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American Journal of Epidemiology Advance Access originally published online on February 19, 2007
American Journal of Epidemiology 2007 165(9):1031-1038; doi:10.1093/aje/kwk113
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American Journal of Epidemiology Copyright © 2007 by the Johns Hopkins Bloomberg School of Public Health All rights reserved; printed in U.S.A.

ORIGINAL CONTRIBUTIONS

Childhood Abuse, Adult Health, and Health Care Utilization: Results from a Representative Community Sample

MJ Chartier1, JR Walker2 and B Naimark3

1 Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
2 Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
3 Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada

Correspondence to Dr. M. J. Chartier, Healthy Child Manitoba, Room 219, 114 Garry Street, Winnipeg, Manitoba R3C 4V6, Canada (e-mail: mariette.chartier{at}gov.mb.ca).

Received for publication August 9, 2006. Accepted for publication October 23, 2006.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
The long-term consequences of childhood abuse on adult mental health have been a major focus of research. Much less attention has been directed to its effects on physical health outcomes. By use of data from the Ontario Health Survey (n = 9,953), the association between retrospective reports of childhood physical and sexual abuse and adult health and health care utilization was examined in men and women. The population health survey was conducted from November 1990 to March 1991 in the Canadian province of Ontario. An association of moderate strength was found between childhood abuse and multiple health problems, poor or fair self-rated health, pain that interferes with activities, disability due to physical health problems, and frequent emergency room and health professional visits but not frequent general practitioner visits. These effects were more pronounced in females and younger respondents. The strength of the associations reported here with odds ratios of 1.3–2.2 was lower than that found between childhood abuse and adult mental health, with odds ratios of 1.9–3.4. Given the growing evidence of the long-term effects of childhood abuse, greater efforts are clearly needed in developing more effective strategies for the prevention and treatment of child abuse.

child abuse; child abuse, sexual; disease; health services needs and demand; health status; pain; population; retrospective studies


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Child abuse clearly has a negative impact on children and can result in behavioral, cognitive, emotional, and developmental difficulties (1–3). From a life course perspective, it has also been recognized that these difficulties can extend into adulthood. To date, the long-term consequences of childhood maltreatment on adult mental health have been a major focus of research (4–6). Wekerle and Wolfe (3), in their review of child maltreatment, concluded that while many individuals with histories of childhood abuse develop into well-functioning adults, this group has higher rates of depression, sexual dysfunction, personality disorder, eating disorder, antisocial and abusive behavior, and substance abuse than those with no abuse histories.

Recent studies have focused on the long-term effects of childhood abuse on adult physical health and health care utilization. Data from the Adverse Childhood Experiences Study show that a history of child maltreatment is associated with perceptions of poor health in adulthood (7). Other researchers report that childhood maltreatment is associated with more physician visits, surgeries, hospitalizations, and higher annual health care costs in adulthood (8–10).

Previous research examining the association between childhood abuse and adult health outcomes has been limited in methodology and scope. Only a few studies have examined this association using community samples (11, 12). The definitions of abuse and of health differ considerably across studies, and much of the previous research used a single question of limited accuracy to determine the presence of abuse (13). In addition, to the best of our knowledge, the association between childhood abuse and adult physical health has only been examined using data from the United States.

No previous studies have examined the association between childhood abuse and health care utilization using community samples. This is important because samples from clinical settings are not representative of the population as a whole and may give inaccurate estimates due to selection biases. The association between childhood abuse and health care utilization in men is often not included in study designs, and usually the focus is only on childhood sexual abuse. Moreover, most of these studies have failed to adequately control for confounders.

