Pre-post Mixed Methods Study of a Parent and Teen Support Intervention to Prevent Violence Against Adolescents in the Philippines.

PURPOSE: This study examines the feasibility of a culturally adapted parenting intervention (MaPa Teens) within the national cash transfer system to reduce violence against adolescents, the first such program in the Philippines. METHODS: Thirty caregiver-adolescent dyads who were beneficiaries of a government conditional cash transfer program participated in a pilot of a locally adapted version of the Parenting for Lifelong Health for Parents and Teens program. Primary outcomes of reducing child maltreatment and associated risk factors were evaluated using a single-group, pre-post design. Focus group discussions explored the perceptions of participants and facilitators regarding program acceptability and feasibility. RESULTS: Significant and moderate reductions were reported in overall child maltreatment and physical abuse (caregiver and adolescent reports) and in emotional abuse (adolescent report). There were significant reductions in neglect, attitudes supporting punishment, parenting stress, parental and adolescent depressive symptoms, parent-child relationship problems, and significant improvement in parental efficacy in managing child behavior. Adolescents reported reduced behavior problems, risk behavior, and witnessing of family violence. Participants valued learning skills using a collaborative approach, sustained their engagement between sessions through text messages and phone calls, and appreciated the close interaction with caring and skilled facilitators. Program areas of improvement included addressing barriers to attendance, increasing adolescent engagement, and revising the sexual health module. DISCUSSION: The study provides preliminary support for the effectiveness and feasibility of the program in reducing violence against Filipino adolescents. Findings suggest potential adaptations of the program, and that investment in more rigorous testing using a randomized controlled trial would be worthwhile.

Measuring antenatal depressive symptoms across the world: A validation and cross-country invariance analysis of the Patient Health Questionnaire-9 (PHQ-9) in eight diverse low-resource settings.

Measures that produce valid and reliable antenatal depressive symptom scores in low-resource country contexts are important for efforts to illuminate risk factors, outcomes, and effective interventions in these contexts. Establishing the psychometric comparability of scores across countries also facilitates analyses of similarities and differences across contexts. To date, however, few studies have evaluated the psychometric properties and comparability of the most widely used antenatal depressive symptom measures across diverse cultural, political, and social contexts. To address this gap, we used data from the Evidence for Better Lives Study-Foundational Research (EBLS-FR) project to examine the internal consistency reliability, nomological network validity, and cross-country measurement invariance of the nine-item version of the Patient Health Questionnaire (PHQ-9) in antenatal samples across eight low-resource contexts. We found that the PHQ-9 scores had good internal consistency across all eight countries. Correlations between PHQ-9 scores and constructs conceptually associated with depression were generally consistent, with a few exceptions. In measurement invariance analyses, only partial metric invariance held and only across four of the countries. Our results suggest that the PHQ-9 yields internally consistent scores when administered in culturally diverse antenatal populations; however, the meaning of the scores may vary. Thus, interpretation of PHQ-9 scores should consider local meanings of symptoms of depression to ensure that context-specific conceptualizations and manifestations of antenatal depressive symptoms are adequately reflected. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Associations Between ADHD Symptoms and Maternal and Birth Outcomes: An Exploratory Analysis in a Multi-Country Cohort of Expectant Mothers.

OBJECTIVE: ADHD symptoms can adversely impact functioning in a range of domains relevant for maternal well-being and fetal development; however, there has been almost no research examining their impact during pregnancy. We aimed to address this gap. METHOD: We used data (n = 1,204) from a longitudinal birth cohort study spanning eight countries to address this gap. RESULTS: ADHD symptoms in the third trimester of pregnancy were associated with lower social support from family (b = -0.16, p = .031), friends (b = -0.16, p = .024), and significant others (b = -0.09, p = .001); higher stress (b = 0.34, p < .001) and depressive symptoms (b = 0.31, p < .001), and increased likelihood of an unwanted pregnancy (b = 0.30, p = .009). Significant associations with tobacco use (b = 0.36, p = .023) and premature birth (b = 0.35, p = .007) did not survive correction for multiple comparisons and there were no significant associations with alcohol use, low birth weight, or unplanned pregnancy. CONCLUSION: Results suggest that women with ADHD symptoms could benefit from earlier, more regular screening for mental health difficulties and greater mental health support during pregnancy.

