By: Charlene K. Baker, Fran H. Norris, Eric C. Jones and Arthur D. Murphy

Transcription

1 Childhood Tauma and Adulthood Physical Health in Mexico. By: Chalene K. Bake, Fan H. Nois, Eic C. Jones and Athu D. Muphy C.K. Bake, F.H. Nois, E.C. Jones and A.D. Muphy. Childhood Tauma and Adulthood Physical Health in Mexico. Jounal of Behavioal Medicine 32(3) (2009): Made available coutesy of Spinge Velag. The oiginal publication is available at: ***Repinted with pemission. No futhe epoduction is authoized without witten pemission fom Spinge Velag. This vesion of the document is not the vesion of ecod. Figues and/o pictues may be missing fom this fomat of the document. *** Abstact: Backgound The pesent study examined the effect of childhood tauma on adulthood physical health among a andomly selected sample of adults (N = 2,177) in uban Mexico. Methods Adults wee inteviewed about thei expeiences of tauma, post-taumatic stess disode, depession, and physical health symptoms using Module K of the Composite Intenational Diagnostic Inteview, the Cente fo Epidemiologic Studies Depession Scale, and the Physical Symptoms Checklist. Results Tauma was pevalent, with 35% epoting a taumatic event in childhood. In geneal, men epoted moe childhood tauma than women, with the exception of childhood sexual violence whee women epoted moe exposue. Fo men, childhood sexual violence was elated to total and all physical health symptom subscales. Fo women, childhood sexual violence was elated to total, muscula-skeletal, and gastointestinal-uinay symptoms; hazads/accidents in childhood wee elated to total, muscula-skeletal, cadio-pulmonay, and nose-thoat symptom subscales. Depession mediated the elationship between childhood sexual violence and physical health symptoms fo men and women. Among women only, PTSD mediated the elationship between childhood sexual violence and total, muscula-skeletal, and gastointestinal-uinay symptoms. PTSD also mediated the elationship between hazads/accidents in childhood and total, muscula-skeletal, cadio-pulmonay, and nose-thoat symptoms. Conclusion

2 These findings can be used to incease awaeness among geneal pactitiones, as well as community stakeholdes, about the pevalence of childhood tauma in Mexican communities and its impact on subsequent physical health outcomes. With this awaeness, sceening pactices could be developed to identify those with tauma histoies in ode to incease positive health outcomes among tauma suvivos. Keywods: childhood tauma adult physical health post-taumatic stess disode PTSD Mexico behavioal medicine Aticle: Intoduction Thee is a geneal consensus in the field of tauma eseach that individuals who ae exposed to taumatic events also expeience psychological and physical health poblems (Fiedman and Schnu 1995; Galea et al. 2005; Koss and Heslet 1992; Nois et al. 2002b; Ullman and Siegel 1996). In paticula, mental health consequences of tauma, such as depession, anxiety, and posttaumatic stess disode (PTSD), have been the focus of much of the eseach (Beslau et al. 1998; Kessle et al. 1995; Nois and Kaniasty 1994; Nois et al. 2002b; Resnick et al. 1993; Soenson and Golding 1990). Reseach has also suggested that exposue to taumatic events affects physical health (Flett et al. 2002; Schnu and Geen 2004; Ullman and Siegel 1996). Futhemoe, studies have shown a elationship between childhood exposue to tauma and adult physical health (Felitti et al. 1998; Moelle et al. 1993; Shaw and Kause 2002; Spetus et al. 2003; Thompson et al. 2002; Walke et al. 1999); howeve much of this wok has been conducted in the US and othe developed counties. This is a shotcoming because some types of tauma (e.g., natual disastes) ae moe pevalent, and typically moe sevee, in developing aeas of the wold (De Giolamo and McFalane 1996; Intenational Fedeation of Red Coss and Red Cescent Societies 2004), and these populations may be paticulaly susceptible to advese health effects given thei povety and lack of healthcae esouces. To begin to fill this gap, the pesent study focuses on how childhood tauma affects physical health in adulthood among a sample of adults in the developing county of Mexico. Although thee is eseach on the effect of tauma exposue on physical health, studies have mostly sampled victims of specific types of tauma (e.g., wa veteans, victims of physical and sexual abuse, and victims of natual and human-caused disastes). Fo example, the Centes fo Disease Contol and Pevention conducted a suvey of ove 7,000 male veteans and found that those who seved in Vietnam epoted geate pevalence of diseases, somatic symptoms, and fetility poblems compaed to those who did not seve (CDC 1987). In the Epidemiologic Catchment Aea study, a lifetime histoy of tauma exposue was associated with epots of poo self-ated health and a geate numbe of chonic medical conditions, even with demogaphic

