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. 2022 Jan 17;9:23333936211035750. doi: 10.1177/23333936211035750

Red Flags of Dating Violence Among College Students: From the Perspective of Campus Service Providers in Costa Rica : Señales de alerta de la violencia en el noviazgo entre estudiantes universitarios: Desde la perspectiva de los proveedores de servicios estudiantiles en Costa Rica

Derby Munoz-Rojas 1,✉, Cristobal Ching-Alvarez 1, Kwynn M Gonzalez-Pons 2
PMCID: PMC8793443  PMID: 35097159

Abstract

Dating violence has negative consequences on the well-being of college students. Thus, it is imperative that providers of student-oriented services can detect and respond to dating violence. Although many universities worldwide have implemented dating violence screenings protocols, they are not yet common practice in Costa Rica. As a result, there is inadequate recognition of this problem, so it remains unaddressed. Therefore, this qualitative descriptive study explored the perceptions of professionals working in student-oriented services in Costa Rica about dating violence warning signs exhibited by college students. 29 providers from four public universities were interviewed, and three main areas were identified from a content analysis: the process that providers follow to identify dating violence, the visible signs that victims display, and the self-protective strategies that victims employ to hide their abuse. These findings are important for researchers and practitioners wanting to improve dating violence screening instruments for the Central American context.

Resumen

La violencia en el noviazgo tiene consecuencias negativas en el bienestar de los estudiantes universitarios. Por lo tanto, es determinante que los proveedores de servicios orientados a los estudiantes universitarios puedan detectar y responder a la violencia en el noviazgo. Aunque muchas universidades en todo el mundo han implementado protocolos de detección de violencia en el noviazgo, aunque aún no es una práctica común en Costa Rica. Como resultado, el reconocimiento de este problema es insuficiente y sigue sin abordarse. Por lo tanto, este estudio descriptivo cualitativo exploró las percepciones de los profesionales que trabajan en servicios orientados a los estudiantes universitarios en Costa Rica sobre las señales de alerta de violencia en el noviazgo manifestadas exhibidas por los estudiantes universitarios. Se entrevistó a 29 proveedores de cuatro universidades públicas. A partir de un análisis de contenido se identificaron tres temas principales: el proceso que los proveedores siguen para identificar la violencia en el noviazgo, los signos visibles que muestran las víctimas y las estrategias de autoprotección que las víctimas emplean para ocultar su abuso. Estos hallazgos son importantes para los investigadores y profesionales que desean mejorar los mecanismos de detección temprana de la violencia en el noviazgo para el contexto universitario.

Keywords: healthcare professionals, domestic abuse, young adults, qualitative research, Costa Rica, Palabras clave, profesionales de la salud, abuso doméstico, adultos jóvenes, investigación cualitativa, Costa Rica

Introduction

Violence is a threat to the safety and productivity of Costa Rican young adults. Homicides are the second leading cause of death among college-aged youth and young adults aged 15–24 (Pan American Health Organization, 2020). In particular, women, youth, and young adults under 24 years of age, and those living in urban areas, are deemed most vulnerable to violence, according to Costa Rica’s 2004 National Security Survey (United Nations Development Program, 2005). These characteristics describe the profile of many college students in Costa Rica. To date, violence against women, and dating violence among college students in particular, remains one of the main concerns facing women in Costa Rica, though little academic research has been dedicated to this topic in this country.

Dating and domestic violence were only brought into national conversations in Costa Rica in the 1980s ,thanks to the work of advocacy organizations (e.g., Feminist Action Information Center, Alliance of Women, Pancha Carrasco Collective, and “Ser y Crecer” (To be and to grow) Foundation). Still, the journey to recognize these forms of violence against women, and subsequently onboard programs and resources to prevent them, has been slow (United Nations Population Fund, 2018). In the 1990s, Costa Rica signed into law legislation to promote social equality for women, which provided some momentum for these efforts. Then, in 1994, Costa Rica’s Health Sector established the first national effort to address these types of violence by preparing a Care Plan for IntraFamily Violence. Subsequently, the first plan to prevent and address domestic violence and sexual abuse against women was presented in 1996. However, it wasn’t until 1999 that a plan was created to address dating violence and rape, under the 2000–2004 National Plan for the Attention and Prevention of Attention to Intrafamily Violence (Women National Institute, 2014). Efforts to address interpersonal violence in Costa Rica continue through organizations like Costa Rica’s National Institute for Women (Women National Institute, 2012).

