The Effect Of Adverse Childhood Experiences On Activities Of Daily Life Among Chinese Middle-aged And Older Adults Based On Marginal Structural Model

ObjectiveThis study aimed to classified the latent class of adverse childhood experiences(ACEs)and clarify the relationship of ACE classes and activities of daily life(ADL)disability among Chinese middle-aged or elderly people,as well as their differences in gender,age and residence to provide scientific evidences of preventing ADL disability.MethodsThe data was from 2011～2018 waves of China Health and Retirement Longitudinal Study(CHARLS),which is a national representative cohort study of Chinese adults aged 45+years.ACEs were measured by the Adverse Childhood Experiences International Questionnaire(WHO-IQ),including abuse(physical abuse,emotional abuse),neglect(physical neglect,emotional neglect),household dysfunction(alcohol and/or drug abuser in the household,incarcerated household member,household member chronically depressed and/or mentally ill,household member being treated violently,and one or no parents,parental separation or divorce),and living surroundings(bullying,disharmony in community).ADL disability was measured using the Katz Index,and the people who need help when did any of the 6 ADL was defined as ADL disability.Life styles,chronic diseases and depressive symptoms were considered as mediators.Life styles included two indicators:self-reported tobacco usage status and alcohol usage.Chronic diseases were measured by numbers of 14 physicians diagnosed chronic diseases.Depressive symptom was measured by the 10item Center for Epidemiologic Studies Depression Scale and depression was indicated when the score≥10.T test,Chi-square test,ANOVA or rank sum test were employed in univariate analysis.Latent Class Analysis(LCA)was used to identify the classes of ACEs,and Bayesian information criterion(BIC)was employed as criterion in choosing the adequate numbers of latent classes.Total effect and controlled direct effect of classes of ACEs on ADL disability,as well as the differences in gender,age and residence,were estimated by generalized estimating equation(GEE)and marginal structural model(MSM),respectively.ResultsA total 7533 objectives were included in this study after excluding the people who were loss to follow-up or had any missing information on ACEs,mediators or ADL disability.In the 2013,2015 and 2018 waves,the prevalence of ADL disability were 11.42%,15.56%and 16.95%,respectively.The people who lived in rural and female had a higher rates of ADL disability than the people who lived in urban and male(P<0.001),respectively.The age of the people with ADL disability were older than the counterpart(P<0.001).The people who smoked or did not drink were more tend to be ADL disability.The prevalence of ADL disability was higher with the increased numbers of chronic diseases.Moreover,the people who have experienced physical neglect,emotional neglect,household member chronically depressed and/or mentally ill,bullying or disharmony in community had higher risk of ADL disability in the waves of 2013,2015 and 2018.The risk of ADL disability was higher in the people who have experienced physical abuse,emotional abuse or household member being treated violently in the waves of 2013 and 2015.Regarding to the result of LCA,three latent classes of ACE("low ACE","household dysfunction and bulling",and "child maltreatment")were identified.The majority of population were classified into "low ACE"(83.23%),followed by"household dysfunction and bulling"(9.88%)and "child maltreatment"(6.89%).The class characteristics were similar for different gender,age or residence,but the posterior probabilities of each types of ACE were different.Based on the analysis of GEE and MSM,comparing to the "low ACE" class,the"household dysfunction and bulling" class and "child maltreatment" class were more tend to be ADL disability(RR=1.50,95%CI:1.34-1.67,RR=1.19,95%CI:1.041.35).After accounting for the mediators appropriately,the "household dysfunction and bulling" class still have a higher risk of ADL disability(RR=1.40,95%CI:1.11-1.76),while "child maltreatment" did not significantly different from the "low ACE" class in the risk of ADL disability(RR=1.02,95%CI:0.82-1.27).Comparing to the "low ACE" class,the "household dysfunction and bulling" class respectively had 42%,24%or 66%higher odds of ADL disability,while "child maltreatment" class did not significantly different from the "low ACE" class in the risk of ADL disability among males,the people who were ≥60 years old or living in urban.After accounting for the mediators appropriately,the "household dysfunction and bulling" class did not have higher odds of ADL disability than the "low ACE" class.In females,the people who were 45～59 years old or living in rural,the "household dysfunction and bulling" class respectively had 46%,59%and 37%higher risk of ADL disability,while "child maltreatment" class had 23%,30%and 20%higher odds of ADL disability,respectively.After accounting for the mediators appropriately,the"household dysfunction and bulling" class still had 34%,44%and 50%risk of ADL disability respectively,while "child maltreatment" class did not significantly different from the "low ACE" in risk of ADL disability.ConclusionsThis study classified the types of ACE into three latent classes("low ACE","household dysfunction and bulling" and "child maltreatment").Comparing to the "low ACE" class,the "household dysfunction and bulling" class and "child maltreatment"class had a higher risk of ADL disability,but the odds of "household dysfunction and bulling" class on ADL disability were larger than the "child maltreatment" class.After controlling the mediators(life styles,numbers of chronic diseases and depression),the"household dysfunction and bulling" class still more tend to be ADL disability than"low ACE" class.The results indicated that preventing "household dysfunction and bulling" and "child maltreatment" could decrease the risk of ADL disability in early life,and implementing interventions to life style,chronic diseases and depression in late life could decrease or offset the effect of ACEs on ADL disability.The relationship of ACEs and ADL disability were different from different gender,age and residence.Among males,the people who were ≥60 years old or living in urban,"child maltreatment" class did not have a higher risk of ADL disability comparing to the "low ACE" class,and mediators could totally explain the relationship of "household dysfunction and bulling" class and ADL disability.Among females,the people who were 45～59 years old or living in rural,"child maltreatment" class had a higher risk of ADL disability comparing to the "low ACE" class and mediators could totally explain the associations,but mediators could not totally explain the relationship of "household dysfunction" and ADL disability.The results indicated that precautions of targeted in reducing ACEs in early life may be beneficial in preventing ADL disability,but gender-,age-and residence-specific prevention should be considered.