Patterns of adverse childhood experiences and associations with prenatal substance use and poor infant outcomes in a multi-country cohort of mothers: a latent class analysis.

BACKGROUND: This paper enumerates and characterizes latent classes of adverse childhood experiences and investigates how they relate to prenatal substance use (i.e., smoking, alcohol, and other drugs) and poor infant outcomes (i.e., infant prematurity and low birthweight) across eight low- and middle-income countries (LMICs). METHODS: A total of 1189 mother-infant dyads from the Evidence for Better Lives Study cohort were recruited. Latent class analysis using the Bolck, Croon, and Hagenaars (BCH) 3-step method with auxiliary multilevel logistic regressions was performed. RESULTS: Three high-risk classes and one low-risk class emerged: (1) highly maltreated (7%, n = 89), (2) emotionally and physically abused with intra-familial violence exposure (13%, n = 152), (3), emotionally abused (40%, n = 474), and (4) low household dysfunction and abuse (40%, n = 474). Pairwise comparisons between classes indicate higher probabilities of prenatal drug use in the highly maltreated and emotionally abused classes compared with the low household dysfunction and abuse class. Additionally, the emotionally and physically abused with intra-familial violence exposure class had higher probability of low birthweight than the three remaining classes. CONCLUSION: Our results highlight the multifaceted nature of ACEs and underline the potential importance of exposure to childhood adversities on behaviors and outcomes in the perinatal period. This can inform the design of antenatal support to better address these challenges.

Perceived stress during the prenatal period: assessing measurement invariance of the Perceived Stress Scale (PSS-10) across cultures and birth parity.

Maternal prenatal stress places a substantial burden on mother's mental health. Expectant mothers in low- and middle-income countries (LMICs) have thus far received less attention than mothers in high-income settings. This is particularly problematic, as a range of triggers, such as exposure to traumatic events (e.g. natural disasters, previous pregnancy losses) and adverse life circumstances (e.g. poverty, community violence), put mothers at increased risk of experiencing prenatal stress. The ten-item Perceived Stress Scale (PSS-10) is a widely recognised index of subjective experience of stress that is increasingly used in LMICs. However, evidence for its measurement equivalence across settings is lacking. This study aims to assess measurement invariance of the PSS-10 across eight LMICs and across birth parity. This research was carried out as part of the Evidence for Better Lives Study (EBLS, vrc.crim.cam.ac.uk/vrcresearch/EBLS). The PSS-10 was administered to N = 1,208 expectant mothers from Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam during the third trimester of pregnancy. Confirmatory factor analysis suggested a good model fit of a two-factor model across all sites, with items on experiences of stress loading onto a negative factor and items on perceived coping onto a positive factor. Configural and metric, but not full or partial scalar invariance, were established across all sites. Configural, metric and full scalar invariance could be established across birth parity. On average, first-time mothers reported less stress than mothers who already had children. Our findings indicate that the PSS-10 holds utility in assessing stress across a broad range of culturally diverse settings; however, caution should be taken when comparing mean stress levels across sites.

Effectiveness of a parenting programme to reduce violence in a cash transfer system in the Philippines: RCT with follow-up.

BACKGROUND: Parenting interventions and conditional cash transfer (CCT) programmes are promising strategies to reduce the risk of violence against children, but evidence of the effectiveness of combining such programmes is lacking for families in low- and middle-income countries with children over two years of age. This study examined the effectiveness of a locally adapted parenting programme delivered as part of a government CCT system to low-income families with children aged two to six years in Metro Manila, Philippines. METHODS: Participants were randomly assigned (1:1) to either a 12-session group-based parenting programme or treatment-as-usual services (N = 120). Participation in either service was required among the conditions for receiving cash grants. Baseline assessments were conducted in July 2017 with one-month post-intervention assessments in January-February 2018 and 12-month follow-up in January-February 2019. All assessments were parent-report (ClinicalTrials.gov: NCT03205449). FINDINGS: One-month post-intervention assessments indicated moderate intervention effects for primary outcomes of reduced overall child maltreatment (d = -0.50 [-0.86, -0.13]), emotional abuse (d = -0.59 [-0.95; -0.22]), physical abuse (IRR = 0.51 [0.27; 0.74]), and neglect (IRR = 0.52 [0.18; 0.85]). There were also significant effects for reduced dysfunctional parenting, child behaviour problems, and intimate partner violence, and increased parental efficacy and positive parenting. Reduced overall maltreatment, emotional abuse, and neglect effects were sustained at one-year follow-up. INTERPRETATION: Findings suggest that a culturally adapted parenting intervention delivered as part of a CCT programme may be effective in sustaining reductions in violence against children in low- and middle-income countries. FUNDING: This research was supported by UBS Optimus Foundation and UNICEF Philippines, and by the Complexity and Relationships in Health Improvement Programmes of the Medical Research Council MRC UK and Chief Scientist Office (Grant: MC_UU_00022/1 and CSO SPHSU16, MC_UU_00022/3 and CSO SPHSU18).