3 chaacteistics, psychiatic histoy, and othe stessful life events contolled (Ullman and Siegel 1996). In a meta-analysis of studies on the elationship between sexual assault histoy and physical health, esults showed that sexual assault histoy was associated with a 46% inceased likelihood of poo subjective health (Golding et al. 1997). Futhemoe, expeiencing emotional o vebal abuse was significantly elated to iitable bowel syndome in adulthood (Talley et al. 1994). Fom the disaste liteatue, a eview by Nois et al. (2002b) showed that many victims of disaste epot declines in thei physical health and an incease in somatic concens. In past studies, disaste victims have scoed highe than noms o contols on objective measues of mobidity (Holen 1991; Palinkas et al. 1993), as well as on self-epoted somatic complaints o checklists of medical conditions (e.g., Claye et al. 1985; Muphy 1984; Nois et al. 2006; Phife et al. 1988). In paticula, eseach has shown that physical health is negatively affected egadless of whethe the disastes wee natual o human-caused, and is paticulaly compomised fo victims who wee foced to elocate afte the disaste (Escoba et al. 1992; van den Beg et al. 2005). Embedded in the eseach on tauma and health ae studies suggesting that childhood tauma has an impact on physical health in adulthood. Evidence suggests that emotional abuse, neglect, and physical and sexual abuse expeienced in childhood ae associated with advese physical health outcomes in adulthood (Moelle et al. 1993; Shaw and Kause 2002; Spetus et al. 2003; Thompson et al. 2002; Waldinge et al. 2006; Walke et al. 1999). Fo example, adult women who epoted childhood sexual abuse also epoted highe levels of gastointestinal disodes, chonic pelvic pain, and othe physical conditions in adulthood (Heitkempe et al. 2001; Leseman et al. 1996; Rimsza and Beg 1988; Walke et al. 1992). In othe studies childhood malteatment was significantly associated with headaches (Golding 1999), chonic back pain (Pecukonis 1996), and shotness of beath in adulthood (McCauley et al. 1997). Anothe type of childhood tauma that has been examined is paental loss. Howeve, thee ae few studies on the effects of ealy paental loss on subsequent physical health. Findings fom one study suggest that ealy paental loss did not have an effect on adult physical health, fo eithe chonic o acute health poblems (Maie and Lachman 2000). Additional eseach is needed to undestand not only how paental loss, but othe types of taumatic beeavement in childhood, affect adult physical health. One impotant consideation in conducting this eseach is that the effects of tauma exposue on health may not be diect. Reviews and past eseach have emphasized an indiect pathway between tauma, PTSD and physical health (Fiedman and Schnu 1995; Kimeling et al. 2000; Nois et al. 2006; Schnu and Geen 2004; Schnu and Jankowski 1999; Zoellne et al. 2000). Othes have poposed that individuals who develop depession following taumatic events may also be at inceased isk of advese health outcomes (Fod 2004). Theefoe, when examining the ole of tauma exposue on physical health it is also necessay to take into account the

4 comobidity of PTSD and depessed affect, as both tend to be pevalent in the aftemath of tauma (Beslau et al. 2000; Fod 2004; Kessle et al. 1995; Nois et al. 2006). Although temendous pogess has been made in ou undestanding of the impact that tauma exposue has on physical health, the field would benefit fom additional data in thee aeas. Fist, many of the studies have been conducted with special populations (e.g., veteans, clinical samples) and settings (e.g., pimay cae clinics, college campuses). Additional data fom the geneal population is needed to incease the genealizability of the eseach. Second, the focus of many studies has been esticted to cetain types of tauma (e.g., sexual abuse). Consideation of a moe divese set of taumatic expeiences and thei impact on adult physical health is needed. Finally, a geneal deficiency in the liteatue is ou lack of undestanding about the effects of tauma on physical health woldwide because elatively little of the eseach has been conducted outside of the United States and othe developed counties (Nois et al. 2002b). To addess these thee gaps, the pesent study examined physical health outcomes of espondents in fou Mexican cities and whethe exposue to diffeent types of taumatic events in childhood was elated to adult physical health symptoms afte contolling fo age, education, living conditions and post-childhood tauma. In addition, we hypothesized that past-week depessed affect and whethe the espondent had met citeia fo a PTSD diagnosis in thei lifetime would mediate the elationship between childhood tauma and adult physical health. Method Sampling and inteviewing pocedues A multi-stage pobability sampling design was used to daw samples of adults who wee epesentative of Oaxaca, Guadalajaa, Hemosillo, and Méida. The sample fo this lage study was compised of 2,509 adults; 907 men and 1,602 women. Inteviewes knocked on the doos of eligible households and asked the peson who answeed to take pat in an intenational study of health in Mexico. The peson s household was asked to paticipate in two phases of the poject: fist in a sociodemogaphic inteview about the household, and then one peson fom the household would be andomly selected to paticipate in an in-depth inteview about health issues they had faced in thei lives. Sample size and esponse ates wee 576 (79%) in Oaxaca, 713 (82%) in Guadalajaa, 618 (76%) in Hemosillo, and 602 (70%) in Méida. The pimay eason fo efusal to paticipate, when paticipants gave one, was lack of time fo the inteview. Inteviews wee completed by tained, local inteviewes in espondents homes in pivate. The demogaphic inteviews lasted about 1 h, and psychological inteviews lasted about 2 h. Demogaphic and psychological inteviews wee typically completed on sepaate days.

5 Fieldwok manages checked all inteviews fo accuacy of selection pocedues, completeness, and quality. Study pocedues wee appoved by institutional eview boads in the United States and Mexico and wee eviewed fo adheence to fedeal (US) guidelines fo conducting eseach in intenational settings. Moe detail about the sampling and assessment pocedues used in this study may be found in Nois et al. (2003). Measues Pedicto vaiables Fo the pesent study, espondents age 60 and olde wee emoved fom the lage study sample. Some eseach suggests that while etospective epots of tauma exposue tend to be valid, the age at which the taumatic event is expeienced may be epoted inaccuately, especially by olde adults and the eldely (Benstein et al. 1994; Kause et al. 2004). In addition, among the eldely thee ae likely age-elated declines in physical health that could influence the findings. Theefoe, to educe potential bias in esponses elated to childhood expeiences of tauma and the subsequent effects of this exposue, the sample is compised of espondents between the ages of yeas. The subset fo the pesent study is compised of 2,177 espondents, of which 64% ae women.1 The aveage age of paticipants was 34.7 yeas (SD = 11.2) and aveage level of education was 9.8 yeas (SD = 4.4; ange 0 24 yeas). Demogaphic chaacteistics of the sample ae pesented in Table 1. Table 1 Sample chaacteistics and study vaiables by sex Men (N = 778) Women (N = 1,399) M SD M SD Age 33.9 (11.3) 35.2* (11.1) Education level 10.7* (4.3) 9.2 (4.4) Poo quality of living conditions (1 4) 1.2 (0.3) 1.3* (0.4)

