Association of adverse childhood experiences with health service use and catastrophic health expenditures in China - evidence from the China Health and Retirement Longitudinal Study

Q: What data and sample size were used in the study?

Data were drawn from CHARLS, collected in 2014 and 2015, with a sample size of 11,072 participants.

Q: How were associations between ACEs and health service use assessed?

Zero-inflated negative binomial regression was used to assess associations with the number of outpatient visits and inpatient hospital days.

Q: Did chronic diseases mediate the relationship between ACEs and catastrophic health expenditures?

Yes. Chronic diseases served as a mediating factor between ACEs and CHE, with reported ACME (0.000904, P=0.03) and ADE (0.00813, P<0.001).

Sep 30, 2026

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Associations between adverse childhood experiences (ACEs) and catastrophic health expenditures (CHEs) among middle-aged or older Chinese individuals remain inadequately documented, and the contribution of chronic diseases is not fully understood. Using data from the China Health and Retirement Longitudinal Study (CHARLS), the study evaluates links between ACEs and hospital visits and medical spending, and tests chronic diseases as a mediator through mediation analysis.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

AccessFree to download

Introduction

Abstract

Background

Methods

Results

Conclusions

Keywords

Environmental Health and Preventive Medicine Environmental Health and Preventive Medicine (2026) 31:1 [https://doi.org/10.1265/ehpm.25-00012](https://doi.org/10.1265/ehpm.25-00012) | RESEARCH ARTICLE | | | --- | --- | | Association of adverse childhood experiences with health service use and catastrophic health expenditures in China: evidence from the China Health and Retirement Longitudinal Study
Shiyu Xie1,3†, Siying Yu2,4,5,6†, Yue Ma7, Jing Luo7, Yonghui Zhang3 , Rui Wang3, Yafei Wang4,5,6, Yuling Wang4,5,6** and Xueqiang Wang3* | | | *[Correspondence:](Correspondence: wangxueqiang@wmu.edu.cn)[ wangxueqiang@wmu.edu.cn](Correspondence: wangxueqiang@wmu.edu.cn)
**[Correspondence:](Correspondence: wangyul@mail.sysu.edu.cn)[ wangyul@mail.sysu.edu.cn](Correspondence: wangyul@mail.sysu.edu.cn)
†These authors have contributed equally to this work and share ﬁrst authorship.
1Department of Basic Teaching, Shanghai Urban Construction Vocational College, Shanghai, 201415, China. 2Department of Cardiology, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, 518052, China. 3Rehabilitation Medicine Center, The Second Aﬃliated Hospital of Wenzhou Medical University, Wenzhou, 325027, China. 4Department of Rehabilitation Medicine, The Sixth Aﬃliated Hospital of Sun Yat-sen University, Guangzhou, 510655, China. 5Guangdong Provincial Clinical Research Center for Rehabilitation Medicine, Guangzhou, 510655, China. 6Biomedical Innovation Center, The Sixth Aﬃliated Hospital, SunYat-sen University, Guangzhou, 510655, China. 7Department of Sport Rehabilitation, Xi’an Physical Education University, Xi’an, 710068, China. | | | Abstract
Backgrounds: Associations between adverse childhood experiences (ACEs) and catastrophic health expenditures (CHEs) among middle-aged or older Chinese individuals remain inadequately documented. In addition, the role of chronic diseases is not entirely clear. This study used data from the China Health and Retirement Longitudinal Study (CHARLS) to investigate the association of ACEs with hospital visits and medical expenditures and the mediating eﬀect of chronic diseases.
Methods: Data were collected from CHARLS in 2014 and 2015 (N = 11,072) . Zero-inﬂated negative binomial regression was used to assess associations of the ACEs with the number of outpatient visits and inpatient hospital days. Logistic regression was used to assess associations between the ACEs and CHEs. The inﬂuence of chronic diseases was examined through mediation analysis.
Results: The prevalence of each ACE indicator ranges from 0 .27%(incarcerated household member) to 31 .5%(emotional neglect) . Our analysis revealed a signiﬁcant dose-response relationship between cumulative ACE score and CHEs (P for trend < 0.001), but not for the number of outpatient visits and inpatient hospital days. The average causal mediation eﬀects (ACME) and average direct eﬀects (ADE) are presented. Chronic diseases served as a mediating factor between ACEs and CHE (ACME = 0.000904, P = 0.03; ADE = 0 .00813, P < 0 .001) .
Conclusions: ACE has the capacity to predict CHE, and the ﬁndings of this study reinforce the potential pathway through which ACE may exert its inﬂuence on CHE via the burden of chronic diseases. Measures should be implemented to prevent ACEs and mitigate the risk of chronic diseases to lessen the economic burden on individuals and families as well as the adverse impact of national ﬁnancial risk.
Keywords: Adverse childhood experiences, Catastrophic health expenditures, Child abuse, Epidemiology, Financial stresses, Mediation | | | Introduction | Many studies suggest that ACEs are associated with several long-term adverse health outcomes [4], including de- | | Adverse childhood experiences (ACEs) are potentially | mentia [5], cardiovascular diseases [6], and mental health | | traumatic events that occur during youth. These events | problems, such as borderline personality disorder and | | are clas

FAQs

What data and sample size were used in the study?

Data were drawn from CHARLS, collected in 2014 and 2015, with a sample size of 11,072 participants.

How were associations between ACEs and health service use assessed?

Zero-inflated negative binomial regression was used to assess associations with the number of outpatient visits and inpatient hospital days.

Did chronic diseases mediate the relationship between ACEs and catastrophic health expenditures?

Yes. Chronic diseases served as a mediating factor between ACEs and CHE, with reported ACME (0.000904, P=0.03) and ADE (0.00813, P<0.001).

Sep 30, 2026

Uploaded by Hazel