The impact of maternal adverse childhood experiences and prenatal depressive symptoms on foetal attachment: Preliminary evidence from expectant mothers across eight middle-income countries.

BACKGROUND: Mothers from middle-income countries (MIC) are estimated to have higher rates of adverse childhood experiences (ACEs) and depression during pregnancy compared to mothers from high income countries. Prenatal depression can adversely impact on a mother's feelings towards her foetus and thus may be partially responsible for intergenerational transmission of risk associated with maternal ACEs. However, the extent to which prenatal depressive symptoms mediate the association between maternal ACEs and foetal attachment is unknown. METHODS: Data on foetal attachment, ACEs, and prenatal depression came from mothers in their third trimester of pregnancy (n = 1,185) located across eight MICs, participating in the prospective birth cohort Evidence for Better Lives Study - Foundational Research (EBLS-FR). Data were from the baseline measurement. RESULTS: Full-sample path mediation analyses, adjusting for relevant covariates, suggested a full mediating effect of prenatal depression. However, at the individual-country level, both positive and negative effects of ACEs on foetal attachment were observed after the inclusion of depressive symptoms as a mediator, suggesting cultural and geographical factors may influence a mother's empathic development after ACE exposure. LIMITATIONS: As no follow-up measurements of depressive symptoms or postnatal attachment were included in the analyses, the findings cannot be extrapolated to the postnatal period and beyond. Further, causality cannot be inferred as the study was observational. CONCLUSIONS: The findings reinforce the importance of screening for prenatal depression during antenatal care in MICs. Addressing prenatal depression within maternal health care may support foetal attachment and contribute to reducing the intergenerational transmission of disadvantage.

Prenatal attachment: using measurement invariance to test the validity of comparisons across eight culturally diverse countries.

Studies in high-income countries (HICs) have shown that variability in maternal-fetal attachment (MFA) predict important maternal health and child outcomes. However, the validity of MFA ratings in low- and middle-income countries (LMICs) remains unknown. Addressing this gap, we assessed measurement invariance to test the conceptual equivalence of the Prenatal Attachment Inventory (PAI: Muller, 1993) across eight LMICs. Our aim was to determine whether the PAI yields similar information from pregnant women across different cultural contexts. We administered the 18-item PAI to 1181 mothers in the third trimester (Mean age = 28.27 years old, SD = 5.81 years, range = 18-48 years) expecting their first infant (n = 359) or a later-born infant (n = 820) as part of a prospective birth cohort study involving eight middle-income countries: Ghana, Jamaica, Pakistan, Philippines, Romania, South Africa, Sri Lanka and Vietnam. We used Multiple Group Confirmatory Factor Analyses to assess across-site measurement invariance. A single latent factor with partial measurement invariance was found across all sites except Pakistan. Group comparisons showed that mean levels of MFA were lowest for expectant mothers in Vietnam and highest for expectant mothers in Sri Lanka. MFA was higher in first-time mothers than in mothers expecting a later-born child. The PAI yields similar information about MFA across culturally distinct middle-income countries. These findings strengthen confidence in the use of the tool across different settings; future studies should explore the use of the PAI as a screen for maternal behaviour that place children at risk.

A South-to-South Cultural Adaptation of an Evidence-Based Parenting Program for Families in the Philippines.

