The association between adverse childhood experiences, neighborhood greenspace, and body mass index: A cross-sectional study.

An association between adverse childhood experiences (ACEs) and elevated body mass index (BMI) has been found in previous investigations. ACEs' effects on BMI have been primarily considered via individual-level physiological and behavioral frameworks. Neighborhood factors, such as greenspace, are also associated with BMI and may merit consideration in studies examining ACEs-BMI associations. This exploratory study examined associations of BMI with ACEs and neighborhood greenspace and tested whether greenspace moderated ACEs-BMI associations. Methods entailed secondary analysis of cross-sectional data. ACEs and BMI were captured from 2012/2013 Philadelphia ACE Survey and 2012 Southeastern Household Heath Survey data; greenspace percentage in participants' (n = 1,679 adults) home neighborhoods was calculated using National Land Cover Database data. Multi-level, multivariable linear regression 1) examined associations between BMI, ACEs, (0 ACEs [reference], 1-3 ACEs, 4 + ACEs), and neighborhood greenspace levels (high [reference], medium, low) and 2) tested whether greenspace moderated the ACEs-BMI association (assessed via additive interaction) before and after controlling for sociodemographic and health-related covariates. Experiencing 4 + ACEs (ß = 1.21; 95 %CI: 0.26, 2.15; p = 0.01), low neighborhood greenspace (ß = 1.51; 95 %CI: 0.67, 2.35; p < 0.01), and medium neighborhood greenspace (ß = 1.37; 95 %CI: 0.52, 2.21; p < 0.01) were associated with BMI in unadjusted models. Only low neighborhood greenspace was associated with BMI (ß = 0.95; 95 %CI: 0.14, 1.75; p = 0.02) in covariate-adjusted models. The ACEs-greenspace interaction was not significant in unadjusted (p = 0.89-0.99) or covariate-adjusted (p = 0.46-0.79) models. In conclusion, when considered simultaneously, low neighborhood greenspace, but not ACEs, was associated with BMI among urban-dwelling adults in covariate-adjusted models.

The Intersection of Neighborhood Environment and Adverse Childhood Experiences: Methods for Creation of a Neighborhood ACEs Index.

This study evaluated methods for creating a neighborhood adverse childhood experiences (ACEs) index, a composite measure that captures the association between neighborhood environment characteristics (e.g., crime, healthcare access) and individual-level ACEs exposure, for a particular population. A neighborhood ACEs index can help understand and address neighborhood-level influences on health among individuals affected by ACEs. Methods entailed cross-sectional secondary analysis connecting individual-level ACEs data from the Philadelphia ACE Survey (n = 1677) with 25 spatial datasets capturing neighborhood characteristics. Four methods were tested for index creation (three methods of principal components analysis, Bayesian index regression). Resulting indexes were compared using Akaike Information Criteria for accuracy in explaining ACEs exposure. Exploratory linear regression analyses were conducted to examine associations between ACEs, the neighborhood ACEs index, and a health outcome-in this case body mass index (BMI). Results demonstrated that Bayesian index regression was the best method for index creation. The neighborhood ACEs index was associated with higher BMI, both independently and after controlling for ACEs exposure. The neighborhood ACEs index attenuated the association between BMI and ACEs. Future research can employ a neighborhood ACEs index to inform upstream, place-based interventions and policies to promote health among individuals affected by ACEs.

The intersection of adverse childhood experiences and neighborhood determinants of health: An exploratory spatial analysis.

OBJECTIVE: Adverse childhood experiences (ACEs) are associated with elevated risk for poor physical and psychological health outcomes. Nearly all of the literature on the association between ACEs and poor health focuses on the individual and family level; the potential role of neighborhood environment is overlooked. Understanding the relationship between ACEs and characteristics of the neighborhood environment is a necessary first step in determining if and how place-based, trauma-informed interventions might mitigate the negative effects of ACEs. The purpose of this exploratory study was to describe the neighborhood environment of adults who have experienced ≥ 4 versus ≤ 3 ACEs. METHOD: An exploratory secondary analysis of cross-sectional and geospatial data was conducted during 2021. Data sources included 2011/2012 Philadelphia ACE Survey data, a telephone survey of 1,784 randomly sampled Philadelphia adults, linked with geospatial data on 21 neighborhood-level determinants of health. Neighborhood was defined as participant's home census tract at the time of survey. The sample for this secondary analysis included the 1,679 Philadelphia ACE Survey participants for whom home census tract was available. Bivariate logistic regression examined differences between groups (≤ 3 ACEs vs. ≥ 4 ACEs). RESULTS: Individuals with ≥ 4 ACEs lived in neighborhoods with higher neighborhood poverty rates, less socioeconomic resources, worse food access, poorer perceived physical and mental health, more substance overdose deaths, higher crime, and less green space. CONCLUSIONS: Findings suggest future work may benefit from considering neighborhood environments when examining and intervening upon the association between ACEs and poor physical and psychological health. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Practical Guidance for Using Behavioral Risk Factor Surveillance System Data: Merging States and Scoring Adverse Childhood Experiences.

