imitation of aggressive models, direct operant reinforcement of aggressive acts, and vicarious reinforcement through of observational learning. This is supported by the numerous studies that have found a positive association between exposure to violence in different contexts (school, neighborhood, home, and Television (TV)) and the development of aggressive behaviors in childhood and adolescence.³

Unfortunately many of the television programs contain a high degree of violence. Child and adolescent psychiatrists who have studied the effects of violence on television have found that they can: imitate the violence they see on TV, identify with certain types, characters, victims and/or perpetrators, become "immune", to the horror of violence and gradually accept violence as a way to solve problems. During the 49th World Health Assembly held in 1996, the World Health Organization (WHO) agreed that violence was a priority in public health throughout the world; taking into account the dangerous consequences that it has on health and the health system; being considered by this same organization, as a pandemic. Every year, more than 1.6 million people around the world lose their lives violently. According to WHO data, violence is one of the main causes of death in the population aged between 15 and 44 years.⁴ In 1989, in a context of change in the world order, leaders from many countries met and made a historic commitment in favor of children around the world. They pledged to protect and enforce their rights, adopting an international legal framework: the United Nations Convention on the Rights of the Child. It establishes that childhood is independent of adulthood, which ends at 18 years of age, and that it is a special and protected stage during which children must be helped to grow, learn, play, develop and prosper with dignity.⁵ In September 2015, the Secretary General of the United Nations presented the Global Strategy for the Health of Women, Children and Adolescents (2016-2030),⁶ where he stated that "the survival, health and well-being of these populations are essential for the achievement of the Sustainable Development Goals contained in the 2030 Agenda and highlighted the importance of health promotion and prevention to achieve it.⁶

UNICEF, in its study⁷ on sexual violence against boys and girls, presents the following data:

➣ Around the world, around 15 million adolescent women aged 15 to 19 have been victims of forced sexual relations at some point in their lives. Only 1% of adolescent girls who have been victims of sexual violence say they they had tried to get professional help.

➣ In the 28 countries with data, 90% of adolescent women who had experienced forced sex said, on average, that the perpetrator of the first incident was someone they knew.

➣ Data from six countries reveal that friends, classmates and sexual partners were among the most frequent perpetrators of sexual violence against adolescent boys.

Victims of violence generally suffer more health problems throughout their lives, generate higher health care costs and go to hospital services more frequently. The magnitude that this phenomenon has reached in recent years makes it a health priority.

It is considered that a minimum part of the violence that girls, boys and adolescents receive is that which is denounced, commented on or officially known. Sexual abuse at these ages is more frequent than is thought and most of the crime is not reported, which is known as a "circle of silence", in which the father, mother, family and the parents themselves participate. Affected Data provided by the World Health Organization (WHO) and the Pan American Health Organization (PAHO).⁸ They report that worldwide, 1 in 2 girls and boys between the ages of 2 and 17 suffer some type of violence every year. According to a global review, an estimated 58% of girls and boys in Latin America and 61% in North America suffered physical, sexual or emotional abuse in the last year.

UNESCO according to its analysis states that 32% of students in North America and 30% of students in South America reported being bullied, in it Salvador experienced sexual violence before the age of 18, as reported by 18-24 year olds.⁹

Study on the characterization of violence in adolescents (6) in which 56 students participated, it was found that 20 Twenty students (35.7%), declared having received some form of abuse, distributed in 7 females (35.7%) and 3 males (15%). By using the ratio as a summary measure for qualitative variables, it was obtained that, for every male victim of abuse, there were 6 female victims, which shows that they were abused more frequently. Regarding the place where the victims received the abuse, they identified the school 10 times and the home 7 times. It was observed that the adolescents were victims of abuse in more than one place and; four of the adolescents did not want to respond to this section. The form of school violence between students is the most recognized. Bullying (school bullying) among the students themselves is the most frequent form of violence in schools. Research confirms that future teachers do not have the necessary preparation to prevent violence in the personal, social and professional sphere. Students even acknowledge having been victims of violence and, at the same time, having unconsciously used it on other people, including the school context.