Shifting specifically to addressing dating violence among college students in Costa Rica, there is almost no research published in academic outlets that describes dating violence among this population in this particular setting. Rather, most research on adolescent and young adult dating violence comes from North America and some European countries (Munoz-Rojas, 2014). Drawing from research on dating violence among Costa Rican adolescents, anywhere from 1 in 5 (18.3%) to more than 9 in 10 (93.4%) females experienced physical violence and emotional or verbal abuse, respectively. Further, nearly one-third (31.4%) experienced threats from a partner in the past twelve months, and more than half (54.5%) reported sexual violence at the hands of a dating partner (Fernández-Fuertes et al., 2015). Likewise, a separate study found that around 70% of college students have experienced any type of dating violence. For instance, participants reported having suffered cyberviolence (69.7%), psychological abuse (63.9%), and sexual violence (25.5%), while about 1 in 6 students (15.8%) stated that they have suffered physical abuse (Barley et al., 2017). These results are consistent with recent research which found that over two-thirds (64.6%) of college students have experienced dating violence, where almost half of the sample reported psychological victimization (48%), sexual abuse (33%), and physical violence (19%; Guerrero et al., 2021).

Despite Costa Rica’s efforts to generate support to combat these forms of violence, women face patchwork or limited services and avoid reporting their victimization experiences for fear of violent repercussions from their partners. Thus, there is need and opportunity for those interacting with women in various contexts to identify and respond to dating violence.

College healthcare providers may be uniquely positioned to identify signs of dating violence, recognize young women at risk, and intervene (e.g., treat injuries, engage in crisis intervention, counsel, and implement advocacy services) to reduce violence and improve outcomes (Sutherland & Hutchinson, 2018). Still, debate subsists about the benefits of mandated screening (O’Doherty et al., 2015), and existing guidelines vary in their recommendations regarding screening and identification practices (Sprague et al., 2016). Researchers have identified several merits of universal screening in healthcare settings, including that screening increases dating violence detection rates, and effective screening instruments are available (Sprague et al., 2016).

Identification can be greatly improved when stakeholders have knowledge of dating violence warning signs, which include but are not limited to behaviors such as monitoring, controlling, demeaning, and threatening (Kearney & O’Brien, 2018). This need is particularly salient for those working with college students in Costa Rica, as past research has shown that “although IPV goes unnoticed, it goes to college”, (Munoz-Rojas, 2014 p. 98). College students’ lifestyles, including their experiences of stress, under or unemployment, limited income, mental health concerns, and access to drugs and alcohol, are risk factors for dating violence victimization and perpetration (Duval et al., 2020; Sabina et al., 2017). Still, despite impacts that include disruptions to academic achievement (Brewer et al., 2018; Schrag et al., 2020), physical and mental health impacts (Brewer et al., 2018; Sargent et al., 2016; Schrag et al., 2020; Smith et al., 2018; Voth Schrag, et al., 2020), and even loss of life (Gonzalez-Pons et al., 2020), dating violence remains an under-addressed and under-resourced issue among college students compared to non-partner sexual assaults. As a result, the present study sought to understand college-based healthcare providers’ perceptions of warning signs of dating violence among female college students in Costa Rica.

Method

A qualitative descriptive design as described by Sandelowski (2000) was used. This interpretive approach is used to provide straight forward, comprehensive descriptions in everyday language (Sandelowski, 2000, 2010). The aim of this study was to describe the perceptions of providers about the signs that they recognize as indicators that a student is experiencing dating violence. Drawing on assumptions within a naturalistic perspective, this study was based on an understanding that knowledge is socially constructed not only by the participants, but also by the researchers (Bradshaw et al., 2017).

Settings

In Costa Rica, the public university system is made up of five universities that serve over 100,000 students annually (National Council of Rectors, 2017). Many campuses offer a variety of healthcare services for students, free of charge. Participants were recruited from these student healthcare clinics across 10 campuses from four of the five public universities. Services offered through the clinics include general medical care, routine health exams, injury evaluations, immunizations, and coordination of care for chronic medical issues (Department of Wellness and Health, 2021). Additionally, the clinics offer appointments with nurses, dentists, nutritionists, psychologists, academic counselors, and social workers.