6 Men (N = 778) Women (N = 1,399) M SD M SD Depessive symptoms (0 3) 0.6 (0.4) 0.7* (0.5) Physical health symptoms (1 5) Total scale 1.4 (0.4) 1.6* (0.5) Muscula-skeletal 1.5 (0.5) 1.8* (0.7) Cadiopulmonay 1.2 (0.4) 1.3* (0.5) Nose-thoat 1.4 (0.6) 1.5* (0.7) Gastointestinal/uinay 1.5 (0.5) 1.6* (0.7) % Meeting citeia fo PTSD diagnosis * Mean o pecent highe in this goup than in countepat, * p <.001 Quality of cuent living conditions was assessed and included to contol fo impoveished conditions that could influence health status. The quality of cuent living conditions was scoed as the mean of five items (α =.76), each measued on a fou-point scale (1 = not at all, 4 = a lot). The items captued the extent to which espondents had expeienced shotages of food and wate, cowding, lack of electicity, and poblems with sanitation. Appoximately 54% of the sample had expeienced at least one of these poblems to some degee. Past-week depessed affect was assessed by the Cente fo Epidemiologic Studies Depession Scale (CES-D; Radloff 1977). Fo each question, the espondent epoted the numbe of days he o she expeienced the symptom in the past week, on a fou-point esponse fomat (0 3), α =.86. The scale has pefomed well within Hispanic and Mexican populations (Robets 1980; Saldago de Snyde and Maldonado 1993). Fo the pesent analysis, we deleted five items that closely appoximated items/symptoms on the measue of PTSD (concentation difficulties, fea, sleep disuption) o health (change in appetite, lack of enegy). Scoed as the mean of component items, the esulting 15-item measue had an α of.82. Tauma exposue and PTSD wee measued by using Module K of Vesion 2.1 of the Composite Intenational Diagnostic Inteview (CIDI) developed and tanslated into Spanish by the Wold

7 Health Oganization (WHO 1997).2 Respondents fist epot whethe they have eve expeienced one o moe taumatic events fom a set of events included in the CIDI. Taumatic events in the CIDI included physical assault, theatened with a weapon, sexual assault, sexual molestation, taumatic beeavement, injuy o popety loss in a disaste, injuy o popety loss in a fie, life theatening accident, and witnessing someone killed o injued. Then, the CIDI assesses, in ode, all DSM-IV citeia fo PTSD (APA 1994). The CIDI is stuctued so that people who expeience moe than one type of event ae asked the symptom questions only fo the one event judged by them to have been the most stessful. We modified the potocol slightly so that all symptom questions wee asked of anyone who had expeienced an event (The typical appoach is to skip to the next section of the inteview once a citeion is not met). With WHO s pemission and assistance, we also modified the event potion of Module K to collect infomation about the espondent s age at the time of the tauma (i.e., the espondent was asked if the event had occued befoe the age of 12 [childhood], [adolescence] o 16 and olde [adulthood]). If the event happened moe than once, espondents wee asked to epot the age at which it happened the fist time and last time, which allowed sepaate vaiables to be ceated fo adulthood and childhood tauma. Using the age beakdown above, in the pesent study almost 22% of espondents epoted tauma exposue befoe the age of 12, 20% between 12 and 15 yeas old, and 60% epoted exposue at 16 yeas and olde. Because the focus of this pape was on the impact of childhood exposue to tauma on adult physical health we ceated vaiables fo tauma exposue that epesented whethe these events occued befoe the age of 16 (childhood) o 16 and olde (post-childhood). Fo PTSD, we included a vaiable that measued whethe the espondent had met citeia fo PTSD in his o he lifetime. In the pesent study, 11.9% of the sample met citeia fo a lifetime PTSD diagnosis (see Table 1 fo data boken down fo men and women). Outcome vaiable The scale of physical health symptoms was adapted and tanslated fom the physical symptoms checklist (Leventhal et al. 1996). Each of the scale s items descibed a specific physical symptom expeienced in the last month, with paticipant esponses anging fom not at all tue (1) to extemely tue (5). Two items wee emoved (poblems emembeing things, sleeping poblems) because of thei close ovelap with items on the measue of PTSD used in the pesent study. The scale was also facto analyzed as it had not been used in Mexico peviously; duing this pocess additional items wee emoved because of low facto scoes (see Nois et al. 2006, fo a desciption of these analyses). The esulting 20-item measue of physical health symptoms with fou subscales was used (α =.90): (1) cadio-pulmonay symptoms (e.g., chest discomfot o pain, high blood pessue, difficulty beathing) (α =.78), (2) muscula-skeletal symptoms (e.g., pain o stiffness in shouldes, ams o hands; back poblems; hip, leg, knee, o feet poblems) (α =.77); (3) nose-thoat symptoms (e.g., nose o sinus poblems; thoat poblems;

