Exploring the Co-occurrence and Latent Class Analysis of Adverse Childhood Experiences in University Students in Lahore, Pakistan

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This study aims to determine the prevalence and likelihood of the co-occurrence of different childhood adversities and explore the latent classes in university students in Lahore, Pakistan. An online version of the ACE-IQ was used to collect data from students of randomly selected universities in Lahore with their consent. Descriptive statistics, the chi-square test, Cramer-V, and latent class analysis (LCA) were applied to the collected dataset. All domains had a prevalence of between 30 and 85%, with community/peer violence exposure being the most common (82.9%), followed by physical abuse exposure (65.2%). According to the LCA results, three classes were observed, i.e., Class 1, High/Multiple ACEs; Class 2, Low ACEs; and Class 3, Neglect, Physical Abuse and Violence related ACEs. The percentages of our population in Classes 1, 2, and 3 were 21.38%, 39.26%, and 39.36%, respectively. This study concluded that the prevalence of ACEs is very high in university students in Lahore, with a moderately strong correlation among different adversities, which increases the likelihood of their co-occurrence. Biological sciences/Psychology Earth and environmental sciences/Environmental social sciences Health sciences/Health care Adverse Childhood Experiences Co-occurrence Latent Class Analysis Lahore Introduction Adverse childhood experiences (ACEs) are psychosocial factors with a significant impact on all determinants of health. It is a worldwide issue that affects people of all ages, socioeconomic statuses, and cultures 1 . The term ACE is similar to and often used interchangeably with childhood trauma or childhood maltreatment 2 . Traumatic events during childhood include physical and emotional abuse, sexual abuse, mental illness, substance misuse at home, and household dysfunction, such as separation, divorce, domestic violence, or imprisonment 3 . Multiple studies have shown that there is an association between ACEs and health problems in adulthood, such as obesity, mental disorders, high blood pressure 4 , depression, diabetes, irregular sleep patterns 5 , lung cancer, metabolic issues, inflammation, liver diseases 6 , and mental health issues 7 . Children and adolescents who are exposed to multiple types of ACEs are more at risk of developing adult health risk behaviors and diseases since there is a graded link between the scores of ACEs and health outcomes. Maxia Dong, in one of her studies, found a dose-response relationship between the number of adversities experienced as a child and the risk of developing ischemic heart disease in the future 8 . According to recent studies, college students experience high rates of maltreatment and lifelong rates of potentially traumatic incidents. Although the majority of all 18- to 19-year-olds are enrolled in college, there are very few studies on ACEs in college/university students. A study conducted in Ireland looked at childhood adversities in college students and discovered that 35% of them had at least two ACEs. However, in the United States, college students reported between 38% and 53% of lifetime unfavourable events 9 . In terms of public health, ACEs have been connected to HIV risk exposure, lifetime alcoholism, opioid addiction, homelessness 6 early smoking, depressive and anxious states, and early death. Julia Herzog in her study asserted that the effects of early exposure to unpleasant experiences (ACEs) may activate toxic stress during or after ACE exposure and affect children's normal brain development 3 , 10 . ACEs are widely prevalent globally, and some researchers have found that low- and middle-income nations have higher rates of ACEs than high-income countries 4 owing to limited resources and less social health care 11 . Accumulating evidence shows that ACE is now considered a public health concern 5 . For instance, according to a population survey carried out in Mexico by UNICEF in 2016, 63% of children had suffered physical or psychological violence in the year prior. In the US and UK, however, the prevalence of having at least one ACE was 59% and 46%, respectively. In low middle-income countries, where the majority of children and teenagers live, many forms of challenges, or polyvictimization, are more common than in high-income countries, which increases the burden of health issues 4 . The results of the survey indicated that ACEs may have a greater healthcare cost compared to other causes of healthcare utilization. Evidence generally suggests that people with ACEs may need healthcare services more frequently, especially specialized emergency services. Estimates place the lifetime cost per victim at $ 400,533. Half of the ACEs that are checked for are related to child abuse and neglect. A total of 124 billion USD, or 210,012 USD per victim in 2010 currencies, was projected to represent the economic burden associated with these illnesses in 2008 12 . Although there is a dearth of reliable prevalence data for Pakistan, it is estimated that the country's prevalence may be approximately 50% 13,14 . It should be noted that Pakistan has a high proportion of the youthful population, with 70 million children under the age of 18. Many of these children are living in poverty and have high rates of malnutrition, issues such as child labor, and