Rates of child maltreatment are higher in low- and middle-income countries due to risk factors such as social inequities, economic adversity, and sociocultural norms. Given the evidence showing the effectiveness of parenting interventions to prevent child maltreatment, this study embarked on a cultural adaptation of an evidence-based parenting program with the eventual goal of integrating it within a nationwide conditional cash transfer program for low-income Filipino parents with children aged 2-6 years. We document the systematic adaptation of the Parenting for Lifelong Health for Young Children program that was developed and tested in South Africa, for low-resource Filipino families using the heuristic framework for the cultural adaptation of interventions. We underscore the merits of conducting a multistage top-down and bottom-up process that uses a participatory approach among cultural insiders and outsiders to develop a parenting intervention that reflects the contextual realities and cultural values of end users. The adapted program, Masayang Pamilya Para sa Batang Pilipino, is the product of a delicate and deliberate effort to balance Filipino childrearing goals and values with the scientific evidence on components of parenting interventions known to promote positive parenting and prevent child maltreatment.

Los índices de maltrato infantil son más altos en los países de ingresos medios y bajos debido a factores de riesgo, como las desigualdades sociales, las dificultades económicas y las normas socioculturales. Teniendo en cuenta los datos que demuestran la eficacia de las intervenciones en la crianza para prevenir el maltrato infantil, este estudio inició una adaptación cultural de un programa de crianza factual con el objetivo principal de integrarlo dentro de un programa de transferencia condicional de dinero en efectivo a nivel nacional para padres filipinos de bajos recursos con niños de entre dos y seis años. Documentamos la adaptación sistemática del programa "Crianza para una buena salud durante toda la vida" (Parenting for Lifelong Health, PLH) orientado a niños pequeños que se desarrolló y se probó en Sudáfrica, para familias filipinas de bajos recursos utilizado el marco heurístico para las adaptaciones culturales de las intervenciones. Subrayamos los méritos de llevar a cabo un proceso multietapa descendente y ascendente que emplea un método participativo entre personas conocedoras de las culturas y personas ajenas a ella para desarrollar una intervención en la crianza que refleje las realidades contextuales y los valores culturales de los usuarios finales. El programa adaptado, Masayang Pamilya Para sa Batang Pilipino, es el producto de un esfuerzo comprometido y deliberado de equilibrar los objetivos y los valores de la crianza de los niños filipinos con las pruebas científicas sobre los componentes de las intervenciones en la crianza que promueven la crianza positiva y previenen el maltrato infantil.

What Research Questions Should the Next Generation of Birth Cohort Studies Address? An International Delphi Study of Experts.

OBJECTIVE: Birth cohort studies (BCS) have generated a wealth of invaluable basic scientific and policy-relevant information on a wide range of issues in child health and development. This study sought to explore what research questions are currently a priority for the next generation of BCS using a 3-round Delphi survey of interdisciplinary experts. METHODS: Twenty-four (Round I, N = 17; Round II, N = 21; Round III, N = 18) experts across a wide range of fields (eg, psychology, public health, and maternal/child health) agreed to participate. In Round I, the expert panel was invited to freely respond to the question, "what are the key scientific questions future birth cohort studies should address?" Content analysis of answers was used to identify 47 questions for rating on perceived importance by the panel in Round II and consensus-achieving questions were identified. Questions that did not reach consensus in Round II were posed again for expert re-rating in Round III. RESULTS: Twenty six of 47 questions reached consensus in Round II, with an additional 6 reaching consensus in Round III. Consensus-achieving questions rated highly on importance spanned a number of topics, including environmental effects on child development, intergenerational transmission of disadvantage, and designing BCS to inform intervention strategies. CONCLUSION: Investigating the effects of family/environmental factors and social disadvantage on a child's development should be prioritized in designing future BCS. The panel also recommended that future BCS are designed to inform intervention strategies.

Evidence for Better Lives Study: a comparative birth-cohort study on child exposure to violence and other adversities in eight low- and middle-income countries - foundational research (study protocol).

