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.

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.

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.

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 children's 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 Connelly's 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).

Influential factors for self-care in ambulatory care heart failure patients: a qualitative perspective.

Chronic heart failure is associated with debilitating symptoms, diminished quality of life and frequent hospitalizations. The literature suggests that effective everyday self-care decision-making can improve heart failure outcomes. This article focuses on the qualitative portion of a study of self-care decision-making in community-dwelling individuals attending a heart failure clinic. Semi-structured interviews conducted with 11 participants identified influences that enhance or impede self-care practices and their behavioural responses to them. Content analysis was used to examine predisposing attributes and enabling circumstances described in Connelly's Model of Self-Care in Chronic Illness. These interactive factors were either facilitators or barriers to self-care. The importance of individualizing patient teaching plans and frequent monitoring of factors likely to facilitate self-care were pivotal nursing implications that emerged from this study.

Uncertainty, symptom distress, anxiety, and functional status in patients awaiting coronary artery bypass surgery.

OBJECTIVE: The study's objective was to (1) describe uncertainty, anxiety, the symptom distress experience, and functional status of patients on a coronary artery bypass graft (CABG) waiting list and express the relationship between these concepts; (2) explore whether length of time waited has an influence on the psychosomatic condition of patients; and (3) explore the use of semistructured interviews within the context of a theoretic framework and compare open-ended responses to quantitative results. DESIGN: A descriptive, correlational, cross-sectional design was used with supplementary telephone interviews using semistructured questions. Quantitative data were collected with a mailed questionnaire. Study instruments included the Mishel Uncertainty in Illness Scale (Community), Symptom Frequency and Symptom Distress Scale, Graphical Anxiety Rating Scale, and Kansas City Cardiomyopathy Questionnaire (Physical and Social Limitation). The Mishel Uncertainty in Illness Theory was used as the guiding theoretic framework. SETTING: The study took place in one large tertiary care hospital in Winnipeg, Manitoba, Canada. SAMPLE: The study included a convenience sample of 42 patients undergoing first-time elective CABG only, 25 of whom participated in the telephone interview. RESULTS: Average uncertainty and anxiety were present at moderate levels and were associated with moderate deterioration of functional status. Reported symptom distress was low; however, presence of symptoms showed a strong relationship with anxiety (P=.0002), and this relationship was confirmed through semistructured interviews. Although the relationship between uncertainty and anxiety was nonsignificant, the interviews suggest positive views of uncertainty as an opportunity may have muted the relationship between uncertainty and anxiety, and that it is possible to experience uncertainty as a danger and an opportunity simultaneously. No statistically significant relationship was found between the study variables and waiting time; however, there was a nonsignificant trend toward deterioration of psychologic and physical condition with longer waits, which may be clinically significant. CONCLUSION: Psychosocial distress and physical condition among patients on CABG waiting lists should be continually assessed in all patients regardless of how long they have been waiting. Each patient will have a unique presentation of symptoms and a corresponding unique psychologic response.

Nonspecific behaviors as early indications of cerebral vasospasm.

This study investigated nonspecific behaviors as early indications of vasospasm following subarachnoid hemorrhage. Although symptoms of vasospasm (e.g., lowered level of consciousness, focal deficits such as hemiplegia or aphasia), are well recognized, the significance of early appearance of nonspecific symptoms such as restlessness, unusual behaviors, and impulsive behavior has not been investigated in detail. The study design included descriptive quantitative elements and a small qualitative component. Nonspecific behaviors were recorded, and the prevalence of those behaviors in individuals developing vasospasm was noted. Of 60 participants, 31 developed vasospasm; 24 of the 31 initially presented with nonspecific behaviors (p < .0001). Early detection of cerebral vasospasm allows prompt intervention and treatment, with the goal of preventing further ischemia or infarction.

Cardiovascular health promotion in aging women: validating a population health approach.