INTRODUCTION: The Behavioral Risk Factor Surveillance System is a national health-related survey with an optional adverse childhood experience (ACE) module. States use varying methodologies, question formats, and sampling frames, and little guidance exists for conducting multistate explorations of adverse childhood experiences. In this study, 6 adverse childhood experience scoring approaches are compared, and practical recommendations are offered for when and how each approach can be utilized most effectively. METHODS: This study used 2015 Behavioral Risk Factor Surveillance System data from the adverse childhood experience module administered by 6 states. Data were merged and analyzed between 2018 and 2021. To understand how adverse childhood experience scoring may impact estimates of association, concordance/discordance among 6 approaches (continuous versus categorical, states that collected all adverse childhood experiences versus those that collected any adverse childhood experiences, and normalized versus standard scores) was evaluated. Using separate weighted multivariable logistic regression models controlling for confounders, the relationship between adverse childhood experiences using each approach and the presence of 10 chronic health conditions was also assessed. RESULTS: Comparisons revealed discordance for categorical versus continuous approaches (30%) and all-ACEs versus any-ACEs (20%) but full concordance for standard versus normalized approaches. Discordance occurred more frequently with low-prevalence outcomes (≤7.0%) and lower-exposure samples (any-ACEs). CONCLUSIONS: Results revealed general concordance across adverse childhood experience scoring approaches when outcomes commonly occurred and when the sample was limited to just states that asked the full array of adverse childhood experiences. However, on a deeper exploration of discordant findings, specific nuances were uncovered that may help guide researchers when deciding on which approach to use on the basis of the research question and conceptual model driving study objectives.

Intimate Partner Violence: Childhood Witnessing and Subsequent Experiences of College Undergraduates.

Previous work links witnessing adult violence in the home during childhood ("witnessing") and adolescent relationship violence, but studies are limited to recent experiences with one or two outcomes, missing the holistic viewpoint describing lifetime experiences across multiple types of violence. We measured associations between witnessing and victimization (being harmed by violence) and perpetration (causing harm by violence) among males and females for the three most common types of adolescent relationship violence (physical, sexual, and emotional), and we assessed whether students experienced multiple outcomes ("polyvictimization/ polyperpetration"). We also compared sex-specific differences to assess for additive effect modification. We used an anonymous, cross-sectional survey with 907 undergraduates attending randomly selected classes at three urban East Coast colleges. Multiple logistic regression and marginal standardization were used to estimate predicted probabilities for each outcome among witnesses and non-witnesses; additive interaction by sex was assessed using quantifiable measures. 214 (24%) students reported witnessing and 403 (44%) students experienced adolescent relationship violence, with 162 (17.9%) and 37 (4.1%) experiencing polyvictimization and polyperpetration, respectively. Witnesses had higher risk than non-witnesses for physical, sexual, and emotional victimization and perpetration. Notably, witnesses also had higher risk for polyvictimization and polyperpetration. Additive effect modification by sex was insignificant at 95% confidence bounds, but distinct patterns emerged for males and females. Except for sexual victimization, female witnesses were more likely than female non-witnesses to experience all forms of victimization, including polyvictimization; they also had higher risk for perpetration, particularly physical perpetration. In contrast, victimization outcomes did not differ for male witnesses, but male witnesses were more likely than male non-witnesses to perpetrate all forms of violence, including polyperpetration.

Intergenerational effects of witnessing domestic violence: Health of the witnesses and their children.

