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PUBLIC H EALTH management corporation F INDINGS FROM THE P HILADELPHIA U RBAN ACE S URVEY PREPARED FOR INSTITUTE FOR SAFE FAMILIES PREPARED BY THE R ESEARCH AND EVALUATION G ROUP AT PUBLIC H EALTH M ANAGEMENT CORPORATION 260 SOUTH B ROAD STREET , 18 TH FLOOR PHILADELPHIA , PA 19102 SEPTEMBER 18 , 2013 PUBLIC H EALTH management corporation ACKNOWLEDGEMENTS The Philadelphia Urban ACE Study was supported by a generous grant from the Robert Wood Johnson Foundation. Additional support for the Philadelphia ACE Task Force efforts has been provided by the CHG Charitable Trust, the First Hospital Foundation, the Stoneleigh Foundation, and the Scattergood Foundation. The authors would like to thank members of the Philadelphia ACE Task Force who helped guide the Philadelphia Urban Ace Study. Specifically , Megan Bair Merritt , Sandra Bloom, Peter Cronholm, Martha Da vis, Sandy Dempsey, Joel Fein, Sara Ann Kuykendall , Lee Pachter, and Roy Wade assisted in drafting the Philadelphia Urban Ace Study, reviewing the findings and the commenting on the final report. PUBLIC H EALTH management corporation TABLE OF CONTENTS EXECUTIVE SUMMARY ................................ ................................ ......................... i I. INTRODUCTION ................................ ................................ ....................... 1 II. M ETHODOLOGY ................................ ................................ ...................... 3 III. FINDINGS ................................ ................................ ............................... 7 IV. DISCUSSION ................................ ................................ ......................... 24 APPENDIX A: PHILADELPHIA URBAN ACE SURVEY QUESTIONNAIR E APPENDIX B: COMPARISON OF ACE QUESTIONS FROM THE PHILADELPHIA URBAN ACE SURVEY , KAISER ACE STU DY , AND BRFSS ACE M ODULE The Research and Evaluation Group PUBLIC H EALTH management corporation i EXECUTIVE SUMMARY This report provides findings on the adverse childhood experiences (ACEs) of Philadelphia residents. Past studies, including the seminal 1998 Kaiser study by Felliti and Anda, have confirmed the neg ative impact of ACEs, such as physical, emotional and sexual abuse and household dysfunction , on health behaviors and health outcomes in adulthood. However, most of t hese findings have been confirmed in studies composed of primarily white, middle -class, and highly educated individuals. The Institute for Safe Families (ISF) 1 formed the ACE Task Force in 2012 with an interest in examining the prevalence and impact of ACE s in Philadelphia, an urban city with a socially and racially diverse population. ISF co ntracted with Public Health Management Corporation (PHMC) to develop and conduct a survey of childhood adversity exposures among Philadelphia residents in the fall of 2012. PHMC contracted Social Science Research Solutions to conduct the survey as a follo w-up to P:MC’s 2012 Southeastern Pennsylvania :ousehold :ealth Survey (SEPA HHS) . A total of 1,784 adults completed the Philadelphia Urban ACE Survey for a response rate of 67.1%. The survey found a higher prevalence of ACEs than found in previous studie s. In particular, 33.2% of Philadelphia adults experienced emotional abuse and 35% experienced physical abuse during their childhood. Approximately 35% of adults grew up in a household with a substance -abusing member ; 24.1% lived in a household with someo ne who was mentally ill ; and 12.9% lived in a household with someone who served time or was sentenced to serve time in prison. The Philadelphia Urban ACE Survey also examined the stressors that exist in the communities where people live. The study found t hat 40.5% of Philadelphia adults witn essed violence while growing up, which includes seeing or hearing someone being beaten, stabbed or shot. Over one -third (34.5%) of adults reported experiencing discrimination based on their race or ethnicity, while almo st three in ten adults (27.3%) reported having felt unsafe in their neighborhoods or not trusting their neighbors during childhood. In all, over 37% of Philadelphia respondents reported four or more ACEs. The findings from this study suggest the need for s ervices that address the unique environmental stressors experienced in urban neighborhoods to mitigate their impact on individuals and prevent ACEs. 1 http://www.instituteforsafefamilies.org The Research and Evaluation G roup PUBLIC H EALTH management corporation 1 I. INTRODUCTION Traumatic events in childhood, such as experiencing physical or sexual abuse, witnessing domestic violence among adults at home, and living in a household where someone abuses alcohol or other drugs have obvious negative impacts on children while they are growing up. The impact from these events continues to affect individuals’ adult lives. Persons who experience adverse events during childhood are more likely to have poorer mental and physical health in adulthood compared to adults who do not experience traumatic events during childhood. Beginning in 1995, physicians Vincent Felitti and Ro bert Anda led a collaborative study