8 swollen glands) (α =.71), and (4) gastointestinal/uinay symptoms (e.g., stomach o digestive poblems; intestinal o bowel poblems; uination poblems) (α =.62). Scales wee scoed as the mean of component items (ange 1 5). The aveage esponse acoss all symptoms was 1.51 (SD =.45); espondents epoted that it was a little tue that they had expeienced physical symptoms in the past month (see Table 1 fo a beakdown of physical health subscales fo men and women). Data analysis T-tests and chi-squae analyses wee used to examine diffeences between men and women on pedicto and outcome vaiables. Subsequent analyses used hieachical linea egession, whee physical health symptom subscales wee dependent vaiables and exposue to specific types of childhood taumas wee independent vaiables. Because the liteatue (as well as the pesent study; see Tables 1, 2) has ovewhelmingly found sex diffeences in exposue to tauma as well as the consequences of tauma (Nois et al. 2002a; Tolan and Foa 2006), analyses wee conducted sepaately fo men and women. Age, education, living conditions, and post-childhood tauma exposue wee enteed fist in the analyses. In the second step, vaiables epesenting childhood exposue to taumatic events wee enteed. Specific taumas in the pesent study wee sexual violence (i.e., sexual assault, sexual molestation), physical violence (physical assault, theat with a weapon), accident/hazad (i.e., injuy o popety loss in a disaste, fie, o life theatening accident), taumatic beeavement, and witnessing someone injued o killed. Dummy codes wee ceated to epesent tauma expeienced in adulthood (16 and olde) and tauma expeienced in childhood (befoe age 16). Positive scoes fo childhood violence indicate that at least one event occued when the espondent was younge than age 16. Childhood and adulthood tauma vaiables wee not mutually exclusive. As a test of mediation in each model, PTSD and depession wee enteed in the last step to examine whethe the associations found deceased significantly afte taking into account PTSD and depessive symptoms. Table 2 Tauma exposue by sex (N = 2,177) Men Women Type of tauma n % (SE) n % (SE) Any tauma exposue Adulthood ** (1.6) (1.3)

9 Men Women Type of tauma n % (SE) n % (SE) Childhood ** (1.8) (1.2) Sexual violence exposue Adulthood (0.8) (0.5) Childhood (0.8) ** (0.8) Physical violence exposue Adulthood *** (1.7) (1.0) Childhood *** (1.2) (0.5) Hazad/accident exposue Adulthood ** (1.7) (1.1) Childhood ** (1.4) (0.9) Taumatic beeavement Adulthood * (1.6) (1.2) Childhood (1.2) (0.8) Witnessing someone injued o killed Adulthood ** (1.6) (1.0) Childhood ** (1.3) (0.8) Pecent highe in this goup than in countepat, * p <.05; ** p <.01; *** p <.001

10 Results Pevalence of tauma exposue in adulthood and childhood Appoximately 60% (n = 1,308) of the total sample (<age 60) epoted expeiencing a taumatic event in adulthood. Specifically, 5% epoted sexual violence and 24% epoted physical violence in adulthood. Almost 27% epoted expeiencing a fie, disaste, o life theatening accident in adulthood. Twenty-six pecent of the total sample epoted taumatic beeavement, and 21% epoted witnessing someone injued o killed. Regading childhood tauma, 35% of the total sample (n = 764) epoted expeiencing a taumatic event in childhood. Seven pecent epoted sexual violence in childhood and 6% epoted physical violence in childhood. In addition, 14% epoted a fie, disaste, o life theatening accident. Of the total sample, 11% epoted taumatic beeavement in childhood and 13% epoted witnessing someone injued o killed in childhood (see Table 2 fo specific pecentages fo men and women). Fo all but two types of events (two in childhood and one in adulthood), men epoted exposue to moe taumatic events than women. The exceptions wee childhood sexual violence whee women epoted highe ates of exposue, and exposue to childhood taumatic beeavement and adulthood sexual violence whee thee wee no sex diffeences. Effects of childhood tauma on adult physical symptoms Coelations of tauma pedicto vaiables, and depession and PTSD fo men and women ae shown in Table 3. To examine the effects of childhood tauma type on physical symptoms afte contolling fo covaiates that could affect symptomatology, we conducted five hieachical linea egessions, one fo the total and each physical health subscale (see Table 4 fo men and Table 5 fo women). Results vaied depending on the type of childhood tauma and the set of physical symptoms.

11 Table 3 Coelations of study vaiables: tauma, depession, and PTSD by sex ASV APV AHaz ABeav AWit CSV CPV CHaz CBeeay CWit Dep PTSD ASV.15***.11**.13***.12*** *** APV.16***.25***.12***.21*** **.04.09*.02.10** AHaz.03.16***.13***.23*** *** ABeeav.02.09***.06*.15*** *.23*** AWit.09***.11***.15*** *** CSV.03.18***.07** ***.15*** *.10* CPV *** ***.21***.09*.18***.05.13*** CHaz.05.13***.09*** ***.14***.10**.16***.07.09* CBeeav ***.00.06*.04.14***.17***.09*.05 CWit.07*.09*** ***.18***.14***.19***.15***.13***.07

12 ASV APV AHaz ABeav AWit CSV CPV CHaz CBeeay CWit Dep PTSD Dep.09***.17***.09*** ***.06*.10***.04.06*.17*** PTSD.21***.22***.09***.08**.09***.25***.13***.16***.08**.11***.25*** Coelations fo men above the diagonal and coelations fo women below the diagonal * p <.05; ** p <.01; *** p <.001 ASV adulthood sexual violence; APV adulthood physical violence; AHaz adulthood hazad; ABeeav adulthood beeavement; AWit adulthood witnessing; CSVchildhood sexual violence; CPV childhood physical violence; CHaz childhood hazad; CBeeav childhood beeavement; CWit childhood witnessing; Dep depession (cuent); PTSD post-taumatic stess disode (lifetime) Table 4 Hieachical linea egessions fo men of tauma type on physical health (N = 778) Total health symptoms Muscula-skeletal Cadio-pulmonay Vaiables Step 1 Step 2 Age