OBJECTIVE: Although cardiovascular disease is the leading cause of death in North American women, most cardiovascular research has focused on men. In addition, while there has been a recent trend toward population health promotion (PHP) and a consequent focus on the broad determinants of health, there is still a dearth of research evidence related to the promotion of cardiovascular health within this context. The purpose of this study was to explore and describe the interrelationships between the determinants of health and individual cardiovascular health/risk behaviors in healthy women, within the context of a framework for PHP. DESIGN: A comprehensive inventory of factors affecting the cardiovascular health of women was operationalized in a survey questionnaire, the Cardiovascular Health Promotion Profile. Physical measures were also taken on each participant (n = 206). RESULTS: The multivariate analyses support significant interrelationships between the population health determinants and multiple individual cardiovascular health/risk behaviors in this cohort (p < 0.05). CONCLUSIONS: The evidence from this study provides foundational validation for a population health approach and population-based strategies for cardiovascular health promotion in women. Further research, within the context of a PHP framework, is central to building on the body of knowledge in this area.

A qualitative analysis of the experience of uncertainty while awaiting coronary artery bypass surgery.

The aim of this article is to present a qualitative examination of the phenomenon of uncertainty in patients awaiting CABG surgery. Cardiac symptoms are presented as an antecedent to uncertainty and both positive and negative outcomes of uncertainty are discussed. Semi-structured interview questions, based on Mishel's Uncertainty in Illness Theory, were developed to investigate the experience of waiting for CABG surgery and identify what patients were doing: to make their cardiac symptoms more manageable, to relieve their own anxiety while waiting, and to identify why patients felt having CABG surgery would benefit them. Telephone interviews were conducted with a self-selected sample of 25 participants. The qualitative results presented are part of a larger multimethod study examining the psychosomatic experience of waiting for CABG surgery. Data collected from telephone interviews were analyzed using content analysis and constant comparison techniques. Content analysis identified three conceptual categories: i) taking responsibility; ii) getting my life back; and iii) getting it over with. Strategies associated with each of these categories, the consequences of the strategies, and factors that facilitate or constrain their use were also identified. Participants were actively trying to lessen the impact of their cardiac symptoms and were very aware of their own bodies and what actions would exacerbate symptoms or relieve symptoms if they occurred. Participants envisioned physical and psychological improvements for post-CABG surgery. Participants also identified actions they took to limit their anxiety while waiting. Anxiety levels were influenced by family members as well as stories they had heard from friends, family, or acquaintances who had also experienced CABG. This study concluded that the lengthy waits experienced by some patients can create significant psychological disturbance including anxiety and uncertainty about the future. In addition, patient symptom status requires attentive monitoring.

Effects of a long-term, community-based cardiac rehabilitation program on middle-aged and elderly cardiac patients.

The purpose of this retrospective study was to compare the effects of a 2-year, community-based cardiac rehabilitation exercise program on cardiovascular fitness, body fatness, and blood lipids in middle-aged (65 years, n=40) male cardiac patients. Estimated maximal metabolic equivalents increased in both groups; however, the increase was greater for middle-aged patients (p=0.003). High-density lipoprotein cholesterol level increased significantly after 1 year in both groups, but the change was greater for the middle-aged subjects by Year 2 (p=0.02). The total cholesterol/high-density lipoprotein cholesterol ratio and serum triglyceride levels decreased in both groups, whereas total cholesterol and low-density lipoprotein cholesterol levels decreased only in the elderly group (p<0.01). Body fatness did not change in either group. These findings reinforce the importance of referring elderly as well as middle-aged patients to community-based cardiac rehabilitation exercise programs.

Symptoms and distress in patients awaiting coronary artery bypass surgery.

In this examination of symptom distress in patients awaiting coronary artery bypass graft (CABG) surgery, a convenience sample of 42 patients on a waiting list for first-time CABG-only surgery were contacted via mail as part of a larger study into the experience of waiting for CABG surgery. They were asked to respond to questions about the frequency and distress of their coronary artery disease symptoms. A modified version of the Symptom Frequency and Symptom Distress Scale (SFSDS) was used. The mean symptom distress score was 77.7 out of a possible 386. Strong correlations were established between each individual item on the scale and the total score. The most frequent and distressing symptoms were fatigue, shortness of breath with activity, and chest pain. The most frequent' symptoms were also the most distressing. The findings underscore the significance of symptom experience in patients on a waiting list for CABG surgery and also point to the need for further testing of this version of the SFSDS.