Barbara J. Naimark

Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization

OBJECTIVES Objectives of this population-based study were: (1) to examine the relative contribution of childhood abuse and other adverse childhood experiences to poor adult health and increased health care utilization and (2) to examine the cumulative effects of adverse childhood experiences on adult health and health care utilization. METHODS Data from the Ontario Health Survey, a representative population sample (n=9,953) of respondents aged 15 years and older, were analyzed using logistic regression. Adverse childhood experiences examined were childhood physical and sexual abuse, parental marital conflict, poor parent-child relationship, low parental education and parental psychopathology. RESULTS Most (72%) respondents reported at least one adverse childhood experience and a considerable proportion of respondents (37%) reported two or more of these experiences. In examining the bivariate models, childhood physical and sexual abuse had a stronger influence than other types of adverse childhood experiences. With the addition of other adverse childhood experiences in the model, the odds ratios for childhood abuse were attenuated but remained statistically significant for most health outcomes. This suggests that childhood abuse may have a unique adverse influence on the development of poor adult health. When an aggregate variable was created to explore the cumulative effects of adverse childhood experience, the odds were increased, with each additional experience, for reporting multiple health problems [odds ratio (OR): 1.22], poor self-rated health (OR: 1.18), pain (OR: 1.24), disability (OR: 1.24), general practitioner use (OR: 1.12), emergency room use (OR: 1.29) and health professional use (OR: 1.19). CONCLUSIONS This study suggests that childhood abuse and other adverse childhood experiences are overlapping risk factors for long-term adult health problems and that the accumulation of these adverse experiences increases the risk of poor adult health. PRACTICE IMPLICATIONS This study highlights the importance of the many adverse childhood experiences influencing long-term health. In practice, childhood abuse is often difficult to identify as families tend to keep it hidden and reported cases represent only a small percentage of the actual cases. Assessments and interventions which focus on improving socio-economic status, strengthening marital and parent-child relationships, and supporting parents with mental health issues are less threatening for families than assessing their experiences with abuse and neglect and are more likely to be effective in identifying and supporting at-risk families.

Health Risk Behaviors and Mental Health Problems as Mediators of the Relationship Between Childhood Abuse and Adult Health

OBJECTIVES We examined the relationship between childhood abuse and adult health risk behaviors, and we explored whether adult health risk behaviors or mental health problems mediated the relationship between childhood abuse and adult health problems and health care utilization. METHODS We used logistic regression to analyze data from the Mental Health Supplement of the Ontario Health Survey, a representative population sample (N = 8116) of respondents aged 15 to 64 years. RESULTS We found relationships between childhood sexual abuse and smoking (odds ratio [OR] = 1.52; 95% confidence interval [CI] = 1.16, 1.99), alcohol problems (OR = 2.44; 95% CI = 1.74, 3.44), obesity (OR = 1.61; 95% CI = 1.14, 2.27), having more than 1 sexual partner in the previous year (OR = 2.34; 95% CI = 1.44, 3.80), and mental health problems (OR = 2.26; 95% CI = 1.78. 2.87). We also found relationships between these factors (with the exception of obesity) and childhood physical abuse. Mediation analysis suggested that health risk behaviors and particularly mental health problems are partial mediators of the relationship between childhood abuse and adult health. CONCLUSIONS Public health approaches that aim to decrease child abuse by supporting positive parent-child relationships, reducing the development of health risk behaviors, and addressing childrens mental health are likely to improve long-term population health.

Determinants of self-care behaviors in community-dwelling patients with heart failure.

Background and Research Objective: As the population ages, chronic conditions such as heart failure are becoming more prevalent. An important goal is to understand how patients with heart failure learn to manage the often debilitating disease symptoms. The research objective was to examine the determinants of general and therapeutic self-care behaviors among community-dwelling heart failure patients. Guided by Connellys Model of Self-care in Chronic Illness, enabling and predisposing factors were evaluated using sociodemographic characteristics, functional ability, and psychological status. Self-care maintenance, self-efficacy, and self-care management characteristics were also evaluated. Participants and Methods: Using a cross-sectional design, a convenience sample of 65 ambulatory care patients were recruited. Data were collected through chart reviews and questionnaires. Results and Conclusions: Common self-care maintenance behaviors included taking medication as prescribed (95%), seeking physician guidance (80%), and following sodium dietary restrictions (70%). These behaviors were influenced by enabling characteristics such as psychological status (P = .030), ethnicity (P = .048), and comorbidity (P = .023). A unique finding was that self-care maintenance behaviors were significantly lower in aboriginal participants. The predisposing characteristic of self-efficacy influenced self-maintenance behaviors (P = .0002), overall self-care (P = .04) and number of hospital admissions (P < .0001). Higher overall self-care scores, measured by the summative Self-care Heart Failure Index score was correlated with fewer hospital admissions (P = .019).

