Abstract
BACKGROUND: Previous research has suggested that there is a certain degree of relationship between adverse childhood experiences (ACEs) and chronic diseases and their comorbidities. However, the association between ACEs and health poverty vulnerability, along with the role played by chronic diseases and their comorbidities in this context, has been scarcely investigated. Therefore, this study aims to explore whether ACEs are related to the health poverty vulnerability of middle-aged and elderly people in rural Ningxia and whether chronic diseases and their comorbidities mediate the association between them. METHODS: A total of 5,533 valid samples were included from the 2024 Ningxia Rural Residents’ Health Status and Health Service Utilization Survey data. Pearson’s test was applied to investigate the relationships among the key variables. Regression models were used to examine the mediating effects of chronic diseases and their comorbidities, and the Sobel test and the bootstrap method were used to determine the final path effects. Following the mediation analysis, a moderated mediation model was further examined to investigate the moderating effect of depression on the mediating mechanism. Additionally, to assess the robustness of the association between ACEs and health poverty vulnerability, we conducted multiple sensitivity analyses. These included E-values, missing data simulation, boundary analysis, and bias factors. RESULTS: There was a significant correlation between ACEs, chronic diseases and their comorbidities and health poverty vulnerability (p < 0.001). ACEs are directly associated with health poverty vulnerability (β = 0.0177, p < 0.001). ACEs are significantly associated with chronic diseases and their comorbidities (β = 0.0904, p < 0.001), whereas chronic diseases and their comorbidities have a significant association with health poverty vulnerability (β = 0.0256, p < 0.001). Chronic diseases and their comorbidities partially mediated the correlation of ACEs on health poverty vulnerability (β = 0.0023, p < 0.001). The Sobel test and bootstrap method validated the robustness of the regression analysis results. The moderated mediation model analysis revealed that while the moderating effect was not significant, the mediating effect remained significant across different levels of depression. Multiple sensitivity analyses consistently indicate that the positive correlation between ACEs and health poverty vulnerability exhibits robust stability. CONCLUSION: ACEs are significantly positively associated with health poverty vulnerability, and chronic diseases and their comorbidities mediate this relationship. Our research findings indicate that prevention strategies for the health poverty vulnerability of middle-aged and elderly individuals should focus on creating a positive childhood environment and developing comprehensive strategies for integrating medical and preventive care for chronic diseases. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-026-26298-4.