Participants

This study focused on the perceptions of healthcare professionals that work directly with students. Directors of the clinics were informed about the study so the research team could request help to disseminate recruitment materials in each setting. A digital invitation for the interview was sent to each director, which they then forwarded to all the professionals working at the clinics. Detailed information about the study and the researchers was included in the materials. Interested professionals were instructed to contact the researchers if they wanted to participate. To be eligible to participate, individuals had to specifically offer either counseling or medical healthcare services to Costa Rican college students; no exclusion criteria were defined for the recruitment. A purposive sample of 45 healthcare providers was invited to participate, and ultimately 29 of them were enrolled into the study.

Data Collection

Once individuals consented to participate in the study, they completed a demographic form to provide sociodemographic information (including age, gender, profession, etc.) and information about training in dating violence. They were also asked about any requirements regarding screening for dating violence among women. Participants then completed semi-structured interviews facilitated by research team members. Data presented in this article were collected between 2019 and 2020, as part of a larger study focusing on perceptions of healthcare providers about dating violence among college students. Interviews were conducted in Spanish and in-person at the participant’s office at the university student clinic. The researcher used a guide to conduct the interview, with questions flowing from general to more specific. The following are examples of questions that were included in the guide: What are your thoughts about warning signs of dating violence among female students? How would you describe the signs that college students display whenever they are experiencing dating violence? Please, tell me about the process of screening for dating violence, How would you describe the overall perception that healthcare providers held about the signs that female college students display whenever they are experiencing dating violence? The aim was to generate discussion about the providers’ perceptions of warning signs of dating violence exhibited by their female-identifying patients, thus questions were geared toward elicit discussion about dating violence in any kind of dating relationship (i.e., same-sex and different-sex relationships). Participants were not instructed to think of female patients through a certain lens, such a cisgender and straight. The interviews, which generally lasted for 60 minutes, were audio-recorded and transcribed verbatim. All study procedures were approved by the University of Costa Rica IRB (Project number CEC-840-B8-328). Participants did not receive any reimbursement, as it is not customary in the country (Law for Biomedical Research, 2014).

Data Analysis

The participants’ responses were mainly short statements, in some cases with examples. The interview transcripts were entered in QCAmap ((Fenzl & Mayring, 2017) Mayring & Fenzl, 2019) and analyzed using procedures described by Graneheim and Lundman (2004) for conventional content analysis. This process included the researchers exploring the data to identify patterns in the way healthcare providers recognize dating violence among college students during their service provision to students. First, transcriptions were read through while listening to the audio recording to validate the content and get an overall picture of it. Meaning units were comprised of sentences or phrases related to the study aim. These units were then labeled with codes based on the content. Similarities and differences were used to compare the codes. As a result, similar codes were grouped into subcategories, which were then analyzed again to identify similarities and differences and then grouped into categories, which were finally clustered into a theme. An example of the analysis is given in Table 1. The final scheme with data belonging to each category is presented in Table 2. There were no patterns in the data to indicate any difference in the way participants from different professions and genders understand and recognize warning signs of dating violence among female-identifying patients. Likewise, results did not show differences related to socioeconomic status, race, ethnicity, sexual orientation, and age of the female-identifying students that received services at the university clinics; however, all the providers’ perceptions tended to gravitate toward situations in which the patient was as a cisgender victim of violence. To reduce bias that could be introduced by a single coder, a second researcher audited the analysis, repeating the coding process (Armat et al., 2018). Themes were then compared to the original analyses. Agreement of 90% between reviewers was determined to be adequate. To maintain the integrity of the statements, analyses were also conducted in Spanish.

Table 1.

Example of the analysis.

Codes Subcategories Categories Theme
Taking self-protection postures Psychosocial strategies Self-protective strategies Red flags of dating violence
Displaying aggression
Pretending to be fine
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Table 2.

Overview of the main theme, categories, and subcategories.

Theme Categories Subcategories
Red flags of dating violence What to look for It is not a priority
No seeking help for dating violence
Making a decision
Visible signs Psychosocial manifestations
Physical and sexual signs
Academic red flags
Self-protective strategies Psychosocial strategies
Academic strategies
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Results

Participants included 29 service providers (41.5 ± 10.6 years old), who averaged 10 years (10.4 + 8.2) of experience working with college students at the university health clinics. Eleven providers worked as social workers (37.9%), six as psychologists (20.7%), four as physicians (13.8%), three as academic counselors (10.3%), and two as nurses (6.9%). The rest of the sample was comprised of a dentist (3.4%), a teacher (3.4%), and a physical educator (3.4%). Nine of the providers held a Master’s degree (31%), while the rest were licentiate ([degree below that of a Master] 69%, n = 20). The majority of the sample were women (79.3%, n = 23).