between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente to assess the association between adverse childhood experiences and subsequent health and wellbeing in adulthood. i Over 17,000 patients w ho were members of Kaiser Permanente’s :ealth Maintenance Organization (:MO) underwent a comprehensive physical examination at Kaiser Permanente’s Health Appraisal Clinic in San Diego and completed a confidential survey about their childhood experiences wi th abuse, neglect and family dysfunction. Felitti and Anda found that adverse childhood experiences (ACEs) , specifically psychological, physical, or sexual abuse; violence against one’s mother; or living with household members who were substance abusers , mentally ill or suicidal, or ever imprisoned were prevalent among the population. More than half of the respondents reported experiencing at least one ACE and one - fourth experienced two or more ACEs. The study also found a dose response relationship bet ween ACE scores and risky health behaviors , such as smoking, physical inactivity and multiple sexual partners . Adults who had experienced four or more categories of ACE, compared to those who had experienced none, had the following increased risk for neg ative health behaviors:  1.4 - to 1.6 -fold increase in physical inactivity and severe obesity;  2- to 4 -fold increase in smok ing, poor self -rated health, multiple sexual partners (i.e., ≥50 sexual intercourse partners), and sexually transmitted disease; and  4- to 12 -fold increased risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs were found to be linked in a dose response relationship to poor health outcomes in adulthood. ii As the number of ACEs a person experienced increased the likelihood of cardiovascular disease; cancer; AIDS and other sexually transmitted diseases; chronic obstructive pulmonary disease ; skeletal fractures; and liver disease increased as well. The seven categories of adverse childhood experiences were also found to be strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. In 2008, the Centers for Disease Control and Prevention (CDC) developed an ACE module for use in the Behavioral Risk Factor Surveillance System (BRFSS), a state -based system of telephone surveys , established by the CDC . This survey collects information on health risk behaviors, prevalence of chronic diseases, use of preventive health practices, injury, and health care access. The ACE module was administered in five states (Arkansas, Louisiana, New Mexico, Tennessee, and Washington) iii in 2009 and Wisconsin iv and Pennsylvania v in 2010. In the original five states The Research and Evaluation G roup PUBLIC H EALTH management corporation 2 that incorporated the ACE module, 59% of respondents reported having at least one ACE and 15% had four or more ACEs. Among Wisconsin residents, 56% of the adult population exp erienced at least one ACE and 14% had an ACE score of four or more. Approximately 53% of Pennsylvania residents experienced at least one ACE and 13% experienced four or more ACEs. The majority of the respondents of the original Kaiser study, five -state B RFSS survey, and the Wisconsin and Pennsylvania surveys were primarily White non -Hispanic, middle -class, and had more than a high school education. vi Four out of five participants in the Kaiser study were white (80%) and three out of four participants in the BRFSS study were white (75%) (Table 1). The majority of the Kaiser study participants had more than a high school education; 32% had completed some college and 43% were college graduates. Three out of five BRFSS study participants (62%) had more than a high school education. The respondents to the Kaiser and five -state BRFSS survey are less racially and socioeconomically diverse than residents of urban communities. For example, in Philadelphia only two out of five residents 18 years and older are wh ite (38.8%) (Table 1). More than three out of ten resident s are Black (36.1%) and 11.4% are Latino. Less than half of the adult population has completed more than a high school education. Approximately one out of five Philadelphia residents has complete d some college and 22.5% are college graduates. Table 1. Demographic Characteristics of Participants in the Kaiser Study and BRFSS ACE Suvey, and Philadelphia Residents, 18 years and older, 2013 Kaiser Study BRFSS ACE Survey Philadelphia Residents Race Race Race White 74.8% (n=12,968) White, non - Hispanic 75% (N=19,770) White 38.8% (N=466,677) Black 4.6% (n=798) Black, non - Hispanic 10% (N=2,662) Black 36.1% (N=434,312) Hispanic 11.2% (n=1,942) Hispanic 8.5% (N=2,217) Latino 11.4% (N=136,697) Asian 7.2% (n=1,248) Other, non - Hispanic 5% (N=1,381) Asian 6.2% (N=74,916) Other 1.9% (n=329) Biracial 7.4 % (N= 88,939 ) Education Education Education No t HS graduate 7.2% (n=1,248) High school 62% (N=16,175) Some college 21.8% (N=220,191) College graduate or higher 39.3% (n=6,813) College graduate 22.5% (N=226,748) All Participant s 17,337 26,229 Total Residents 1,201,541 Data Source: Felitti, et al. vii and Centers for Disease Control and Prevention viii and Nielsen -Claritas 2013 Pop -Facts Database . Prepared by the Research and