Results of the Multiple Indicator Cluster Survey (MICS) carried out by the Directorate of Medical Records and Health Statistics of the Ministry of Public Health (MINSAP) found aspects related to violent discipline, child marriage and a victimization module observing that in minors the use of punishment and violent forms of discipline at home is maintained, 41.6% of children between 1 and 14 years of age in which they experienced psychological aggression and/or physical punishment from their caregivers during the last month.⁹ It is also verified that there is an increase in the mortality rate due to suicide (maximum expression of violence) in children under 19 years of age for both sexes, in the population between 10 and 19 years of age, which constitutes the third cause of death with a rate of 2.5 x 100 thousand inhabitants for both sexes).⁹ Other research results in Cuba report that there is an increase in the mortality rate due to suicide (maximum expression of violence) in children under 19 years of age for both sexes, in the population between 10 and 19 years it constitutes the third cause of death. Rate of 2.5 x 100 thousand inhabitants for both sexes). Mortality statistics in Cuba at school ages reflect a significant number of violent deaths from various causes.¹⁰ The National Health Survey.^10,11 In his study, he found manifestations of psychological violence in adolescents between the ages of 10 and 14 when he named them. Bullying as a manifestation of violence between peers is a reality for children and adolescents of school age in different cultural contexts and a serious problem in several countries. The phenomenon contributes to the experience of students in episodes of mental suffering, in addition to compromising the teaching-learning process and influencing the way of responding to social demands throughout the cycles of life. These negative consequences that affect all participants, associated with the increase in its prevalence and occurrence, have made it a serious global public health problem. Bullying has acquired increasing attention and social alarm in recent years, due to the greater dissemination of events due to the influence of the media (press, radio, television, internet), so that specific events, inadmissible, have become highly topical issues. It occurs in children and adolescents during the school stage and it is probably a phenomenon that has always been present in our society. The word bullying derives from the English word bully that symbolizes bully, bully; while as a verb it means to mistreat, intimidate, harass.¹² A study conducted with adolescents from 14 to 17 years old from the Saúl Delgado Pre-University in Havana with a sample of 103 students whose objective was describe the behavior of bullying as well as identify the role of parents and teachers before it.¹³ It was found that18.4% of victims (19), 10.7% of aggressors (11) and 70.9% of spectators and only one student turned out to be a victimized aggressor. They also refer to the different forms of harassment in which "Nicknames and teasing" predominate with 61.1% and rejection and isolation with 32.0%. Regarding the places of occurrence, the classroom prevailed. In Cuba, few investigations have been carried out that have addressed this phenomenon. UNESCO states that Cuba is the country with the lowest percentage of children who are physically or verbally assaulted.^13,14 Another phenomenon related to violence on social networks that is gaining momentum and shows the less privileged face of uncontrolled use of the Internet is the so-called Blue Whale that arose as a dangerous joke or perhaps as personal revenge by an unbalanced man, but it immediately gave way to around the world and right now it raises alarms in a good part of the planet. This game presumes that it is behind a wave of adolescent suicides in more than a dozen countries, its mechanism is simple but extremely risky. Once the participant enters one of the closed groups promoting the game, they are assigned an administrator or "curator" in charge of guiding the tasks to be carried out for the next fifty days and collecting the photos or videos sent as proof of compliance.¹⁵

In the Violence Prevention Program¹⁶ among its manifestations to prioritize is "Violence against vulnerable groups (children, the elderly, people with disabilities)." In Cuba, despite the efforts made to reduce the incidence of violence, this phenomenon is still not visible in socio demographic, medical, legal-criminal statistics and, especially, in the perception of the population. which has made it a health problem.¹⁷ Aphysical and psychological abuse still subsist in the family, which, not because it is less frequent and serious, ceases to constitute a problem, where traditions and family rules hide it, cover it up and justify it to such an extent that we observe it every day and in all the scopes. It has always existed, but the worst thing is that we have become so used to it that we see it as something normal, as a natural part of life at home or abroad. All of which motivated us to carry out a work instrument validated for the first time in the country that would allow us to identify the various manifestations of violence to which adolescents are exposed (physical, psychological, sexual, economic violence and due to negligence and/or abandonment). in the home, school and community scenarios, which also include cyberbullying variables that have caused so many negative consequences in this vulnerable and risk-exposed population. The implementation of this instrument at the country level with a representative sample will allow us to identify and outline the relevant strategies that contribute to the prevention of exposure to violence in this population group.^18-20

Technology development research,130 adolescents (12 to 18 years of age) from Basic Secondary, Pre-university, Technical and Vocational Educationand Special Behavior Schools Categories 1 and 2.

Operationalization of variables: Questions were included that explored the types of violence: physical, psychological, sexual, due to negligence or abandonment, and economic.

Scenario or context: home, school, community and through information technologies.

Techniques and procedures:

Information collection: a questionnaire was designed to assess exposure to violence in adolescents, it was administered at the time of recruitment and then 30 days later (test-retest).

A database created in Excel 2013 was made and processed with the statistical package SAS 9.3.

The content validity was evaluated by a group of experts using Moriyama's criteria for each item with which it was intended to explore violence of some kind in each context.

1. That they are reasonable and understandable: It refers to the fact that the respondent understands what is asked in the item.
2. Sensitive to variations in the phenomenon being measured: refers to the fact that the possible responses of the item show differences in the variable to be measured.
3. Relevance or with justifiable and intuitively reasonable basic assumptions: refers to the fact that from a logical and theoretical point of view it is reasonable to think that the item contributes to measuring violence in the selected scenarios.
4. With clearly defined components: That each item is clearly defined
5. Derivable from data that can be obtained: refers to the fact that it is possible in practice to obtain the information necessary to respond to the item. Construct validation: factorial analysis with varimax rotation was applied to reduce information and identify factors that grouped the questionnaire items within each block of type of violence.