Participants were also asked about their training in dating violence. All interviewees reported that modules related to dating violence, violence against women, children, and elders were part of the curricula they took during their undergraduate studies. Moreover, all of them indicated that no other additional training about the topics has been taken. Regardless of the area of specialty, all participants indicated that screening for dating violence is not part of the primary protocol of service provision for patients; however, if providers suspected or confirmed signs of dating violence, they would provide appropriate care.

Overview of the Overarching Theme

From the analysis, one overarching theme was identified (i.e., red flags of dating violence (invivo quote)), which includes three categories that mapped the path that healthcare providers take to identify experiences of dating violence among college students who received counseling and health services at the university clinics. The first category entails the participants’ description of the process they follow to decide whether a student is a victim of dating violence; the second category comprises the perceptible warning signs that providers recognize in students who are experiencing dating violence. Finally, the third category encompasses the strategies that victims present while trying to hide their abuse, behaviors that were also identified by providers as possible indicators of dating violence (Table 2).

What to look for. Participants noted that screening for dating violence is not part of the activities that they perform on a daily basis as it is not part of the student’s service provision protocols. Regarding this, one of the interviewees expressed that “we have to stick to the list and respond to the protocols in place” (participant 14). Despite this, providers believe that dating violence is a prevalent issue among college students, as one of the providers stated, “you know that many of the kids that knock on ours doors are victims and are struggling with that (dating violence)” (participant 2).

Interviewees claimed that students usually do not recognize dating violence as a primary problem, so they do not seek help on this matter, as evidenced by one provider: “most of the time they [students] seek for help to fix academic or health issues, but not for dating violence” (participant 5). However, all participants agreed that they identify dating violence during interactions with students while they are addressing other problems, “you sniff something and turn on the “sospechometro” [expression to infer that one is aware that something is going on], then you realized you were right” (participant 24). Providers claimed that the hints that students provide about possible dating issues include references to the quality of the relationship and their partners’ responses to their concerns and problems. Hence, data suggested that providers identify these clues as potential indicators that the student was involved in an unhealthy relationship. As a result, interviewees described that because of the suspicion that the person was suffering violence, they expand the focus of the care that is being offered to start looking for specific signs that might confirm whether the student was suffering from dating violence.

Providers explained that, since non-specific screening tools are used, they instead follow their clinical judgment and ask questions about possible signs of dating violence. One of the participants said that “each of us has his own way to ask about abuse; in my case, I often follow the nature of the conversation and ask questions about changes in the way that she behaves” (participant 25). Another provider stated that “at this point I just ask myself ‘what to look for?’ and I start to look for a path to follow based on the students’ responses to my questions about their boyfriends and their relationships” (participant 8).

Regarding the warning signs, providers described that they must carefully analyze the information that students share with them to organize the facts and decide if they should keep probing them. For example, some interviewees explained that students often seek help for consequences of the abuse (e.g., sexual, physical, and psychological effects), information that is then processed by providers and mentally labeled as indicators that suggest the person is suffering abuse. If needed, cases are discussed in providers’ group sessions. As a result, the final decision and the care plan are decided based on the consensus of several providers. One of the participants expressed that “from my experience, victims often do not cry out that they are victims. We need to put together the pieces, for example, I have had patients that just reported physical or psychological problems, which I interpret as red flags of dating violence” (participant 11).

Visible signs. The visible signs of dating violence are represented within two subcategories (Table 2). Participants described how violence always left a mark on victims, so these symptoms act as visible signs that victims display as a result of the abuse they have suffered. Regarding the psychosocial manifestations, providers explained that some students stopped taking care of themselves, instead engaging in self-destructive habits. As one participant described, “it looked like victims were blaming and punishing themselves” (participant 2). Agreement was noted among interviewees regarding a range of self-punishment behaviors, including how participants stopped engaging in healthy habits, damaged their own belongings, quit leisure activities, and bit their nails. One of the providers said that “for me it is like they (victims) were self-blaming and self-punishing because of the abuse. It is common to see that they have” (participant 26).