Studies that explore intergenerational effects of witnessing domestic violence during childhood ("witnessing") are lacking. We examined effects of witnessing on general health status for adults who witnessed domestic violence during childhood and their children. Cross-sectional data from population-based phone interviews conducted in Philadelphia during 2012-2013 provided health information for 329 parents and children, and parent's witnessing exposure. We used propensity scores to predict parent's witnessing status using childhood confounders; response models included inverse probability of treatment weighting and population weights for standardization. Separate standardized multivariate logistic regression models provided average treatment effects and 95% CIs for associations between childhood witnessing and below average health for: 1) adults who witnessed and 2) their children. Sensitivity analyses guided interpretation. Standardized models showed no differences in average treatment effects for below average adult health for witnesses vs. non-witnesses [0.04 (-0.12, 0.19)]. Conversely, children whose parents witnessed had considerably higher probability of having below average health than children whose parents did not witness [0.15 (0.02, 0.28)]. An unmeasured confounder would need 3.0-fold associations with both exposure and outcome to completely remove observed effects, indicating a moderate relationship. However, the lower confidence bound could cross 1.0 in the presence of a weaker unmeasured confounder having 1.2-fold associations with both exposure and outcome, while controlling for our same measured confounders. Witnessing during childhood did not affect adult health in our population, but we found moderate evidence supporting harmful intergenerational effects of witnessing on health, with parent's witnessing exposure affecting their child's health.

Witnessing intimate partner violence as a child: How boys and girls model their parents' behaviors in adolescence.

Childhood witnesses of adult violence at home are at risk for future violence. It is unclear how gender of the child and adult perpetrator are related to adolescent relationship violence. We explore how childhood witnessing of same-gender, opposite-gender, and bidirectional violence perpetrated by adults is associated with adolescent relationship violence victimization only, perpetration only, and combined victimization/perpetration for male and female undergraduates. We gathered cross-sectional data from 907 undergraduates attending 67 randomly-selected classes at three distinct East-Coast colleges using pencil-and-paper surveys administered at the end of class time. Multiple imputation with chained equations was used to impute missing data. Multinomial regression models controlling for gender, age, race, school, and community violence predicted adolescent outcomes for each witnessing exposure; relative risk ratios and average adjusted probabilities with 95% confidence intervals are presented. Adolescent relationship violence outcomes vary based on gender of the child witness and adult perpetrator. Witnessing adult males perpetrate is associated with higher perpetration for boys and higher combined victimization/perpetration for girls. Witnessing adult females perpetrate - either as the sole perpetrator or in a mutually violent relationship with an adult male - increases risk for combined victimization/perpetration for boys and girls during adolescence.

Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population.

Adverse Childhood Experiences (ACEs), which include family dysfunction and community-level stressors, negatively impact the health and well being of children throughout the life course. While several studies have examined the impact of these childhood exposures amongst racially and socially diverse populations, the contribution of ACEs in the persistence of socioeconomic disparities in health is poorly understood. To determine the association between ACEs and health outcomes amongst a sample of adults living in Philadelphia and examine the moderating effect of Socioeconomic Status (SES) on this association, we conducted a cross-sectional survey of 1,784 Philadelphia adults, ages 18 and older, using random digit dialing methodology to assess Conventional ACEs (experiences related to family dysfunction), Expanded ACEs (community-level stressors), and health outcomes. Using weighted, multivariable logistic regression analyses along with SES stratified models, we examined the relationship between ACEs and health outcomes as well as the modifying effect of current SES. High Conventional ACE scores were significantly associated with health risk behaviors, physical and mental illness, while elevated Expanded ACE scores were associated only with substance abuse history and sexually transmitted infections. ACEs did have some differential impacts on health outcomes based on SES. Given the robust impact of Conventional ACEs on health, our results support prior research highlighting the primacy of family relationships on a child's life course trajectory and the importance of interventions designed to support families. Our findings related to the modifying effect of SES may provide additional insight into the complex relationship between poverty and childhood adversity.

Adverse Childhood Experiences: Expanding the Concept of Adversity.

INTRODUCTION: Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS: Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS: Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS: To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Validity of medical record documented varicella-zoster virus among unvaccinated cohorts.

