James S. Marks

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.

BACKGROUND The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Original ArticlesRelationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study

BACKGROUND The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults.

Major depression has been associated with mortality from ischemic heart disease (IHD). In addition, a symptom of depression—hopelessness—has been suggested as a determinant of health status. We studied the relation of both depressed affect and hopelessness to IHD incidence using data from a cohort of 2,832 U.S. adults age 45–77 years who participated in the National Health Examination Follow-up Study (mean follow-up = 12.4 years) and had no history of IHD or serious illness at baseline. We used the depression subscale of the General Well-Being Schedule to define depressed affect and a single item from the scale to define hopelessness. At baseline, 11.1% of the cohort had depressed affect; 10.8% reported moderate hopelessness, and 2.9% reported severe hopelessness. Depressed affect and hopelessness were more common among women, blacks, and persons who were less educated, unmarried, smokers, or physically inactive. There were 189 cases of fatal IHD during the follow-up period. After we adjusted for demographic and risk factors, depressed affect was related to fatal IHD [relative risk = 1.5; 95% confidence interval (CI) = 1.0–2.3]; the relative risks of fatal IHD for moderate and severe levels of hopelessness were 1.6 (95% CI = 1.0–2.5) and 2.1 (95% CI = 1.1–3.9), respectively. Depressed affect and hopelessness were also associated with an increased risk of nonfatal IHD. These data indicate that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD. (Epidemiology 1993;4:285–294)

The relationship between pregnancy intendedness and physical violence in mothers of newborns

Objective To determine if pregnancy intendedness is associated with physical violence, and to identify factors that modify this association. Methods Three to 6 months after delivery, we mailed a questionnaire to a population-based sample of 12,612 mothers of infants born during 1990 and 1991 in four states. We used multiple logistic regression to compute odds ratios. Results The state-specific prevalences (± standard error) of physical violence ranged from 3.8 ± 0.5 to 6.9 ± 0.8%; the prevalences of unwanted or mistimed pregnancies ranged from 36.9–46.3%. In each state, higher rates of physical violence were reported by women who had fewer than 12 years of education, lived in crowded conditions, participated in the Special Supplemental Food Program for Women, Infants, and Children, received no or delayed prenatal care, or were of races other than white, under 20 years old, or not married. Regardless of other attributes, women with unwanted or mistimed pregnancies reported higher rates of physical violence than women with intended pregnancies and accounted for 70% of women who reported physical violence. Overall, women with unwanted pregnancies had 4.1 (95% confidence interval 2.7–6.2) times the odds of experiencing physical violence than did women with intended pregnancies. This association was weaker for women with few social advantages than for those with more advantages. Conclusion Physical violence toward women during the periconceptional and antenatal periods occurs in all sociodemographic groups. Women with unwanted or mistimed pregnancies are at an increased risk for violence by their partners compared with women with intended pregnancies.

Violence and Reproductive Health: Current Knowledge and Future Research Directions

Objectives: Despite the scope of violence against women and its importance for reproductive health, very few scientific data about the relationship between violence and reproductive health issues are available. Methods: The current knowledge base for several issues specific to violence and reproductive health, including association of violence with pregnancy, pregnancy intention, contraception use, pregnancy terminations, and pregnancy outcomes, are reviewed and suggestions are provided for future research. Results: Despite the limitations of current research and some inconclusive results, the existing research base clearly documents several important points: (1) violence occurs commonly during pregnancy (an estimated 4%–8% of pregnancies); (2) violence is associated with unintended pregnancies and may be related to inconsistent contraceptive use; and (3) the research is inconclusive about the relationship between violence and pregnancy outcomes. Conclusions: Improved knowledge of the risk factors for violence is critical for effective intervention design and implementation. Four areas that need improvement for development of new research studies examining violence and reproductive-related issues include (1) broadening of study populations, (2) refining data collection methodologies, (3) obtaining additional information about violence and other factors, and (4) developing and evaluating screening and intervention programs. The research and health care communities should act collaboratively to improve our understanding of why violence against women occurs, how it specifically affects reproductive health status, and what prevention strategies may be effective.

Increased cesarean section rates and emerging patterns of health insurance in Shanghai, China.

OBJECTIVES This study examined the trend in cesarean section deliveries and the factors associated with it in the Minhang District of Shanghai, China. METHODS A representative sample of the members of 2716 households in the district were interviewed in the fall of 1993. This study analyzed the data from 1959 married women of reproductive age with at least one live birth. RESULTS During the past 3 decades, the proportion of infants born by cesarean section increased from 4.7% to 22.5%. Logistic regression analysis revealed that the highest cesarean section rate, which occurred in the most recent period of 1988 through 1993, was associated with form of medical payment, self-reported complications during pregnancy, higher birthweight, and maternal age. Government insurance pays all costs of cesarean sections and accounted for the highest proportion of the cesarean section rate. CONCLUSIONS The high rates of cesarean sections in China are surprising given the lack of the factors that usually lead to cesarean sections. The increasing cesarean section rates may be an early indication that emerging forms of health insurance and fee-for-service payments to physicians will lead to an excessive emphasis on costly, high-technology medical care in China.

The American Cancer Society challenge goals

Cancer incidence and mortality rates both began to decline in the U. S. in the early 1990s. Recognizing the unprecedented potential benefits of accelerating this decline, the American Cancer Society (ACS) has set ambitious challenge goals for the American public for a 25% reduction in cancer incidence rates and a 50% reduction in cancer mortality rates by the year 2015. This analysis examined the feasibility of reaching those goals by estimating future changes in cancer rates that can result from past and future reductions in cancer risk factors.

Violence during pregnancy: measurement issues.

OBJECTIVES Standardized quantitative methods are needed to study occurrence and timing of violence in relation to pregnancy and to study the context in which pregnancy-related violence occurs. METHODS Data from three published studies of prevalence of violence during pregnancy are used to illustrate ways to measure the association of violence in relation to pregnancy. RESULTS Four patterns of violence in relation to pregnancy are identified, and related research issues are discussed. Also, 2 population-based surveys that address the suggestions presented here are discussed. CONCLUSIONS Better measurement of the association between violence and pregnancy will facilitate development of data-based prevention and intervention programs.

Measuring the public's health.

Allocation of public health resources should be based, where feasible, on objective assessments of health status, burden of disease, injury, and disability, their preventability, and related costs. In this article, we first analyze traditional measures of the publics health that address the burden of disease and disability and associated costs. Second, we discuss activities that are essential to protecting the publics health but whose impact is difficult to measure. Third, we propose general characteristics of useful measures of the publics health. We contend that expanding the repertoire of measures of the publics health is a critical step in targeting attention and resources to improve health, stemming mounting health care costs, and slowing declining quality of life that threatens the nations future.

Effectiveness of a mailed reminder on the immunization levels of infants at high risk of failure to complete immunizations.

The Ohio Department of Health initiated a program of mailing an immunization reminder to the mothers of six-month-old children predicted to be at high risk of failure to receive vaccinations based on birth certificate information. The evaluation results indicated a 50% gain in immunizations amongst children whose parents received the letter when compared with those not receiving the letter.