The aim of this study was to gain a greater understanding of the association between childhood physical and sexual abuse and adult physical health and health care utilization. Our study also explored whether the associations differed by gender and age. We used cross-sectional data from the Ontario Health Survey, a representative population sample of residents in the province of Ontario, Canada. Valid and reliable instruments were used to assess childhood abuse, data on four dimensions of adult health and three types of health care utilization were collected, and age, gender, income, and marital status were included in the analysis to control for potential confounding effects.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Data source
The Ontario Health Survey is a population health survey of Ontario residents, aged 15 years or older, commissioned by the Ontario Ministry of Health to provide information on general health for health planning and policy development purposes. The Mental Health Supplement (n = 9,953) was collected between November 1990 and March 1991 from a subsample of Ontario Health Survey respondents to study the prevalence, severity, and risk factors of psychiatric disorders and to gather data on mental health services. A small proportion of residents were excluded: foreign service personnel, homeless people, people living in institutions (e.g., hospitals, prisons), First Nations people living on reserves, and residents of extremely remote locations (14).

Boyle et al. (14) provide a comprehensive description of the survey that used a multistage design with stratification and clustering to ensure representation and feasibility. The survey was conducted in two stages. 1) A probability sample averaging 46 "enumeration areas" was selected from each of the province's 42 public health units. Enumeration areas are the smallest geographic units for which census counts can be retrieved by automatic means. These areas were sorted into urban and rural strata to ensure proper representation. 2) Probability samples of 15 households from urban enumeration areas and 20 households from rural enumeration areas were selected. Cluster sampling of households was used to decrease costs of data collection. The cluster effect was higher in rural areas than in urban areas because of fewer clusters in rural areas, and consequently more households were selected per enumeration area in rural settings. The 15- to 24-year age group was oversampled to increase its statistical reliability in this group.

Study variables
Childhood physical abuse questions were based on an abridged version of the Conflict Tactics Scale (15). Seven questions covered the presence and frequency of physical abuse by an adult while the respondent was growing up. Being slapped or spanked was not included in the definition of physical abuse because of the high prevalence of corporal punishment in this population. Childhood physical abuse was defined as often or sometimes being pushed, grabbed, or shoved, having something thrown at the respondent, or being hit with something. It also included often, sometimes, or rarely being kicked, bitten, punched, choked, burned or scalded, or being physically attacked in some other way.

Childhood sexual abuse questions were based on items from the National Population Survey of Canada (16). Respondents were questioned about four specific situations to determine if sexual abuse had occurred during childhood. These included having an adult exposing himself/herself to the respondent more than once, being threatened by an adult to have sex, being touched in a private area by an adult, or having an adult attempt to have sex with the respondent or being sexually attacked. This definition does not include juvenile offenses involving older children or adolescents preying on younger children; therefore, some aspects of childhood sexual abuse were not included.

Adult physical health.
Self-rated health indicators were drawn from the scientific literature to describe physical health (17). Four dimensions of health were taken into consideration: number of medical conditions, self-rated health, pain that restricts daily activity, and disability due to physical health. Research indicates that self-rated health may predict mortality more accurately than more objective measures (18, 19). Respondents were defined as having multiple health problems if they reported more than two medical conditions in response to open-ended questions. Poor self-rated health was defined as having answered "fair" or "poor" to the question, "In general, compared with other people your age, would you say your health is ... excellent, very good, good, fair, or poor?" Pain that interferes with activities was defined as experiencing pain or discomfort during some or most activities. Disability due to physical health was defined as currently experiencing limitations in work, school, home, or leisure activities. This variable is based on a series of 44 questions inquiring about the degree of disability that respondents were experiencing because of physical health problems.

Adult health care utilization.
Three types of health care utilization indicators were used. High general practitioner use referred to respondents who utilized general practitioner services six or more times in the previous 12 months. High emergency room use referred to use of emergency services twice or more in the previous 12 months. High professional use refers to use of health professional services 20 times or more in the previous 12 months. Health professionals included in this measure were family physicians, medical specialists, nurses, optometrists, chiropractors, physiotherapists, dentists, or other health professionals. Those excluded were psychologists, social workers, and pharmacists.