13 Total health symptoms Muscula-skeletal Cadio-pulmonay Vaiables Step 1 Step 2 Education.10** ***.09*.10*.03.09* Poo living conditions.17***.15***.14***.11**.20***.17***.16***.13***.10**.09*.08*.05 Sexual violence adulthood Physical violence adulthood.12***.11**.08*.08*.08* *.09* Hazad adulthood Beeavement adulthood Witnessing adulthood Sexual violence childhood.14***.13***.09*.10**.08*.04.10**.09*.05 Physical violence childhood.11** ***.10**.10**

14 Total health symptoms Muscula-skeletal Cadio-pulmonay Vaiables Step 1 Step 2 Hazad childhood.13***.09*.08*.14***.10**.10** Beeavement childhood Witnessing childhood.08* Lifetime PTSD.14***.04.13***.03.11**.05 Cuent depession.39***.36***.36***.33***.31***.29*** R 2 change.05***.04***.12***.06***.03**.10***.03**.01.08*** Adjusted R 2.04***.07***.20***.05***.07***.17***.02*.03**.10*** Vaiables Nose-thoat Gastointestinal-uinay

15 Age Education Poo living conditions.11**.11**.10**.08*.12***.12***.12***.09* Sexual violence adulthood.08* Physical violence adulthood.09*.08* ***.13***.11**.10** Hazad adulthood Beeavement adulthood Witnessing adulthood Sexual violence childhood.09*.09*.06.16***.16***.13*** Physical violence childhood

16 Nose-thoat Gastointestinal-uinay Vaiables Hazad childhood.09* ** Beeavement childhood Witnessing childhood Lifetime PTSD ***.05 Cuent depession.24***.22***.27***.23*** R 2 change.03**.01.05***.04***.03**.06*** Adjusted R 2.02*.03**.08***.03**.07***.11*** * p <.05; ** p <.01; *** p <.001 Note: Coelations wee compised of Peason o point-biseial, depending on whethe associations wee between two continuous vaiables o a binay and continuous vaiable

17 Table 5 Hieachical linea egessions fo women of tauma type on physical health (N = 1,397) Total health symptoms Muscula-skeletal Cadio-pulmonay Vaiables Age.08** *.18***.10***.12***.15** *.13***.06*.08**.10*** Education.21** *.14** *.13** *.04.24** *.15** *.14** *.06*.22** *.15** *.14** *.08* * Poo living conditions.27***.20***.20***.12** *.26***.18***.18***.11** *.22***.15***.15***.10*** Sexual violence adulthood.09***.06*.05*.01.07** * Physical violence adulthood.19***.10***.07**.03.18***.09***.06*.03.17***.10***.08**.05* Hazad adulthood.16***.12***.12***.09** *.16***.12***.12***.09** *.11***.07**.07**.05* Beeavemen.08**.05* **.06*.05*.05*.08**

18 Total health symptoms Muscula-skeletal Cadio-pulmonay Vaiables t adulthood Witnessing adulthood.14***.10***.10***.09** *.13***.09***.09***.08**.09***.06*.06*.06* Sexual violence childhood.16***.10***.06*.14***.09**.06*.10*** Physical violence childhood.06* Hazad childhood.11***.08**.05*.08**.06*.04.10***.08**.06* Beeavemen t childhood Witnessing childhood.06* **.06*.05* Lifetime PTSD.27***.10** *.23***.07**.22***.09***

19 Total health symptoms Muscula-skeletal Cadio-pulmonay Vaiables Cuent depession.45***.36** *.42***.33** *.32***.23*** R 2 change.14***.02***.12** *.16***.01**.10** *.11***.01**.06*** Adjusted R 2.14***.15***.28** *.15***.16**.26** *.10***.11**.17*** Nose-thoat Gastointestinal-uinay Vaiables Age.05.08**.07** **.06*.03 Education **.07**.06*.01 Poo living conditions.15***.13***.13***.08**.15***.11***.11***.04

20 Nose-thoat Gastointestinal-uinay Vaiables Sexual violence adulthood * Physical violence adulthood.06* ***.06* Hazad adulthood.11***.10***.11***.09***.10***.09***.09***.06* Beeavement adulthood Witnessing adulthood.10***.08**.07**.07**.09***.06*.06*.04 Sexual violence childhood.07** ***.11***.08** Physical violence childhood.06* Hazad childhood.08**.06*.04.08** Beeavement childhood Witnessing childhood

21 Nose-thoat Gastointestinal-uinay Vaiables Lifetime PTSD.16***.09***.19***.08** Cuent depession.22***.17***.33***.28*** R 2 change.05***.00.03***.05***.02***.07*** Adjusted R 2.04***.04.08***.04***.06***.13*** * p <.05 ** p <.01 *** p <.001 Note: Coelations wee compised of Peason o Point-biseial, depending on whethe associations wee between two continuous vaiables o a binay and continuous vaiable

