Trauma exposure and chronic physical conditions in South Africa Lukoye Atwoli MBChB, MMed Psych, PhD Associate Professor of Psychiatry and Dean Moi University School of Medicine

Co-authors Jonathan Platt; Columbia University Archana Basu; Columbia University David R. Williams, PhD; Harvard University Dan J. Stein, MD, PhD; University of Cape Town Karestan C. Koenen, PhD; Harvard University

Outline Introduction Methods Results Conclusion

Introduction It has long been established that trauma exposure results in poor mental health, with certain mental disorders commonly arising after trauma exposure Evidence is emerging linking trauma exposure to abnormal physiological function- including in the immune, endocrine and cardiovascular systems Research from more developed countries is now showing that trauma exposure is linked to a number of chronic physical conditions This is the first such study from Africa, a continent with the highest trauma exposure rates in the world

The main objective of this analysis was to examine the association between the number and types of lifetime Potentially Traumatic Events and chronic physical conditions including arthritic, cardiovascular, respiratory, and chronic pain disorders Data analyzed was from the South African Stress and Health (SASH) study

Methods Details methods of the SASH have been published previously 4315 people were interviewed in randomly selected households mapped in accordance with South African Census Enumeration Areas The resulting dataset was weighted to reflect the general population

Methods 27 PTEs were examined, in eight categories based on the WHO CIDI, as presented previous work by Williams et al (2004) and Atwoli et al (2013) Physical health was assessed for five categories- Cardiovascular, Arthritis, Respiratory, Chronic pain and Others Demographic factors assessed included sex, age, marital status, education, employment status and race

Methods Rao-Scott chi-square tests were used to determine whether demographic groups reported statistically significant differences in the frequency of previous year physical conditions, as well as the number of cumulative reported PTEs The Cochran-Armitage test for trend was used to examine whether the binomial proportions of physical conditions were statistically significantly different with each cumulative PTE Logistic regression models were then used to measure the association between trauma exposure and occurrence of chronic physical conditions

Results The most commonly reported physical condition was chronic pain (46.6%) Up to 60.2% of the sample reported having at least one physical condition Female respondents reported a higher prevalence of all conditions except respiratory conditions Other associations are as shown in the table

Any PTE exposure increased odds of all examined physical conditions PTEs differed in association with individual physical conditions

The odds of developing any physical condition increased with the number of PTEs experienced This trend also held for individual physical conditions

Key points This is the first study to comprehensively assess occurrence of physical conditions after PTE exposure, and the findings of robust associations should guide interventions chronic diseases Our findings concur with previous cross-national work by several researchers, including in World Mental Health Survey series Sexual and physical violence, unexpected death of a loved one and network events were most 'toxic'- (compare with witnessing for PTSD in South Africa) War events were associated with smallest number of physical conditions, perhaps due to 'healthy warrior' effect

Conclusions PTE exposure appears to be a risk factor for chronic physical conditions in the SA population There's a dose-response relationship between PTE exposure and risk of chronic ill health Assessment and interventions for trauma survivors must include physical health considerations