Statistics
Multiple regression was utilized to test the association between childhood abuse and adult physical health and health care utilization. The analyses controlled for age, sex, marital status, and personal income. Because the outcome variables in the study were summarized into categories, logistic regression was used (20). Odds ratios and 95 percent confidence intervals were reported by use of SPSS 13 (SPSS, Inc., Chicago, Illinois) for Windows (Microsoft Corporation, Redmond, Washington) statistical software. Sampling weights and design effects adjustments were incorporated in the analysis, because of the multistage survey design that included stratification and clustering (21, 22). Sampling weights were used to adjust for the number of people in the population that each case represents and to adjust for characteristics of nonresponders. The analyses incorporated a published design effect, calculated by Statistics Canada to be 2.2. Use of this design effect gives estimates and confidence intervals that are very close (within a fraction of a decimal point) to the estimates generated by SUDAAN (SUDAAN Statistical Software Center, Research Triangle Park, North Carolina) (V. Goel, University of Toronto, unpublished manuscript). The frequencies in the tables will not agree because of missing data. Discomfort with questions, inability to answer questions because of age or poor health, and interviewer error may have contributed to the incomplete data.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Table 1 shows high prevalence rates of childhood physical abuse and childhood sexual abuse in this representative sample. Many statistically significant associations were observed. Childhood sexual abuse was reported more often by females than males; however, males were more likely to report childhood physical abuse. Rates of occurrence of health problems and health care utilization varied in the sample. Females and older respondents reported higher rates of health problems and health care utilization than did males or younger respondents, with some exceptions.


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  		TABLE 1. Prevalence of childhood abuse, adult health problems, and health care utilization, Ontario Health Survey, Canada, 1990–1991

 
Association among childhood abuse, health problems, and health care utilization
Table 2 illustrates that respondents with childhood physical and sexual abuse reported higher rates of health problems and health care utilization. When logistic regression analyses were conducted, an association of moderate strength between childhood abuse and health problems was observed after controlling for demographic factors (age, sex, marital status, and low income). Odds ratios for childhood physical abuse ranged between 1.39 for multiple health problems and 1.68 for pain that interferes with activities. For childhood sexual abuse, they ranged between 1.34 for pain that interferes with activities and 1.81 for disability due to physical health problems. An association of moderate strength was found between childhood physical and sexual abuse and high emergency room use and high professional use, but not high general practitioner use (table 2). The odds ratios for childhood physical and sexual abuse were, respectively, 1.85 and 1.79 for high emergency room use and 1.32 and 1.51 for high health professional use.


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  		TABLE 2. Prevalence of health problems among respondents with and without childhood abuse and summary of logistic regression models of childhood abuse predicting health problems and utilization, Ontario Health Survey, Canada, 1990–1991

 
Abuse, health problems, and health care utilization by gender and age
Table 3 shows the odds ratios of the association between childhood abuse and health indicators when the sample was stratified by gender and age. Preliminary data analyses indicated potential interactions between abuse and gender and between abuse and age for some of the variables. Dividing the sample by gender and age effectively decreased the power of statistical tests, and comparisons for some cells could not be calculated because of small cell sizes. Statistically significant interactions across genders or age levels in relation to the health indicators are indicated in the table.


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  		TABLE 3. Summary of logistic regression for childhood abuse as a predictor of health problems and utilization by gender and age, Ontario Health Survey, Canada, 1990–1991*