22 Men As Table 4 shows, expeiences of sexual violence in childhood wee significantly elated to total symptoms, and all physical health subscales (). Physical violence was elated to musculaskeletal symptoms. In addition, hazads/accidents in childhood wee positively elated to total and muscula-skeletal symptoms. The set of childhood exposue vaiables accounted fo a small, but significant amount of vaiance in the total scale, muscula-skeletal, and gastointestinaluinay subscales (4, 3, and 3%, espectively). Women Childhood sexual violence was positively elated to total symptoms, muscula-skeletal, and gastointestinal-uinay symptoms (see Table 5). Hazads/accidents in childhood wee positively elated to all but gastointestinal-uinay symptoms. Childhood beeavement was not significantly elated to physical health symptoms. Witnessing someone injued o killed in childhood was elated to only cadio-pulmonay symptoms. Childhood tauma vaiables accounted fo a small but significant amount of vaiance in all but the equation elated to nosethoat symptoms. Testing PTSD and depession as mediatos Following Baon and Kenny (1986), evidence of mediation is suggested when the independent vaiable is elated to the mediato and the dependent vaiable; the mediato is elated to the dependent vaiable; and the effect of the independent vaiable on the dependent vaiable is less when the mediato is also in the equation. Theefoe, to examine whethe PTSD and depession wee mediatos to the childhood tauma-adulthood physical health symptoms elationship, these vaiables wee enteed in (see Tables 4, 5 fo men and women, espectively). Men When PTSD and depession wee enteed in the set made a unique contibution to all symptom domains; howeve, only depession was significantly elated to health symptoms. Notably, the effects of childhood sexual violence dopped out of the muscula-skeletal, cadiopulmonay, and nose-thoat symptoms equations when depession was taken into account. In addition, coefficients wee educed fo the effect of childhood sexual violence on the total scale and the gastointestinal-uinay symptoms subscale; and the effect of childhood hazads/accidents on total symptoms, though these wee still significant in the last step. This

23 appaent evidence of mediation was futhe veified in a seies of analyses that explicitly tested the indiect effects of these childhood taumas on health outcomes though depession. Fist, to test fo the necessay elationship between the independent vaiables and the poposed mediato, depession was egessed on the same vaiables included in the second step of the analyses on physical health (Table 4, ). Only sexual violence in childhood (B =.20, SE =.07, =.11, p <.05) and witnessing someone injued o killed in childhood (B =.09, SE =.04, =.08, p <.05) wee significantly elated to depession. Next, when examining the effect of witnessing someone injued o killed in childhood (IV) on health outcomes (DV), esults showed no significant elationships. Theefoe, additional analyses to test fo mediation wee not conducted fo this tauma type as the citeion that the IV be elated to the DV was not met. By contast, childhood sexual violence was elated to all health outcomes. With this citeion met, we used Sobel s fomula (cited by Baon and Kenny 1986) fo calculating the indiect effect of the independent vaiable on the dependent vaiables via the mediato. Results showed that the indiect effects of childhood sexual violence on health outcomes though depession wee significant fo the total and all physical health subscales (data not shown), thus poviding stong evidence of mediation. Finally, because PTSD was not significantly elated to health symptoms, with depession contolled, no additional tests fo mediation wee conducted. Women When PTSD and depession wee enteed in, both made significant contibutions to the total health symptoms scale as well as all subscales. The effect of childhood hazads/accidents dopped out of the muscula-skeletal and nose-thoat symptoms equations when PTSD and depession wee taken into account. In addition, coefficients wee educed fo the effect of childhood sexual violence on total symptoms, muscula-skeletal, and gastointestinal-uinay symptoms; the effect of childhood hazads/accidents on total symptoms and cadio-pulmonay symptoms; and the effect of witnessing someone injued o killed on cadio-pulmonay symptoms, though these wee still significant in the last step. Again, the pesence of mediation was veified in a seies of analyses that explicitly tested the indiect effects of childhood tauma on health though depession and PTSD. Fist, depession was egessed on vaiables and esults showed that only childhood sexual violence was elated to depession (B =.13, SE =.05; =.07, p <.01). Calculated by using Sobel s fomula, the indiect effects wee found to be significant in these tests (data not shown), poviding stong evidence that depession is a mediato of childhood sexual abuse and total, muscula-skeletal, and gastointestinal-uinay symptoms. Next, to examine PTSD as a mediato, PTSD was egessed on vaiables fom Table 5; esults showed that childhood sexual violence (B =.93, SE =.12, =.18, p <.001), childhood physical violence (B =.59, SE =.19, =.08, p <.01), childhood hazads/accidents (B =.37, SE

24 =.11, =.08, p <.01), and childhood beeavement (B =.30, SE =.12, =.07, p <.01) wee all elated to PTSD. Howeve, childhood physical violence and childhood beeavement wee not elated to any of the health symptoms scales and theefoe, additional tests of PTSD as a mediato wee not conducted fo these vaiables. Using Sobel s fomula, the indiect effects of childhood sexual violence wee significant fo the total, muscula-skeletal, and gastointestinaluinay subscales; indiect effects of childhood hazads/accidents wee significant fo the total, muscula-skeletal, cadio-pulmonay, and nose-thoat subscales (data not shown). Discussion Tauma exposue was quite pevalent in this sample. Appoximately 60% of espondents below age 60 epoted tauma in adulthood, and 35% epoted taumatic events in childhood. In geneal, men epoted moe taumatic events in childhood and adulthood than women, a finding that is consistent with pevious eseach in the US and Canada (Beslau et al. 1998; Kessle et al. 1995; Stein et al. 1997). In addition, women epoted highe ates of depessive symptoms and wee moe likely to meet citeia fo PTSD than men. This discepant finding between men and women, as well as the magnitude found in the cuent study, is simila to pevious eseach with a community sample in the US (i.e., 13% of women and 6% of men in a US study met citeia fo PTSD compaed to 15% of women and almost 7% of men in the cuent study; Beslau et al. 1998). Howeve, compaisons must be intepeted with caution as the methods and measues diffe between studies. Regading ou hypotheses, childhood tauma was associated with adult physical health symptoms afte contolling fo demogaphic vaiables, poo living conditions, and postchildhood tauma, but the effects wee small. The childhood tauma vaiables that seemed to have the most consistent impact acoss models wee childhood sexual violence and hazads/accidents. In paticula, childhood sexual violence was significantly elated to total symptoms, as well as muscula-skeletal, and gastointestinal poblems fo women; and to the total and all symptom subscales fo men. Childhood hazads/accidents wee also elated to one o moe adult physical health symptoms fo men and women. By contast, childhood beeavement and witnessing someone injued o killed in childhood wee not significantly elated to any symptoms fo men and only to cadio-pulmonay symptoms fo women. At fist glance these esults seem to be discepant with pevious eseach which suggests that taumatic beeavement and witnessing a taumatic event do affect health. Howeve, much of the eseach has not diffeentiated between childhood and adulthood expeiences of tauma. Pevious eseach has also focused on mental health outcomes with esults suggesting a small to modeate effect of these taumas on psychological symptoms (Beslau et al. 1998; Ceame et al. 2001; Edwads et al. 2003; Kessle et al. 1995; Nois et al. 2003). Thee is a death of eseach on the effects of these taumatic expeiences on physical health outcomes. Fo example, the effects of