BACKGROUND: A varicella diagnosis or verification of disease history by any healthcare provider is currently accepted for determining evidence of immunity by the Advisory Committee on Immunization Practices (ACIP). OBJECTIVE: To examine the accuracy of medical record (MR) documented varicella history as a measure of varicella-zoster virus (VZV) immunity among unvaccinated individuals born after 1980. We also assessed methods to practically implement ACIP guidelines to verify varicella history using medical records. STUDY DESIGN: As part of a larger cross-sectional study conducted at three Philadelphia clinics from 2004-2006, we recruited 536 unvaccinated patients aged 5-19 y (birth years: 1985-2001). Varicella history was obtained from three sources: parent/patient interview, any MR documentation (sick and well visits) and MR documentation of a sick visit for varicella. All participants were tested for VZV IgG. For each source and three age groups (5-9, 10-14, 15-19 y old), positive predictive value (PPV) was calculated. Specificity of varicella history was compared between different sources using McNemar's Chi-square. RESULTS: Among participants aged 5-9, 10-14 and 15-19 y the PPV for any MR documentation and sick visit diagnosis were 96% and 100%, 92% and 97%, and 99% and 100%, respectively. The specificity for sick visit documentation was higher than any MR documentation and patient/parent recall among all age groups; however, these differences were only statistically significant when comparing sick visit documentation to parent/patient recall for 10-14 y olds. CONCLUSION: Sick visit documentation of varicella in the MR is an accurate predictor of varicella seropositivity and useful for confirming disease history among unvaccinated persons (birth years: 1985-2001). This method is a practical way to verify varicella history using the ACIP guidelines.

Religiosity as a protective factor against HIV risk among young transgender women.

PURPOSE: Young transgender women (YTW) face many challenges to their well-being, including homelessness, joblessness, victimization, and alarming rates of HIV infection. Little has been written about factors that might help in preventing HIV in this population. Our objective was to examine the role of religion in the lives of YTW and its relationship to HIV risk. METHODS: This study is derived from baseline data collected for an HIV prevention intervention. A convenience sample of YTW aged 16-25 years from Chicago were recruited consecutively and completed an audio computer-assisted self-interview. Logistic regression models were used to evaluate the relationship between sexual risk taking (sex work, multiple anal sex partners, unprotected receptive anal sex), alcohol use, formal religious practices (service attendance, reading/studying scripture), and God consciousness (prayer, thoughts about God). RESULTS: A total of 92 YTW participated in the study, their mean age being 20.4 years; 58% were African American, 21% white, and 22% other. On multivariate logistic regression, alcohol use was significantly associated with sexual risk in both models, with adjusted odds ratio (OR) of 5.28 (95% confidence intervals [CI]: 1.96-14.26) in the Formal Practices model and 3.70 (95% CI: 1.53-8.95) in the God Consciousness model. Controlling for alcohol use, it was found that Formal Practices was significantly associated with sexual risk (OR = .29, 95% CI: .11-.77), but God Consciousness was not (OR = .60, 95% CI: .25-1.47). CONCLUSION: Among YTW, formal religious practices may attenuate sexual risk-taking behaviors and therefore HIV risk. Further research is needed to explore the role of the religion in the lives of YTW as a protective asset.

Validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated children, adolescents, and young adults in the post-vaccine licensure era.

OBJECTIVES: We assessed the validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated persons 1 to 29 years of age, and we examined varicella disease characteristics associated with varicella zoster virus immunity among those reporting positive histories. METHODS: We conducted a cross-sectional study at 7 community-based sites in Philadelphia, Pennsylvania, between June 2004 and May 2006 and recruited 1476 participants 1 to 29 years of age who had not been vaccinated against varicella. Sensitivity, specificity, and positive predictive value were determined by comparing self-reported or parent-reported varicella histories from a standardized study interview with varicella zoster virus immunoglobulin G serological results for each participant. We performed multivariate logistic regression analyses to determine which disease characteristics best predicted seropositivity. RESULTS: The sensitivity of reported varicella history was highest (81%-89%) among participants > or =10 years of age, whereas specificity was highest among participants 1 to 4 years of age (99%) and > or =20 years (88%). Reported varicella history was highly predictive of seropositivity (>95%) only among participants > or =15 years of age. For participants 10 to 14 years of age, parental reports of a generalized itchy rash with 1 of the following were highly predictive of seropositivity: varicella transmission to another household member or being raised in a household with no other children. Among participants < or =9 years of age, no combination of disease characteristics was both highly predictive of seropositivity and common. CONCLUSIONS: The validity of reported varicella history varies according to age, and a reported history is no longer highly predictive of seropositivity among cohorts born since 1994 (participants < or =9 years of age). Universal varicella vaccination, regardless of history, for these children should be considered, as should simplified criteria for varicella zoster virus immunity among unvaccinated persons born before 1994.