INTRODUCTION: Violence against children is a health, human rights and social problem affecting approximately half of the world's children. Its effects begin at prenatal stages with long-lasting impacts on later health and well-being. The Evidence for Better Lives Study (EBLS) aims to produce high-quality longitudinal data from cities in eight low- and middle-income countries-Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam-to support effective intervention to reduce violence against children. EBLS-Foundational Research (EBLS-FR) tests critical aspects of the planned EBLS, including participant recruitment and retention, data collection and analysis. Alongside epidemiological estimates of levels and predictors of exposure to violence and adversity during pregnancy, we plan to explore mechanisms that may link exposure to violence to mothers' biological stress markers and subjective well-being. METHODS AND ANALYSES: EBLS-FR is a short longitudinal study with a sample of 1200 pregnant women. Data are collected during the last trimester of pregnancy and 2 to 6 months after birth. The questionnaire for participating women has been translated into nine languages. Measures obtained from mothers will include, among others, mental and physical health, attitudes to corporal punishment, adverse childhood experiences, prenatal intimate partner violence, substance use and social/community support. Hair and dry blood spot samples are collected from the pregnant women to measure stress markers. To explore research participation among fathers, EBLS-FR is recruiting 300 fathers in the Philippines and Sri Lanka. ETHICS AND DISSEMINATION: The study received ethical approvals at all recruiting sites and universities in the project. Results will be disseminated through journal publications, conferences and seminar presentations involving local communities, health services and other stakeholders. Findings from this work will help to adjust the subsequent stages of the EBLS project.

Safe schools for teens: preventing sexual abuse of urban poor teens, proof-of-concept study - Improving teachers' and students' knowledge, skills and attitudes.

Child sexual abuse (CSA) is a difficult form of abuse to detect, with the peak age of reports from 13 to 15 years old. The recent revision of the Philippine school curriculum provided an opportunity to incorporate an educational intervention for prevention of CSA. This study aimed to improve the teachers' and students' knowledge, skills and attitudes on disclosure, identification, and reporting of CSA. This research is a two-phase proof-of-concept cross-sectional study of 237 teachers and 1,458 Grade 7 students from 2 public high schools in metro Manila over a two-year period. Phase 1 involved in-service training curriculum for all teachers on the recognizing, recording, reporting, and referral (4R's) of child abuse and establishment of a referral and support system. Outcome measures included pre- and post-tests and number of CSA reports. Phase 2 involved implementation of eight student modules through the Health and Values Education subjects of the curriculum. Outcome measures were pre- and post-intervention measurement of abuse and module content. Training of teachers resulted in an increase in confidence for identifying CSA from 25% to 57%, and a decrease in apprehension of reporting CSA from 40% to 33%. The Safe Schools for Teens intervention significantly improved self-reported knowledge on abuse, dating violence, and how to help friends as well as on adolescent's impulse control and emotional clarity. There was a significant decline from pre- to post-intervention in self-reported experiences of dating violence which includes physical, sexual and emotional violence, t(793) = 3.363, p = 001 as well as a significant decline in self-reported experiences of emotional abuse from a dating partner, t(837) = 2.693, p = 0.008. The Safe Schools for Teens intervention increases awareness and reporting of child sexual abuse. The intervention also reduces dating violence highlighting that the mindfulness focused approach in connection with systems strengthening is useful for addressing adolescent violence.

The Intergenerational Effects of Intimate Partner Violence in Pregnancy: Mediating Pathways and Implications for Prevention.

Prenatal intimate partner violence (P-IPV) can have significant adverse impacts on both mother and fetus. Existing P-IPV interventions focus on the safety of the mother and on reducing revictimization; yet expanding these to address the adverse impact on the fetus has considerable potential for preventing long-term negative developmental outcomes. In this review, we draw together evidence on major pathways linking exposure to P-IPV and child outcomes, arguing that these pathways represent potential targets to improve P-IPV intervention efforts. Using a narrative review of 112 articles, we discuss candidate pathways linking P-IPV to child outcomes, as well as their implications for intervention. Articles were identified via key word searches of social science and medical databases and by inspection of reference lists of the most relevant articles, including recent reviews and meta-analyses. Articles were included if they addressed issues relevant to understanding the effects of P-IPV on child outcomes via six core pathways: maternal stress and mental illness, maternal-fetal attachment, maternal substance use, maternal nutritional intake, maternal antenatal health-care utilization, and infection. We also included articles relevant for linking these pathways to P-IPV interventions. We conclude that developing comprehensive P-IPV interventions that target immediate risk to the mother as well as long-term child outcomes via the candidate mediating pathways identified have significant potential to help reduce the global burden of P-IPV.

Exploring opportunities for coordinated responses to intimate partner violence and child maltreatment in low and middle income countries: a scoping review.