homelessness. It is difficult to discuss this sensitive subject, and it has become socially taboo due to conservative cultural ideas and corporal punishment. This is made worse by a lack of institutional and national financing for child protection, as well as a lack of knowledge in this area, all of which contribute to an atmosphere where children are exposed to abuse 1 . There is no previous study performed in Pakistan that focused on the co-occurrence of multiple childhood adversities or their correlation. This study aims to determine the prevalence of ACEs in university students in Lahore, Pakistan, and their correlations with each other along with a Latent Class Analysis. In the cultural prospect of this region, the co-occurrence of multiple ACEs is very common as some of them have become a part of the societal norms and family system. This study will provide a better understanding of patterns of Adverse Childhood Experiences and help policymakers in planning prevention campaigns in the future. Materials and Methods Setting and data collection: A random sampling method was used, by a system-generated list, to select three universities in Lahore, Pakistan. Subsequently, an online version of the ACE International Questionnaire (ACE-1Q) was circulated among various departments within these universities. The study included students from different educational levels, and a stratified sampling technique was employed to ensure the selection of students for data collection, thereby guaranteeing a representative sample across various education levels within the student population. Subsequently, students were randomly selected from each group, ensuring the study's accurate representation of the entire student population. In order to confirm their voluntary participation in the study and informed consent for the researchers to use their data in a confidential and anonymous manner, online written consent was obtained from all participants prior to their participation in the study. The questionnaire utilized in this research incorporated a consent statement as the first question, wherein participants were required to indicate their agreement to participate in the study before proceeding with the survey. Only responses from participants who provided explicit consent were included in the analysis. Since this is a sensitive subject from a cultural standpoint, the online ACE-IQ version was employed to protect participants' privacy and confidentiality. These were the universities that were chosen: University of Lahore University of Central Punjab The University of Punjab. Study design and sample size: The design of a cross-sectional study was utilized to determine the prevalence of ACEs as it is the most appropriate study design to find the prevalence of any issue in a large population size 1 . The target audience totalled more than 100,000 people. The confidence interval was chosen to be 95%, and the standard deviation was chosen to be 5% to determine the suitable sample size. The calculation determined that a sample size of 289 students was necessary; however, to account for data collection errors, we used a sample size of 309 students. Data collection tool: The prevalence of ACEs was determined using the World Health Organization's preapproved and reliable ACE-IQ questionnaire. A total of 41 items make up the ACE-IQ, which includes demographic data, details about marriage, relationships with parents and guardians, family environments, and personal experiences with abuse, violence, and peer and community violence. Statistical analysis: To calculate the prevalence of ACEs, descriptive statistics were employed to analyse the quantitative data gathered through questionnaires. The analysis of the ACE-IQ was conducted following WHO guidelines, which required the researchers to score each respondent's ACEs before calculating the prevalence and percentage of each ACE domain in the study population. The data were further analysed by cross-tabulation and chi-square tests to determine the relationship between the occurrences of different ACEs. For latent class analysis, we employed the most useful statistical R package version 4.2.3. This analysis included both the Cramer V and latent class analysis. Cramer’s V quantifies associations among several categorical variables, such as emotional neglect, physical neglect, witnessing domestic violence, and mental illness at home, corresponding to physical abuse, sexual abuse, bullying, and peer/community violence, respectively. Furthermore, the LCA method was applied to multiple variables that identified three latent classes. The LCA variables consisted of emotional neglect, physical neglect, substance abuse at home, mental illness at home, incarceration of a family member, parental divorce, parental death, witnessing domestic violence, physical abuse, sexual abuse, bullying, exposure to war, and peer/community violence. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethical considerations: Before data collection, all study participants provided informed written consent. According to the online version of the ACE questionnaire, only participants who fully comprehend the topic and are willing to participate should fill out the questions. Before it began, the study project was fully explained to the participants. The World Health Organization-approved protocol was meticulously adhered to, and the study only included adults. In accordance with ethical standards and guidelines, all methods described in this study were conducted following the principles outlined in the Helsinki Declaration and in compliance with relevant regulations and institutional policies. Before beginning this study, an institutional review board (IRB) letter (Ref no. D/42/FIMS) was obtained from the institutional review board of the University of Punjab. Results Each response form was scored, and the frequency and percentage values for each domain were then used to determine the prevalence of every category of adverse childhood experiences. All domains had a prevalence that ranged from 30 to 85%, with community/peer violence exposure being the highest at 82.9% and physical abuse exposure coming in at 65.2%. There were 97.73% of participants with at least one ACE score, 93.52% with at least two ACE scores, and 80.25% with at least three ACE scores. A total of 69.57% (CI, 95%) of participants had four or more ACEs. Frequency estimation was used to measure the participants' demographics. Table no.1 Demographics of study participants No. Characteristic Frequency Percentage 1 Gender Female Male Prefer not to say 184 122 3 61% 38% 1% 2 Employment status Government employee Nongovernment employee Self employed Student only Missing value 4 36 30 237 2 1.3% 11.7% 9.7% 76.5% 0.8% 3 Marital status Married Never married Missing 30 278 1 9.7% 90.3% 0.0% Table No. 2 Prevalence of subcategories of Adverse Childhood Experiences in the study population No Adverse experience Frequency Percent 1 Physical Neglect 94 30.3% 2 Emotional neglect 189 61.2% 3 Sexual abuse 89 28.8% 4 Emotional abuse 167 54.2% 5 Divorce/separation of parents 21 6.8% 6 Death of either of the parents 41 13.3% 7 Witnessing domestic Violence 208 67.1% 8 Exposure to someone with substance abuse problem 14 4.5% 9 Mental illness at home 53 17.2% 10 Having a family member incarcerated 19 6.1% 11 Physical abuse 202 65.2% 12 Bullying 177 57.1% 13 Community/Peer Violence 257 82.9% 14 Exposure to war or terrorism 63 20.3% Co-occurrence of Adverse Childhood Experiences: The likelihood of different childhood adversities co-occurring in our study population was determined by applying the chi-square test to find the association between different adversities, and the strength of the association between these experiences, i.e., physical abuse, sexual abuse, bullying, peer violence, and emotional neglect, physical neglect, witnessing domestic violence, and mental illness at home, was determined by applying the Cramer-V test. The results are shown in Tables 3 and 4 . Table 3 Likelihood of co-occurrence between different Adverse Childhood Experiences with a substantial p-value (0.05 or less). Independent adversities Dependent adversities Physical abuse Sexual abuse Bullying Peer/Community violence Emotional neglect Yes No Yes No Yes No Yes No Yes No f % f % f % f % f % f % f % f % 146 47.2 56 18.1 43 13.9 64 20.8 62 20.1 26 8.4 126 40.8 94 30.4 116 37.5 61 19.7 73 23.6 59 19.1 157 50.8 100 32.4 32 10.4 20 6.5 Physical neglect Yes No 73 23.6 129 41.7 21 6.8 86 27.8 39 12.6 49 15.9 55 17.8 165 53.4 59 19.1 118 38.2 35 11.3 97 31.4 84 27.2 173 56.0 10 3.2 42 13.6 Witnessed domestic violence Yes No 167 54 35 11.3 41 13.3 66 21.4 68 22.0 20 6.5 140 45.3 80 36.4 131 42.4 46 14.9 77 24.9 55 17.8 181 58.6 76 24.6 27 8.7 25 8.1 Mental illness at home Yes No 45 14.6 157 50.8 8 2.6 99 32 29 9.4 59 19.1 24 7.8 196 63.4 37 12.0 140 45.3 16 5.2 116 37.5 43 13.9 214 69.3 10 3.2 42 13.6 These results show that physical abuse, bullying, and peer violence adversities have a likelihood of co-occurrence with emotional neglect and witnessing domestic violence, whereas sexual abuse has the likelihood of co-occurrence with emotional neglect, physical neglect, and witnessing domestic violence. The result of the Cramer-V test shows that there is a weak to moderate association between the selected experiences in our dataset, as shown in Table 4 . Table 4 Results of the Cramer-V test Physical abuse Sexual abuse Bullying Peer/Community violence Emotional neglect 0.313 0.120 0.104 0.003 Physical neglect 0.171 0.191 0.073 0.109 Witnessing domestic violence 0.45 0.134 0.165 0.148 Mental illness at home 0.187 0.265 0.115 0.025 Latent Class Analysis: To further study the co-occurrence or grouping of certain adversities within our dataset, a latent class analysis test was applied, and as a result, the data were divided into three different classes, as shown in Table 5 . According to the estimated probabilities, Class 1 exhibits High/Multiple ACEs, Class 2 includes Low ACEs and Class 3 has Neglect, Physical Abuse, and Violence-related ACEs. The percentages of our population in Classes 1, 2, and 3 were 21.38%, 39.26%, and 39.36%, respectively. Table 5 Results of Latent Class Analysis (LCA) No. Variables Class 1 Class 2 Class 3 1 Emotional neglect 0.80 0.34 0.77 2 Physical neglect 0.45 0.18 0.33 3 Substance abuse at home 0.17 0.01 0.004 4 Mental illness at home 0.51 0.02 0.12 5 Incarcerated family member 0.26 0.00 0.01 6 Divorce/separation of parents 0.26 0.00 0.02 7 Death of either of the parents 0.22 0.19 0.02 8 Witnessing domestic violence 0.80 0.37 0.89 9 Physical abuse 0.84 0.20 1.00 10 Sexual abuse 0.68 0.09 0.25 11 Bullying 0.69 0.41 0.66 12 Community violence 0.83 0.76 0.89 13 Exposure to war 0.41 0.13 0.15 Discussion For decades, the factors related to the health of human beings have been rigorously studied. In today's world, most diseases