The Coronary Artery Bypass Graft Surgery Trajectory: Gender Differences Revisited

Over the past several decades there has been substantial research interest in gender differences within the coronary artery bypass graft (CABG) surgery trajectory. However, the debate persists regarding the reasons why women may have less favorable outcomes. As part of a larger study, we explored gender differences in the physiological and psychosocial dimensions of pre-operative status, and post-operative morbidity and quality of life outcomes in CABG surgery patients. A purposive sample of patients on the waiting list for CABG surgery (N = 195; 157 males; 38 females) was followed for 6 months post-surgery. The results reflected consistent evidence of a male advantage across the CABG surgery trajectory. Though gender differences in age were non-significant, females had significantly more post-operative respiratory complications (p = 0.005), a longer hospital stay (p = 0.003), more symptoms at 2 weeks post-discharge, and a lower quality of life at 6 weeks and 6 months post-discharge. Our findings provide important insights for improving CABG surgery outcomes for both men and women. In particular, implementing creative strategies to improve physical functioning pre-operatively, may improve post-operative quality of life outcomes in this population.

Coronary artery bypass graft surgery: exploring a broader perspective of risks and outcomes.

Although the literature is replete with evidence related to physiological predictors and short-term outcomes of coronary artery bypass graft (CABG) surgery, there is still a paucity of data that encompass a broader perspective of risk and outcomes. The primary objective of this prospective cohort study was to explore the physiological and psychosocial dimensions of preoperative status that may be predictive of the short- and longer term outcomes of CABG surgery. Patients (N = 136) scheduled for elective/urgent CABG surgery were followed from the time of placement on the waiting list until 6 months after the surgery. Significant predictors of intensive care unit length of stay (LOS) included the following: age, urgency of operation, and perioperative complications. Hospital LOS was best predicted by baseline unemployment, longer bypass time, and perioperative complications. Baseline unemployment and less optimism regarding surgery outcomes were predictive of postdischarge home care utilization. Lower baseline physical functioning predicted postdischarge emergency room visits. Sex and baseline mental status predicted quality of life/health satisfaction scores at 6 weeks and 6 months after discharge. The ability to predict patient outcomes has implications for program planning, patient education, and policy development. The findings of this study provide rationale for clinicians, educators, and administrators to consider a broader scope of physiological and psychosocial parameters to predict outcomes of CABG surgery. Although the sample size was relatively small, the broader perspective on risk and outcomes provides insight for strategies to optimize overall outcomes for the CABG surgery population. These findings also establish the cornerstone for ongoing CABG surgery outcomes evaluation and research.

1410 Coronary artery bypass graft surgery: An early post-discharge patient needs assessment

Purpose: Coronary artery bypass graft (CABG) surgery is the most frequently performed intervention for coronary heart disease. Although much research attention has been directed towards gender differences in post-operative recovery, there are still concerns that women may have worse outcomes. As part of a larger study, we explored gender differences in the physiological and psychosocial dimensions of pre-operative status and post-operative morbidity and quality of life outcomes in CABG surgery patients.

Cardiac Structure and Exercise Blood Pressure in Urban and Rural Canadian Men of Icelandic Descent

The objective of the study was to determine the relationship between exercise systolic blood pressure (ESBP), during bicycle ergometry, and echocardiographically determined left ventricular structure in rural and urban Canadian men of Icelandic descent. The study was cross-sectional in design. The settings were urban Winnipeg and the rural Interlake District in the province of Manitoba, Canada. Subjects were adult male volunteers from families of wholly Icelandic descent. The subjects were 30 to 60 years of age and had supine blood pressure < 160/95 mm Hg. Anthropomorphic measurements, echocardiography and sphygmomanometry, at rest and during bicycle ergometry, were performed on all subjects. Prevalence of exaggerated ESBP (> or = 200 mm Hg) and left ventricular hypertrophy (LVH) was not significantly different in the two groups. In all but one individual LVH was classified as eccentric hypertrophy. In both urban and rural subjects with exaggerated ESBP, left ventricular mass index (LVMI) was greater than in those subjects without exaggerated ESBP. The LVMI correlated with ESBP at the highest workloads (> or = 150 W). Multivariate analysis of all subjects showed that cardiac index, ESBP, body mass index, and low exercise heart rate were predictive of LVMI. There was no significant difference in prevalence of ESBP or LVH between urban and rural Manitobans of Icelandic descent. However, LVMI levels were lower, and values for ESBP greater, in the rural group compared with the urban group. Within each of the two groups there was a positive association between ESBP and LVMI; hence, the study supports findings of our previous investigation showing evidence of early target organ effects in normotensive men with an exaggerated ESBP.