Internal consistency: Cronbach's alpha was used for the items within each type of violence and also the global coefficient for each type of violence of the questions that remained at the end. It was considered acceptable when this statistic was at least equal to 0.6. Temporal stability: The difference in the scores of the initial application and after 30 days will be calculated using the mean comparison test of the signed ranks with a level of significance, considering stability when the p value is not less than 0.05.

Procedures: The instrument was subjected to a pilot test to test whether it was understood by the students, minimal word changes were made and the final instrument was applied under conditions of privacy and anonymity both at the first moment and after 30 days.

Ethical aspects: The research has the approval of the scientific research ethics committee and the scientific council of the National Institute of Hygiene, Epidemiology and Microbiology. All information obtained was used only for research purposes.

Validation

An instrument was built where the items have three or 5 ordinal response options (Never, Sometimes, and Always/Every day) and it has the peculiarity that there is no scale that is the result of the individual items, but rather with the response. To some item it was already possible to conclude the exposure to the specific type of violence as defined by the subject matter experts.

Content validity was carried out by a group of experts and using Moriyama's criteria, all the items evaluated met said criteria.

Construct validation:

The factorial analysis allowed us to identify the following factors within each type of violence:

For physical violence, only one factor was identified that summarizes the following items from question block

1- Do they hit you?

2- Do they scold you by pushing, pulling your hair, scratching, pinching, slapping or punching you?

4- Do they hit you with a belt, belt, flip-flop, sticks or wood?

6- Do they punish you kneeling on objects (peas, chapillas, stones or with something else)?

7- Do you get hit for not doing your homework?

In the case of psychological, 8 factors or patterns were identified:

In bold, the factor with the highest factor loading is identified.

Regarding sexual violence, two patterns were obtained according to coefficients:

• Factor 1: Exposure to sexual violence with intimidation.
• Factor 2: Exposure to sexual violence by observation.

Regarding sexual violence, two patterns were obtained according to coefficients:

• Factor 1: Exposure to sexual violence with intimidation.
• Factor 2: Exposure to sexual violence by observation.

Regarding violence due to negligence, only one factor associated with the items in block 3 was identified, all of which explore protective aspects for violence:

3- Do they wash your clothes and iron your uniform?

6- Does anyone from your house participate in the meetings organized by the school?

8- Do they help or support you in carrying out homework and school work?

10- Do you guarantee breakfast, lunch, food and snacks?

11- Do they guarantee your personal hygiene (bathroom and clean clothes)?

12- When you have a problem, do you feel cared for?

Internal consistency: It was evaluated by means of Cronbach's alpha coefficient with standardized variables, considering as acceptable when it is at least 0.6. It was applied to all the items and then grouped according to the type of violence that it intended to explore.

Global: included 68 items, Cronbach's alpha = 0.92

Physics: included 5 items, Cronbach's alpha = 0.72

Psychological: included 42 items, Cronbach's alpha = 0.93

Negligence: included 6 items, Cronbach's alpha = 0.82

Sexual: included 9 items, Cronbach's alpha = 0.91

Cyber: included 6 items, Cronbach's alpha = 0.84

In the case of temporal stability, the Wilcoxon signed rank test was used to detect the difference in the means of the responses of each item between the applications before (test) and after 4 weeks the application of the retest, in none of the cases. For the 68 items, the difference in the means between the responses in the test and the retest was significantly different from zero (p > 0.05), which allows us to say that temporal stability was achieved.

When analyzing validation studies in the literature, the study was found to validate a bullying scale in adolescents from educational institutions in Medellín, Colombia, applying the California School Climate and Safety Survey (CSCSS) scale, in which excellent reliability and validity in the population was found. Adolescent from public educational institutions in Medellín, which reflects the availability of a short instrument, easy to apply and with psychometric guarantees in a population similar to the one studied. Alluding to internal consistency and reliability, it was shown that the CSCSS presents Cronbach's alpha greater than 0.80 in all domains, results higher than the original research carried out on 650 California students, since in it Cronbach's alpha for the domain of unsafe behaviors it was 0.70; school climate 0.63; school safety 0.61, and victimization 0.75.¹⁸ In our results, although other variables were measured, acceptable results were found by Cronbach's alpha coefficient in its internal consistency. Orue³ in his study "Elaboration and validation of a questionnaire to measure exposure to violence in childhood and adolescence" included items referring to both the observation of violence and victimization, in four different contexts: home, school, and community. The items refer to physical and emotional violence. In its confirmatory factor analysis carried out, it confirmed, like ours, a hierarchical structure that meets the objectives set. Mrug et al.,¹⁹ who performed an exploratory factor analysis with a questionnaire that also yielded a three-factor solution representing each of the three contexts studied. The structure of the Violence Exposure Questionnaire (CEV) makes it possible to evaluate multiple aspects of exposure to violence, differentiating, for example, direct from indirect exposure. This means that this instrument can be used with different objectives and in different fields of research. In addition, the internal consistency indices found in our study were adequate.

The instrument designed and validated to explore the exposure to violence in adolescents as a victim and observers in the home, school and community scenarios in the variables; physical, psychological, sexual, economic and negligence violence met the objectives for which it was designed.

None.

The authors declare that there are no conflicts of interest.

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