Providers perceived that victims often pushed them away, as the victim emotionally expressed feelings, behaviors, and thoughts that kept providers at arm’s length. For instance, some of the participants identified that victims are introverted, nervous, and insecure, presenting with withdrawn attitudes. In addition, violence victims also suffered from a range of psychological problems, including anxiety, hopelessness, depression, onychophagy, and low self-esteem. One participant said that “victims may also justify the aggression they experienced, taking responsibility for the abuse and expressing irrational beliefs about the romantic relationship” (participant 22). Providers felt, as a result, that the victim often did not recognize the violence, instead perceiving it as a normal part of the relationship. As one of the participants said that “most of them (victims) normalize violence, they think it comes with the relationship” (participant 1).

Dating violence victims also experienced social manifestations of their victimization. Providers explained that, because of the abusers’ controlling behaviors, victims changed the way they interacted with others: “female students usually changed their social behaviors with friends, choosing instead to isolate from other students and their own families” (participant 16). Because victims’ actions were controlled by their partners, they commonly only socialized with their partner or only went places that were approved by him. This created conflict in their personal lives, as students had difficulty relating to others and even had quarrels with their close peers and teachers. Even their patterns of speech or communication patterns could be altered, as some dating violence victims experienced stuttering, limited communication, insecure speaking, or constantly repeating words. As part of the psychosocial manifestations, economic signs were also present for students who held jobs, manifesting as absenteeism at work, labor disputes, economic limitations, and occupational demotivation.

Physical and sexual signs of dating violence were also noted by providers. Regarding the former, participants indicated that many victims of dating violence had visible marks on their skin as a result of the physical violence they experienced, most commonly in the form of bruises or wounds. As one provider explained, “it is easy to see the evidence of the blows, for example I have seen bruises, cuts, wounds and lacerations” (participant 21). Indirect physical impacts, such as body changes, were also noted, as victims would also engage in unhealthy coping mechanisms like snacking or skipping meals, leading to fluctuations in weight. Other physical signs included lack of sleep, self-harm, and poor athletic performance.

In addition, participants also noted several signs related to sexual ramifications of dating violence. Victims expressed negative attitudes towards sex, which usually is referred to by students as a loss of sexual desire, fear of sex, and sexual dissatisfaction. Moreover, some victims tended to engage in risky sexual behaviors and practices such as sexual harassment of other students, engagement in compulsive sexual activities, and lack of self-care when engaging in casual sex. Perhaps unsurprisingly, some victims exhibited poor personal care in regard to their sexual and reproductive health. As one of the participants said, “they skip their GO controls (contraceptive methods) and their PAP tests” (participant 14). As a result, interviewees agreed that there are some visible consequences that victims show because of the sexual violence that they suffer, including unplanned pregnancies, presence of genital injuries, and sexually transmitted infections.

Regarding academic red flags, participants described that victims also displayed negative cognitive effects from dating violence, including learning difficulties, academic demotivation, lack of attention, and an inability to concentrate. As one of the participants claimed, “these struggles are often present in the students’ school records in the form of missed classes, lower grades, late assignments, and even dropping out of school” (participant 2).

Self-protective Strategies. The category of self-protective strategies was comprised of two subcategories (Table 2). Providers claimed that victims engaged in different tactics to either prevent abuse or to keep them from facing questions from others about dating violence. Regarding psychological strategies, one participant said that “it looks like they take self-protective postures” (participant 15). Victims adopted survival or protection strategies to prevent revictimization. For instance, they obsessively controlled the activities they participated in (e.g., obsessing over the time to leave, monitoring the people at the event, and so on), in a hyperaware manner. Victims did not talk about the violence they have experienced and hid their injuries while keeping alert and reactive.

Additionally, participants described how students took aggressive stances to prevent others from approaching them or inquiring about the warning signs that they exhibited. As an example, participants stated how students were irritable and became hostile towards their peers, appearing aggressive and more likely to try to scare away their friends by threatening them. For example, one of the interviewees shared: “I have noticed how victims tend to report that they often fight with their friends whenever they ask question about how much control the boyfriend has over the student” (participant 20). Interestingly, some victims portrayed a false appearance of being fine, wanting to present themselves as empowered.

Finally, a subcategory related to the academic strategies were identified as well. Providers claimed that some victims tried to keep a low profile at the school, self-regulating their academic performance. For instance, one of the interviewees said “I remember a case in which a female student who was excelling in class and actively participating 1 day stopped doing so, even though she knew the answers to the teacher’s questions” (participant 7). Unfortunately, providers noted that some victims even transferred from classes and to different campuses to escape from their partners.