Intimate partner violence (IPV) and child maltreatment (CM) by a parent or caregiver are prevalent and overlapping issues with damaging consequences for those affected. This scoping review aimed to identify opportunities for greater coordination between IPV and CM programmes in low- and middle-income countries (LMIC). Nine bibliographic databases were searched and grey literature was identified through the scoping review team. Eligible studies were published in English; described primary prevention programmes in LMIC that addressed IPV and CM, or addressed one form of violence, but reported outcomes for the other; reported IPV and CM outcomes; and evaluated with any study design. Six studies were identified published between 2013 and 2016 (four randomised controlled trials, one pre-post non-randomised study and one qualitative study). Programmes were based in South Africa (2), Uganda, (2), Liberia (1) and Thailand (1). All except one were delivered within parenting programmes. The emphasis on gender norms varied between programmes. Some parenting programmes addressed gender inequity indirectly by promoting joint decision-making and open communication between caregivers. Conclusions are tentative due to the small evidence base and methodological weaknesses. More robust evaluations are needed. Improved coherence between IPV and CM programmes requires equal attention to the needs of women and children, and the involvement of fathers when it is safe to do so.

Y-STR DNA analysis of 154 female child sexual assault cases in the Philippines.

The laboratory evaluated 154 sexual assault cases from four Child Protection Units in the Philippines involving female child victims aged from 2 years to 18 years old. All child victims sought medical attention within 72 h after sexual contact. In 130 cases, the child victim knew the alleged offender and identified them during the interview with the social worker. Penile ejaculation was reported by 68 child victims with varying reports of washing after contact. Overall, 84 child victims admitted having wiped their genitalia prior to the collection of biological samples for DNA testing. Laboratory personnel examined vaginal smears in only 109 cases using a light microscope and reported 23 samples to be positive for sperm cells. Using the PowerPlex® short tandem repeat of the Y chromosome (Y-STR) DNA multiplex system, male DNA was detected in vaginal swab samples from 63 child victims. In 39 cases, positive amplification at 11 Y-STR DNA markers consistent with a single male DNA profile was observed. Twenty-eight of these full single Y-STR DNA profiles were found to be unique when searched in worldwide Y-STR DNA population databases (~40,000 haplotypes), eight haplotypes matching Filipinos and/or Asian haplotypes and one Y-STR DNA profile only matching European, Caucasian, and Latin American haplotypes. Y-STR DNA profiles generated will be compared with reference DNA profiles of alleged offenders once reference samples are submitted to the laboratory.

Menkes disease mimicking non-accidental injury in a Filipino child

We report an 11-month-old male who presented with recurrent seizures, subdural bleed, skull fracture, lightly pigmented hair, and fair lax skin. Copper and ceruloplasmin levels were low and gross deletion of ATP7A gene was found confirming the diagnosis of Menkes disease. The presence of subdural bleed and skull fracture prompted a referral to the Child Protection Unit to rule out child abuse.

Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting.

OBJECTIVE: This study aimed to examine the association among adverse childhood experiences, health-risk behaviors, and chronic disease conditions in adult life. STUDY POPULATION: One thousand and sixty-eight (1,068) males and females aged 35 years and older, and residing in selected urban communities in Metro Manila participated in the cross-sectional survey. METHODS: A pretested local version of the Adverse Childhood Experiences Questionnaires developed by the Centers for Disease Control and Prevention, USA, was used. Data were collected through self-administration of the questionnaire. Prevalence and estimates of odds ratio were computed to obtain a measure of association among variables. Logistic regression analysis was employed to adjust for the potential confounding effects of age, sex, and socio-economic status. RESULTS: The results indicated that 75% of the respondents had at least 1 exposure to adverse childhood experiences. Nine percent had experienced 4 or more types of abuse and household dysfunctions. The most commonly reported types of negative childhood events were psychological/emotional abuse, physical neglect, and psychological neglect of basic needs. Majority of respondents claimed to have experienced living with an alcoholic or problem drinker and where there was domestic violence. Health-risk behavior consequences were mostly in the form of smoking, alcohol use, and risky sexual behavior. The general trend shows that there was a relatively strong graded relationship between number of adverse childhood experiences, health-risk behaviors, and poor health. CONCLUSION: This study provided evidence that child maltreatment is a public health problem even in poorer environments. Prevention and early intervention of child maltreatment were recommended to reduce the prevalence of health-risk behavior and morbidity in later life.