25 ealy witnessing on adulthood physical health have yet to be exploed in any detail. With egad to taumatic beeavement, one study that did examine the elationship between childhood beeavement and physical health found that paental loss in childhood was not significantly elated to eithe acute o chonic physical health symptoms (Maie and Lachman 2000). It may also be that, consideing the Mexican context, death is moe nomalized than in the US o othe developed counties. The facts of life and death ae not hidden fom childen in Mexico, and once a yea on the Day of the Dead eveyone gathes at cemeteies to visit and commune with the dead (Camichael and Saye 1991). Theefoe, while exposue to someone s death may be taumatic, it may have less of an impact on health than othe types of tauma. Anothe possibility is that ou findings wee due to the types of taumatic events included in the cuent study and how we measued them. The ange of expeiences captued by witnessing someone injued o killed and taumatic beeavement may have been too boad (e.g., the deceased o injued peson was not necessaily a paent o othe membe of the family) to show an effect that would pesist into adulthood. By contast, violence was compised of physically detimental events and those that could also lead to inceased anxiety (e.g., theatened with a weapon, sexual assault). Physical effects fom these sevee types of tauma may be appaent immediately in tems of muscula-skeletal poblems fom the attacks with an exacebation of these poblems ove time; similaly, it is also possible that the ongoing distess ceated by the loss of contol may eode health ove time and esult in moe gastointestinal symptoms (McEwen 1998). Fo cadio-pulmonay symptoms, childhood hazads/accidents wee elated to moe symptoms fo women. This finding is suppoted by past eseach that suggests that, in paticula, disaste victims (who wee included in ou hazad/accident categoy) may expeience excessive nevous system eactivity that inceases vulneability fo cadiovascula illness (Fiedman and McEwen 2004). Consistent with ou hypothesis, thee was suppot fo PTSD and depession as mediatos of the elationship between some childhood taumas and adult physical symptoms. Fo men, depession mediated the elationship between childhood sexual violence and all health outcomes. Fo women, depession and/o PTSD mediated the elationship between childhood sexual violence, childhood hazads/accidents, and adult physical symptoms acoss all health domains. By contast, although depession was a significant pedicto and mediato fo men, PTSD was not significantly elated to health symptoms in any model. It may be that the low pevalence of PTSD among men contibuted to the lack of significance when examining both the diect elationship on adult symptoms, and the indiect elationship of childhood tauma on adult symptoms though PTSD. One eason fo the diffeence in pevalence could be that, in geneal, cognitions elated to tauma, such as helplessness and emotional distess, may be moe dissonant with men s self-concepts than with women s. This dissonance may be even geate in cultues that foste moe taditional views of men and women, with the esult being that men, and in paticula Mexican men, may be moe likely to suppess symptom expeiences than women (Saxe and Wolfe 1999; Wolfe and Kimeling 1997). It is unclea in ou study whethe men did

26 indeed have a lowe pevalence of PTSD o whethe it was simply that they undeepoted symptoms. Additional eseach is necessay to examine this phenomenon in moe detail as well as to investigate othe potential mediatos of the elationship between childhood tauma and adult physical health that ae moe meaningful fo men. Although the esults of the pesent study show that thee is a elationship between childhood tauma and adulthood physical health, the magnitude of this elationship appeas smalle than in pevious eseach. One eason may be due to the samples; most of the eseach has been conducted with samples in the US and othe developed counties. By contast, in Mexico, taumatic events in childhood may not be as salient to suvivos in elation to the othe hadships that they may endue in thei lifetime (e.g., poo living conditions, physically demanding jobs), and theefoe not as impotant to adult physical health. Indeed, 54% of ou sample epoted at least one poblem in thei cuent living conditions (e.g., shotages of food and wate, cowding, lack of electicity, and poblems with sanitation). Given the death of eseach on tauma and physical health in Mexico, additional wok is needed. Of paticula impotance may be cosscultual eseach, as well as eseach that is qualitative in natue so that we can begin to undestand the inticacies of people s lives fom an ecological pespective, including thei individual expeiences of tauma and health, the context in which the tauma occued, and the esouces available to the suvivo aftewad (which could diectly impact the onset and chonicity of mental health poblems such as depession and PTSD). In addition to sample and contextual diffeences thee may be othe easons fo the elatively low magnitude of the association between childhood tauma and adulthood physical health. Fo the pesent study, we included seveal contol vaiables: age, education, poo living conditions, and post-childhood tauma exposue. Pevious studies have included some, but not all of these contol vaiables, e.g., education and age (Felitti et al. 1998; Shaw and Kause 2002), while othes have only included age as a covaiate (Spetus et al. 2003). Also, although pevious eseach has shown a positive elationship between childhood and adulthood tauma exposue (Beslau et al. 1999; Coid et al. 2001; Follette et al. 1996; Schaaf and McCanne 1998), not all studies that have examined the effect of childhood tauma on adulthood mental and physical health have contolled fo adulthood tauma. Futhemoe, pevious wok often has not included othe vaiables that could affect physical health and be intetwined with tauma, such as PTSD o depessed affect. Given the pevalence of PTSD and depession in the aftemath of tauma, this is an impotant ovesight (Beslau et al. 1998, 2000; Ceame et al. 2001; Kessle et al. 1995; O Donnell et al. 2004). Howeve, although we point out that pevious studies may not have had adequate contols, and theefoe may have oveestimated the contibution of childhood tauma to adulthood physical health, it is also possible that ou findings may be due to the ovely consevative natue of ou analyses (i.e., testing the effect of childhood tauma on adulthood physical health with adulthood tauma and othe advesities contolled). Thus, futhe eseach about the associations between