Transition from pediatric to adult care: internists' perspectives.

OBJECTIVE: The goal was to understand the concerns of adult health care providers regarding transition for young adult patients with childhood-onset conditions. METHODS: Internists from the 2000 American Board of Medical Specialties directory were selected randomly. A 2-stage mail survey was conducted from August 2001 to November 2004. In stage 1, providers stated their concerns regarding accepting care of transitioning young adult patients. In stage 2, providers ranked their concerns. RESULTS: A total of 241 internal medicine providers were selected for participation. In stage 1, 134 of 241 physicians were eligible to participate, and 67 (50%) of 134 completed stage 1 surveys. In stage 2, 112 physicians were eligible, and 65 (58%) of 112 responded. Concerns elicited in stage 1 were clustered into 6 categories: patient maturity, patient psychosocial needs, family involvement, providers' medical competency, transition coordination, and health system issues. In stage 2, concerns rated highest were lack of training in congenital and childhood-onset conditions, lack of family involvement, difficulty meeting patients' psychosocial needs, needing a superspecialist, lack of adolescent training, facing disability/end-of-life issues during youth and early in the relationship, financial pressures limiting visit time, and families' high expectations. CONCLUSIONS: Internists clearly stated the need for better training in congenital and childhood-onset conditions, training of more adult subspecialists, and continued family involvement. They also identified concerns about patients' psychosocial issues and maturity, as well as financial support to care for patients with complex conditions.

Relationship violence among female and male college undergraduate students.

OBJECTIVES: To assess prevalence of victimization and perpetration of relationship violence before and during college, to explore variations by gender, and to examine differences by relationship type. DESIGN: Anonymously surveyed students in 67 randomly chosen classes. SETTING: Three urban college campuses. PARTICIPANTS: Nine hundred ten undergraduate college students aged 17 to 22 years. MAIN OUTCOME MEASURES: Self-reported victimization and perpetration of physical, emotional, and sexual violence; relationship to the victim or perpetrator. RESULTS: Most (57.1%) students were female, and 58.7% were white, 16.4% black, and 15.1% Asian. Of 910 participants, 407 (44.7%) experienced partner or nonpartner violence: 383 (42.1%) reported victimization and 156 (17.1%) reported perpetration. All victimization and perpetration rates were highest before college. Emotional violence was most common before college (21.1%); during college, sexual and emotional violence were equally common (12.0% and 11.8%, respectively). Women reported more victimization than men, but male victimization was considerable (27.2%). More men perpetrated sexual violence; more women perpetrated physical violence. More than half (130 of 227) of the violence experienced during college was partner related. Students experiencing partner violence during college were more likely to experience physical and emotional violence and were less likely to experience sexual violence. CONCLUSIONS: Relationship violence is prevalent among college students and frequently occurs before college. Emotional violence was most frequent before college; sexual and emotional violence were equally common during college. Women reported more victimization than men, but male victimization was common. Men perpetrated more sexual violence; women perpetrated more physical violence. Physical violence and emotional violence were most often committed by partners, while sexual violence was less likely to be partner related.

Important health provider characteristics: the perspective of urban ninth graders.

Clinicians caring for adolescents may be better positioned to provide health care when equipped with an understanding of adolescents' preferences regarding provider characteristics. The purpose of this study is to obtain a manageable framework of adolescents' concerns about health care providers. A series of qualitative and quantitative data-collection methods were used to elicit and organize ideas about health care providers from ninth-grade students in Philadelphia. A 5-point Likert survey, based on ideas generated and prioritized in earlier qualitative stages, was administered in school. Exploratory and confirmatory factor analysis was used to uncover latent factors. A total of 2602 students returned usable surveys. A confirmatory factor analysis model including four latent factors (patient's interpersonal relationship with provider, concern for physical safety, concern for emotional safety, and provider counseling ability) explained 51.6% of the model variability. Urban ninth graders want providers with whom they can develop strong relationships, feel emotionally and physically safe, and turn to for counseling. Communication with adolescent-aged patients should be a standard component of health care training and should promote provider sensitivity to adolescent fears and needs in the health care setting.