 
An association between childhood physical abuse and health problems and health care utilization was observed for men and women. Being female and having a history of childhood abuse (either physical or sexual) increased the risk of having multiple health problems to a greater extent than did the addition of the separate influences of these factors. There was little evidence of negative health effects of childhood sexual abuse on men but clear evidence for women. The association between abuse and health was apparent for both age groups; however, it appeared to be stronger for younger respondents than for older ones on some measures. For example, being a younger respondent and having a history of childhood physical abuse increased the risk of reporting pain and disability.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Based on a representative sample of Ontario residents, this study shows that childhood physical abuse and sexual abuse were associated with adult physical health problems. The strongest effects were generally found among females and younger respondents. To our knowledge, this is the first population-based study that also demonstrates an association between childhood abuse and higher health care utilization. These findings are consistent with previous research that used different sampling methods. Sachs-Ericsson et al. (12), using a population-based sample in the United States, reported an association between childhood abuse and having at least one medical problem. An association between childhood abuse and poor self-rated health was found by Felitti et al. (23) and by Thompson et al. (11) in a health maintenance organization sample and in a nationally representative American telephone survey, respectively. Davis et al. (24), in a meta-analysis including clinical and community samples, found that individuals with childhood abuse reported more pain symptoms than those with no childhood abuse. In a study of women from a health maintenance organization, Walker et al. (25) reported higher rates of physician-coded health problems (infectious diseases, pain disorders, and other diseases), as well as greater levels of functional disability, among those with childhood abuse compared with those with no childhood abuse.

In other studies of health care utilization and abuse with methodological weaknesses (e.g., clinically based samples and inadequate control of confounding variables), the findings were inconsistent. An association was found between childhood abuse and the frequency of physician visits (8, 9, 26, 27), hospitalizations (9, 28, 29), and emergency room visits (26). McCauley et al. (30), however, reported no association between childhood abuse and hospitalization, miscarriages, and medication use.

In contrast with other studies, our study did not find higher rates of general practitioner visits by respondents reporting childhood abuse. We did find higher use of emergency room services and other health professionals (in a measure that included nurses, dentists, chiropractors, physiotherapists, and medical specialists). These results may reflect that, in Ontario, general practitioners are encouraged to refer severely distressed individuals. On the other hand, respondents with childhood abuse may turn to the emergency room instead of primary care providers, perhaps because they are, as a result of unstable lifestyles, least likely to have maintained a relationship with a general practitioner.

The strength of the association between childhood abuse and adult physical health in the present study, as assessed by odds ratios in the range of 1.3–2.1, was generally similar to those assessed by odds ratios in the range of 1.2–2.2 reported in many previous studies (11, 23, 25, 30, 31). The most likely bias operating in these studies is that the strength of the association is underestimated, because childhood abuse is typically underreported. The strength of association between childhood abuse and physical health reported in the current study was lower than that found between childhood abuse and mental health. Using the same Ontario Health Survey data as the current study, MacMillan et al. (6) found odds ratios that ranged from 1.9 for the association between childhood physical abuse and anxiety disorders to 3.4 for childhood sexual abuse and major depressive disorder. Similar and higher rates were found in other studies examining the association between abuse and mental health (5, 32, 33).

The present study suggests that childhood physical abuse is related to poorer health and higher health care utilization in both men and women but that the association between childhood physical abuse and multiple health problems is stronger in women. There was little evidence of negative health effects of childhood sexual abuse on men but clear evidence for women. Gender differences in the strength of the association between childhood abuse and adult health problems were also found in a nationally representative American sample (34). A possible explanation for the gender differences is that childhood sexual abuse (which occurs more often in women) may be more traumatic than other types of abuse. In addition, men may be affected in different ways by childhood abuse. Holmes and Sammel (35) found that males with a history of childhood abuse had higher rates of legal troubles and incarceration, as well as more lifetime sexual partners than those with no childhood abuse.

The association between abuse and health appeared to be stronger for younger respondents than for older ones on some health measures. A possible explanation may be that the assessment of health is closer in time to the period when the abuse occurred. With the passage of time, other life events are likely contributing to health status, such as exposure to social, behavioral, and environmental risks, as well as exposure to factors that strengthen health. Kessler et al. (32) examined the association between adverse childhood experiences and psychopathology in adulthood and found that the associations were stronger in early onset mental disorders than in late-onset disorders.

Possible explanations for a childhood abuse–adult health association
Researchers have suggested that the childhood environment can influence health through biologic and psychosocial pathways (36–38). Evidence is mounting that explains how childhood maltreatment can negatively impact biologic systems (39–41). In a developing child, stressful stimuli and lack of positive stimuli adversely affect brain development and the stress response throughout the entire body (42). Physiologic studies suggest that persistent stress, such as childhood abuse, brings about changes in the nervous system, thereby predisposing an individual to ill health (43–45).

