BMI greater than 30 at the time of interview was related to history of a decreased number of TBIs per person, greater frequency and severity of CSA, having attempted suicide, and decreased frequency and severity of CPA, adjusting for current smoking, depression, currently using SSRIs, and age. However, because the power analysis was based on design and methods of original studies, findings must be interpreted with caution due to limited power. Yet, this study does provide critical information upon which to base further scholarly inquiry.
Because this model explained 42% of the variance, there are other factors contributing to why one might be obese that have not been measured here. They might include numerous variables such as hormonal, metabolic, environmental, and lifestyle behaviors; all of which could be related to BMI of patients in rehabilitation.
These findings are consistent with reports of others who documented obesity related to previous maltreatment (Hollingsworth, Callaway, Duhig, Matheson & Scott, 2012; Shin & Miller, 2012) and suicide attempts (Klinitzke et al., 2013). However, this study provides new information regarding TBI and obesity when adjusting for these related variables.
Strengths and limitations
Though one might suspect that prison inmates are not reliable sources of information, studies indicate congruence between prisoner self-reports and other records (Brewer-Smyth et al., 2004; Schofield, Butler, Hollis & D'Este, 2011). Reporting false information for secondary gain was limited or eliminated based on federally required informed consent for studying prison inmates and certificates of confidentiality (Brewer-Smyth, 2008). For example, informed consents must clearly include in advance that participation in research has no effect on parole. A confidentiality certificate issued by the National Institutes of Health (NIH) protected identifiable research information from forced disclosure. Prisons can be reliable settings for research because many variables are controlled by the system. Furthermore, childhood abuse self-reports have been reported to be reliable in longitudinal studies (Pereira da Silva & da Costa Maia, 2013).
Causation cannot be determined by this retrospective cross-sectional study. Initial studies are preferable to secondary analysis. However, this design is less costly and time consuming than longitudinal studies, and randomizing into conditions of this study cannot be considered for clinical trials. Critical information is gained from these findings to inform future inquiry.
Obesity is a serious, complex problem that will not be alleviated by teaching patients about diet and exercise, as most people know they should not smoke, abuse alcohol or other substances, overeat, or live a sedentary lifestyle. Yet the population in general does not do what they know they should do. Though every effort must be made to assist patients in understanding how to limit obesity with all available resources (CDC, 2013c), nurses also need to understand that obesity may be the result of dietary self-medication of painful previous experiences including childhood physical and emotional trauma.
Obese individuals are accessing health care including acute and long-term rehabilitation at increasing rates. Rehabilitation nursing involves much more than bowel, bladder, and physical mobility. Rehabilitation nurses are in a critical position to help stop the revolving door for patients with comorbidities associated with obesity that could require frequent readmissions.
Obese females who access rehabilitation facilities for any reason, especially due to injuries that occur during suicide attempts, need to be evaluated for other underlying etiologies such as previous physical and emotional trauma including CSA. Experiencing child abuse has been associated with an increased risk of poor physical health outcomes in adulthood including neurological, musculoskeletal, respiratory, cardiovascular, and metabolic disorders (Wegman & Stetler, 2009); all of which could increase the likelihood of child abuse survivors requiring rehabilitation resources.
Obesity is a particularly critical problem for females who had attempted suicide that was frequently reported to have been committed because of poor self-esteem and lack of regard for self after having been a victim of abuse. Because the vast majority of suicide attempts committed by these adult females had occurred during their teen years after having been a victim of childhood abuse, these findings are particularly applicable for pediatric nurses. Some participants reported that they denied having been abused when asked by healthcare workers at the time of their injury because they either feared the abuser or the abuser was perceived to be their only source of financial support. Some denied having been abused when asked by this investigator, then reported otherwise in response to abuse scale questions; suggesting that they had grown accustomed to abusive behaviors that they perceived to be normal. Building a trusting relationship is critical to obtaining self-reports of abuse.
Nurses need to be aware of their state laws and resources available within their state, while being vigilant in identifying signs and symptoms of abuse and self-harm. Overviews of suicide prevention in youth populations have been reported (Amitai & Apter, 2012; Cooper, Clements & Holt, 2011). Yet, further research is needed to evaluate and compare the effectiveness of interventions.
Rehabilitation nursing should begin in critical care settings, progress to acute rehabilitation settings, and continue into longer-term rehabilitation and community follow-up. Yet funding and other barriers may prevent patient access to rehabilitation nurses. Though TBI and other neurological abnormalities were prevalent in 95% of this female prison population, the vast majority had never been in a rehabilitation setting, nor had they ever seen a rehabilitation nurse. Unfortunately, as mental health facilities that once housed individuals with long-term neurological and other mental health conditions have closed, prison systems seem to be the main alternative for those in need of some form of neurological rehabilitation. Rehabilitation nurses need to measure and document the critical impact of our skills to justify associated costs and decrease the major public health implications of the epidemic of incarceration (Dumont, Brockmann, Dickman, Alexander & Rich, 2012).
In conclusion, CSA is a serious problem that can precipitate suicide attempts, obesity, and subsequent comorbidities requiring rehabilitation. Laws and procedures for reporting child abuse vary from state to state. Failure to report child abuse could result in large fines in some states such as Delaware. Rehabilitation nurses are uniquely positioned to play a critical role in decreasing associated staggering public healthcare costs by assessing and addressing potential underlying etiologies, making referrals when needed, and reporting abuse to proper authorities.