Discussion

Healthcare providers working on university campuses are in a unique position to recognize red flags of dating violence among female college students. Though research has identified warning signs of dating violence broadly, little is known about how they manifest in the Costa Rican context, limiting the effectiveness of any interventions intended to assist victims in this Central American country. This study summarized thematic findings from interviews with 29 healthcare service providers at Costa Rican universities, filling an important gap in the research literature. Three focus areas were identified from the transcripts, namely that providers follow a process to identify dating violence, that there are visible signs of dating violence, and that victims take self-protective measures because of the violence they face. The emerging themes highlight the complex nature of the manifestations of dating violence among female college students in Costa Rica.

Screening practices at university healthcare clinics have the potential to limit the negative impact that dating violence has on female college students (Halstead et al., 2017b; Sutherland & Hutchinson, 2018). However, previous studies have shown that screening is not commonly conducted (Halstead et al., 2017a, 2017b). Diverse situations could explain this issue, including lack of training in screening for dating violence, insufficient institutional regulations, absence of protocols defining how best to engage and support dating violence victims, and a tendency to focus on a medical condition rather than on what the student is experiencing (Halstead et al., 2017b; Rabin et al., 2009; Sutherland & Hutchinson, 2018). Our results suggest that although dating violence is prevalent among college students, and there are available several validated screening tools for dating violence (McCarthy & Bianchi, 2020; Wong et al., 2018), in Costa Rica there is a lack of protocols in place for screening. Consequently, providers usually ask about dating violence whenever they perceive that indicators are suggesting that the student is experiencing abuse. However, this process is dependent upon the providers’ knowledge and comfort engaging students about this topic (Gear et al., 2021). It is not standardized, which could lead to some providers to miss warning signs and fail to intervene, negatively impacting students.

University clinics are safe settings where dating violence victims can access specialized assistance; however, they sometimes do not feel comfortable disclosing the abuse (Halstead et al., 2017b; Sprague et al., 2016; Sutherland & Hutchinson, 2018). As such, providers must pay attention to subtle signs that might indicate that the student is in an unhealthy relationship. Most of the screening tools available focus on specific questions asking the victim to recall for experiences of specific violent behaviors (e.g., Has your partner ever abused you physically?) (Rabin et al., 2009). However, our findings suggest that warnings signs of dating violence might be expressed as symptoms that victims exhibit as consequences of the abuse they suffered. Subsequently, providers must carefully analyze these symptoms to decide whether they are red flags of dating violence. Dating violence victims experience consequences associated with problems in the psychological, physical, sexual, social, economic, and academic context. Therefore, it is also important for providers to understand how dating violence victimization manifests across contexts.

Dating violence victims engaged in different tactics to deal with the abuse (Archer, 2019; Rader & Haynes, 2014). Providers claimed that victims engaged in different tactics to either prevent abuse or to keep them from facing questions from others about dating violence. However, the presence of these mechanisms might be interpreted as well as red flags of dating violence. Some victims establish diverse strategies to prevent the abuse by the perpetrator. On the other hand, victims also implement actions to keep them from facing questions from others about dating violence (Sprague et al., 2016). Regardless of what mechanisms victims are using, those behaviors act as indicators that the person is experiencing dating violence.

Finally, screening of dating violence not only encompasses the identification of warning signs but also requires that providers carefully analyze each indicator (Wong et al., 2018), because a combination of indicators might be a sign that another problem is occurring. Researchers consistently have concluded that dating violence among college students is correlated to other health concerns, such as drug and alcohol abuse and risky sexual behaviors (Duval et al., 2020; Sabina et al., 2017).

Strengths and Limitations

These study findings are important because they not only add to the scant literature on dating violence among college students in Costa Rica, but the findings are also consistent with previous literature on the physical and mental health problems, including sexual consequences, exhibited by dating violence victims (Amar & Gennaro, 2005; Ohnishi et al., 2011; Spencer et al., 2016).