Childhood abuse can also have a negative effect on adult health through the development of health risk behaviors such as smoking, poor nutrition, sedentary lifestyle, high alcohol consumption, and higher-risk sexual practices (7, 26, 46–48). Kuh et al. (37) suggest that parents can inadvertently promote poor health habits and lack of autonomy in children by failing to teach important skills, communicating poor attitudes, and providing negative role models. Some authors suggest that psychological distress may be a mediator in the association between childhood abuse and health (49, 50). Engaging in risk behaviors, such as smoking or consuming alcohol, can bring about temporary relief from the depression or anxiety resulting from childhood adversities (23).

Policy implications
Following asthma and allergies, childhood abuse can be considered the third most common public health concern for children (51). Although greater efforts are clearly required to prevent both the primary and secondary effects of abuse, child abuse prevention is not easily achieved. Corporal or physical punishment of children is still accepted and is lawful in many developed nations. These laws have been challenged on the grounds that the distinction between abuse and punishment is not easily made (52, 53).

Programs to improve parent-child relationships may ultimately decrease child abuse rates. Home visiting programs, which consist of regular visits by a nurse or trained paraprofessional, have been shown to decrease child abuse and to improve child outcomes (54). The most effective home visiting programs were 2 or 3 years in duration, had built on the family's strengths, provided teaching on healthy child development and parenting, and increased the family's support systems. The Triple P Program (Positive Parenting Program), which provides a multilevel program focused on supporting parents in their role through various types of education, has demonstrated improvements in child outcomes (55).

Self-reported data from community studies and from child welfare agencies suggest that rates of child sexual abuse may be decreasing (56, 57). Jones and Finkelhor (56) posit that public awareness campaigns, prevention programs, and criminal justice interventions may be responsible for the substantial decline. Preventive efforts aimed specifically at reducing rates of child sexual abuse have been primarily school-based programs for children (58–60). Although these strategies have been criticized for placing the burden of protection on the children, the decreasing trends in child sexual abuse may be an indication of their effectiveness.

Strengths and limitations
The cross-sectional Ontario Health Survey has a practical design that may be conducted over a short period of time, reducing the cost and time involved. However, cross-sectional studies limit the conclusions that can be made about the causal nature of associations. Although longitudinal designs have advantages in clarifying temporal and causal associations, there are few examples of longitudinal designs in child abuse research. Practical and ethical barriers have limited the study of children who have experienced abuse. The Ontario Health Survey did not include items assessing childhood neglect or psychological abuse. These types of childhood maltreatment have also been linked to adult health (23, 25).

Strengths of the Ontario Health Survey were the extensive evaluation of abuse and health. A series of questions, based on abridged versions of well-known instruments, were used to establish a history of childhood physical abuse and sexual abuse. Although recall bias is a common criticism of retrospective reports of abuse, Hardt and Rutter (13) concluded in their review that they were sufficiently valid to be used for research purposes. Their review points to underreporting of childhood abuse, which would attenuate the association between childhood abuse and health.

Conclusions
The present study provides compelling evidence for the association between childhood abuse and adult health, as it is consistent with previous research and addresses many of the methodological weaknesses in these studies. It lends support to a life-course approach, whereby early life events are linked to later health outcomes. Given the growing evidence of the long-term effects of childhood abuse and its high prevalence rates, it is imperative that effective child abuse prevention strategies be developed. Ideally, this strategy should be part of a larger, comprehensive plan to improve the multiple dimensions of health and well-being.


   ACKNOWLEDGMENTS
 
This study was supported in part by a Canadian Institute of Health Research scholarship awarded to the first author.

The authors are grateful to Dr. Elizabeth Lin, Dr. Robert Murray, and Dr. Robert Tate for their thoughtful review of earlier versions of this paper.

Conflict of interest: none declared.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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