27 tauma, depession, PTSD, and health symptoms, paticulaly in developing counties, is needed befoe any definitive conclusions can be dawn. As with othe studies, ous is not without limitations. Physical symptoms wee based on selfepoting athe than physical examination; theefoe we could not assess the pesence of medical disodes. Rathe, ou findings descibe subjective health athe than veified mobidity, but this is also tue of most othe studies conducted outside of clinics o laboatoies. Anothe shotcoming is that the health measue had not been used in Mexico peviously; thus, although its facto stuctue povided easonable evidence of constuct validity, we cannot asset with cetainty that the measue was coss-cultually valid. In addition, thee may have been a biased ecall fo events expeienced in childhood. Fo example, espondents cuent health status may have diffeentially influenced how they esponded to questions about thei past exposue to taumatic events (Shaw and Kause 2002). Also, women wee oveepesented in ou sample compaed to the Mexican census data. Howeve, a compaison between selected men and women and the lage populations fom which they wee chosen suggest that the magnitude of the bias was elatively small. Finally, ou findings ae limited due to the coss-sectional natue of the data. While thee is an inceased confidence that the taumatic event peceded health outcomes because of the stuctue of ou exposue questions, which wee sepaate fom ou questions about cuent physical health, all data wee collected at one point in time and so a tue time odeing is difficult to distinguish with cetainty. Ou study also had seveal stengths. Ou sample was composed of a epesentative sample of community-dwelling men and women, whose selection was independent of whethe o not they sought teatment fo thei physical o mental health symptoms. Moe compehensive contols wee included in the analyses so as not to oveestimate the influence of childhood tauma on adult physical health. Also, pevious eseach in this aea has focused on US populations and theefoe, by inteviewing Mexicans about thei expeiences of tauma and health we extended ou undestanding of the elationship between childhood tauma and adult physical health moe globally. In conclusion, ou esults povide suppot fo the pemise that childhood tauma has a detimental impact on adult physical health, though the impact appeas to be small in ou Mexico sample. Ou study also suppots the ole of depession and PTSD as mediatos of childhood tauma and adult physical health, though PTSD was a mediato fo women only. The pesent study could be used to help aise the awaeness of health pactitiones and community stakeholdes in Mexico about the pevalence of tauma among community esidents and the effect of that exposue on individual and community health. In tems of the pactical utility of these findings, afte aising awaeness, geneal pactitiones could be encouaged to sceen thei patients fo tauma histoy. The sceening would povide the pactitione with additional infomation that could be used not only in the teatment of physical ailments but also to povide

28 patients with mental health sevices, if necessay. One outcome of sceening is that patients may eceive moe compehensive sevices, thus inceasing the potential fo positive health outcomes and patient well-being. Additionally, it will be impotant to establish collaboative patneships among pactitiones, community-based agencies, policymakes, and eseaches to develop intevention stategies that conside the elationship between tauma and health. And, not only ae inteventions needed to teat suvivos afte a taumatic event has aleady occued, but just as impotant will be the development of pevention effots to educe the numbes of Mexicans exposed to tauma. We view this eseach as a step towad these goals by seeking to undestand and document some of the expeiences that affect the physical health of people in Mexico. Acknowledgments This eseach was suppoted by Gant No. 2 R01 MH51278 fom the National Institute of Mental Health, Fan H. Nois, Pincipal Investigato, Athu D. Muphy, Co-Pincipal Investigato Refeences Ameican Psychiatic Association. (1994). Diagnostic and statistical manual of mental disodes (4th ed.). Washington DC: Ameican Psychiatic Association. Baon, R. M., & Kenny, D. A. (1986). The modeato-mediato vaiable distinction in social psychological eseach: Conceptual, stategic, and statistical consideations. Jounal of Pesonality and Social Psychology, 51(6), doi: / Benstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., et al. (1994). Initial eliability and validity of a new etospective measue of child abuse and neglect. The Ameican Jounal of Psychiaty, 151, Beslau, N., Chilcoat, H., Kessle, R., & Davis, G. (1999). Pevious exposue to tauma and PTSD effects of subsequent tauma: Results fom the Detoit aea suvey of tauma. The Ameican Jounal of Psychiaty, 156, Beslau, N., Davis, G. C., Peteson, E. L., & Schultz, L. R. (2000). A second look at comobidity in victims of tauma: The posttaumatic stess disode-majo depession connection. Biological Psychiaty, 48, doi: /s (00) Beslau, N., Kessle, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andeski, P. (1998). Tauma and posttaumatic stess disode in the community. Achives of Geneal Psychiaty, 55, doi: /achpsyc Camichael, E., & Saye, C. (1991). The skeleton at the feast: The day of the dead in Mexico. Austin: Univesity of Texas Pess.

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