Despite the promise of these findings, they should still be interpreted with caution, given important methodological limitations. The sample of healthcare providers was not representative of all Costa Rican universities. Rather, participants were recruited from 10 clinics across four of the five public universities in Costa Rica. Further, almost 80% of the interviewees were women. Therefore, future studies should include other strategies, such as purposeful sampling, to reach professionals from all Costa Rican universities and to represent more balanced social and demographic identities. Finally, researchers were affiliated with the universities where the participants were employed, which could have led to participants providing biased responses in the name of social desirability. In order to help minimize these concerns in the future, studies should include researchers from other schools and/or institutions and utilize individual focus groups to complement interviews.

Implications for Future Research/Practice

First, nurses could use the results of this study to advocate for policies and regulations that establish screening practices for dating violence at university clinics. In addition, nurses could organize educational programs for healthcare providers to train them on the use of screening tools for dating violence. Likewise, nurses could consider the results to develop culturally tailored screening tools that are appropriate within the Costa Rican context. For instance, findings could be used to expand the scope of the questions that are included in the screening tools (i.e., the inclusion of items about current manifestations of dating violence).

At the same time, Costa Rican universities would benefit from policies that advocate for the program’s implementation of warning signs recognition targeting dating violence among female college students. As part of programming, all health program personnel should be trained in recognizing and appropriately responding to students who may either disclose experiences with, or exhibit signs of, dating violence. Further, universities should follow previously successful strategies for recognizing, addressing, and preventing violence among students, which emphasizes multi-sector, networking, and comprehensive approaches among college healthcare providers to share education, best practices, and therefore meet the comprehensive needs of students experiencing dating violence (Dills et al., 2016). These strategies must work toward early recognition, safety, enhanced well-being, and prevention of further violence while accounting for the unique context of providing services to female victims of dating violence (Voth Schrag et al., 2020).

As mentioned briefly above, there are several additional avenues that future research can expand upon in regard to exploring warning signs of, and improving the response to, dating violence among female college students. First, it will be important to know how university-employed healthcare providers in Costa Rica perceive dating violence, as it can inform how they respond to disclosures or signs of abuse. Secondly, future studies should include employees from various college settings across Costa Rica and ensure a more balanced demographic sample. Case studies or interviews and surveys with students can provide a more comprehensive picture of the distinct factors surrounding their experiences during disclosure of dating violence, which can then be used in future trainings and programming. In addition to empowering healthcare providers to recognize signs of dating violence, students should also be made aware of how dating violence can manifest in relationships and be provided with resources and skills to protect themselves or offer guidance to peers.

Presently, there is a lack of protocols in place for dating violence screening in university clinics in Costa Rica. Thus, researchers and practitioners should create, refine, and test screening tools for dating violence. Though there are successful protocols being implemented in other contexts, it is important than any programming and training is culturally congruent to students in Costa Rica.

Conclusions

To summarize, the findings of this study can be used to inform new initiatives on this matter in two ways. First, the results can be used as foundation in dating violence screening training programs targeting healthcare providers at university clinics in Costa Rica. Second, efforts should also be built out to implement screening protocols for female students seeking services at college clinics.

Author Biographies

Derby Munoz-Rojas, PhD, MS, BSN, is a Professor at the University of Costa Rica School of Nursing. He earned a Doctorate of Philosophy in Nursing from the University of Miami, a Master of Science in Integral Health and Human Movement from the National University, Costa Rica, and a Licentiate of Science in Nursing from the University of Costa Rica, Costa Rica. His research focuses on the intersection of intimate partner violence, alcohol and substance abuse, and risky sexual behaviors among adolescents and college students.

Cristobal Ching-Alvarez, MS, BSN, is a Professor at the University of Costa Rica School of Nursing. He earned a Master of Science in Nursing (focused on Occupational Health) from the National University, Costa Rica, and a Licentiate of Science in Nursing from the University of Costa Rica, Costa Rica. His research focuses on nursing research methods, disasters management, and occupational health.

MS. Kwynn M. Gonzalez-Pons, MPH, CPH, is a Ph.D. candidate in Social Work at the University of Utah. She earned a Master of Public Health from the University of North Texas Health Science Center and a Bachelor of Science in Management from McNeese University. Her research focuses on gender-based violence; sexual violence and exploitation; and technology-based interventions. She works as a Policy Enforcement Manager at YouTube, consult for the Last Prisoner Project

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Research Project was sponsored by the University of the Costa Rica, Center for Research on Nursing Care and Health, with project number 840-B8-328.

ORCID iD

Derby Munoz-Rojas https://orcid.org/0000-0003-2143-4716

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