Evaluation Group at PHMC The Research and Evaluation G roup PUBLIC H EALTH management corporation 3 Researchers and adv ocates, including the World Health Organization and the CDC have begun to explore the prevalence of ACEs in other populations, such as low -income, low -education, and non - White populations. ix They have examined the prevalence of ACEs in developing countries and have pushed to expand ACEs to include other sources of adverse stress, such as bullying, peer -to- peer violence, experiencing acts of war, collective violence in the community, and forced marriage. The Institute for Safe Families formed the ACE Task Force to look at the prevalence of ACEs in Philadelphia, an urban community that is more ethnically diverse and of lower -income than populations previously studied for ACEs. In addition, ISF and the ACE Task Force were interested in examining how ACEs and other adversities and stressors of growing up in an urban community may impact health behaviors and health outcomes. To address these needs, ISF contracted Public Health Management Corporation (PHMC) to conduct an urban ACE study to assess the prevalen ce of ACEs in Philadelphia, assess the adversities related to growing up in an urban environment, and examine the impact of ACE s and the additional urban adversities on health behaviors and health outcomes. The urban ACE study was funded by the Robert Woo d Johnson Foundation. II. M ETHODOLOGY The Philadelphia Urban ACE Survey was a follow -up to P:MC’s Southeastern Pennsylvania Household Health Survey (SEPA HHS) – one of the largest local health surveys in the country and a unique regional resource. The SEPA ::S, a part of P:MC’s Community :ealth Data Base, is a representative, community -based telephone survey of over 13,000 residents – both children and adults – living in the Southeastern Pennsylvania region, which includes Bucks, Chester, Delaware, Mon tgomery, and Philadelphia Counties. The HHS is a comprehensive survey providing information on a broad range of topics such as health status and chronic health conditions, access to care, health behaviors and health screenings. The HHS is conducted by tel ephone and uses a dual frame random digit dial telephone survey including both landline and cell phones. The last SEPA HHS was fielded during summer of 2012. The Philadelphia Urban ACE survey was able to leverage significant resources by following up o n the SEPA HHS. The follow -up survey allowed responses from the ACE survey to be linked with demographic and health information already collected through the HHS. In addition, the initial work of developing a sample frame and screening for callers who ar e 18 years and older had already been accomplished. The Philadelphia Urban ACE survey re -contacted Philadelphia residents who participated in the HHS. The study includes interviews with 1,784 Philadelphia adults age 18 and older conducted between Novembe r 2012 and January 2013. Interviews were conducted in English and Spanish and included both landlines and cell phones. The average length of interviews was approximately 12 minutes. With the goal of enhancing cooperation rate s, male interviewers were ass igned to call male respondents and female interviewers were assigned to call female respondents. An advance The Research and Evaluation G roup PUBLIC H EALTH management corporation 4 letter was sent to all respondents inviting them to call a 1 -800 number or schedule a convenient time to complete the survey. Refusal conversion l etters and two refusal conversion attempts were implemented to ensure maximum response rates. Respondents who initially declined the survey were offered five dollars as an incentive to participate. In addition, respondents in the cell phone sample who re quested, without prompting, to be paid or reimbursed for their cell phone minutes were offered five dollars. The response rate for the Urban ACE Survey was 67.1% and was calculated using AAPOR’s RR3 formula .x Interviews were conducted by employees of Socia l Science Research Solutions an experienced survey research firm. Given the delicate nature of some of the topics discussed, information , referrals , and emergency numbers for any of the issues were provided. Due to some over and under -representation of p articular demographic sectors, which is typical in random telephone -based survey samples, the data were slightly adjusted with a projection weight to match the proportion of adult age, poverty status, gender, race, and Hispanic ethnicity distributions with in Philadelphia and to project census population totals (Table 2). Additionally, survey weights were utilized for calculations to ensure that the findings from the survey were applicable to the Philadelphia population. Table 2. Demographic Characteristics of Philadelphia Residents, 18 years and older and Philadelphia Urban ACE Survey Respondents, 2013 Philadelphia Residents Philadelphia Urban ACE Survey Race White 38.8% (N=466,677) 44.1% (n=786) Black 36.1% (N=434,312) 42.5% (n=758) Latino 11.4 % (N=136,697) 3.5% (n=63) Asian 6.2% (N=74,916) 3.6% (n=63) Biracial 2.1% (N=24,778) 3.8% (n=68) Other 5.3% (N=64,161) 2.4% (n=43) Education