have been studied with well-established causation factors, and more advanced treatment options are being researched. However, in the modern research domain, focus has been diverted towards the exploration of distal and indirect factors that may lead to the development of chronic diseases in the long term 2 – 4 . One such factor being studied over the past two decades is childhood adversities 16 . The Centres for Disease Control has defined adverse childhood experiences (ACEs) as being exposed to any of the following categories: childhood physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, substance abuse in the household, mental illness in the household, having a family member incarcerated, divorce or separation of parents, death of either of parents, witnessing domestic violence, bullying, peer or community violence, and war 17 . Recent studies have concluded that ACEs are a major public health concern, as they act as predisposers of many chronic diseases in adult life, e.g., heart diseases, lung diseases, respiratory diseases, gastrointestinal diseases, sexual/reproductive diseases, mental health diseases, and the development of social health disorders and behavioural problems that may start early in the victim's life 2 . There is a growing body of research on the consequences of ACEs around the globe, including diverse races and ethnicities 18 . Unfortunately, in Asian countries such as Pakistan, studies in this area are very scarce. A few studies have been performed, but most of them include the female population 14 . Our study targeted the young population, i.e., university students, as this age group makes up the majority of our population, and they can comprehend and provide the most appropriate data. Globally, there are a few studies on university students, and they show that the prevalence of ACEs is high among them 13 , 15 , 19 . Our study included both male and female students enrolled in 3 major universities in Lahore selected through a random sampling method. The results of our study indicate a potentially high prevalence of ACEs compared to previous studies performed in Pakistan. Almost 80% of the sample population had experienced 3 or more ACEs, which is a cut-off point indicated in global studies for a high risk of developing health and behavioural issues later in life 20 . The most prevalent categories of ACEs in this study population were exposure to community/peer violence (82.9%) and exposure to physical abuse (65.2%). Apart from the high prevalence rates, another important aspect of this study was the determination of correlation between various categories inside the broad term of adverse childhood experiences, which has been studied in a few studies, indicating that some of the childhood adversities co-occur due to positive correlation between them 21 – 23 . Our study data indicated that there is a moderately positive correlation between emotional neglect, witnessing domestic violence, physical abuse, and sexual abuse. Physical neglect was also found to be mildly and positively correlated with physical abuse, sexual abuse, and peer/community violence. Exposure to witnessing domestic violence was positively correlated with physical abuse, sexual abuse, and bullying and peer/community violence. According to the results of the latent class analysis, there were three classes in our dataset, i.e., high/multiple ACEs, low ACEs, and neglect- and violence-related ACEs. These results are consistent with previously performed studies internationally 24 – 26 . Limitation and Strength: The limitations of this study include a small sample size. The strength of this study is that it is the first study of its kind focusing on the correlation among different childhood adversities and their latent class analysis performed in Pakistan. Conclusion This study concluded that the prevalence of ACEs is very high in university students in Lahore, with a moderately strong correlation among different adversities, which may increase the likelihood of their co-occurrence. Further studies should provide a better understanding of their relationship to obtain insights into their prevention. Declarations Acknowledgements: We would like to thank our study participants for their cooperation and for allowing us to collect data from them. Competing interests: None Funding source: This was a self-funded study and was not funded by any source. Consent to participate: The purpose of the study was explained to the participants, and those who gave consent to participate in the study were included in the research. Consent for publication: All authors have approved the final version of the manuscript to be published. Availability of data and material: Data are available upon request to the corresponding author. Author Contributions: RF: conceptualization; methodology; data curation; formal analysis; writing original draft preparation JS: conceptualization; methodology; data curation; validation; supervision MI: conceptualization; methodology; formal analysis; data curation; supervision ZA: formal analysis; data curation; writing review and editing FI: methodology; resources; writing review and editing GMJB: methodology; resources; writing review and editing JF: methodology; resources; writing review and editing SM: methodology; data curation; writing review and editing GA: formal analysis; data curation; writing review and editing Corresponding author Gholamreza Abdi Department of Biotechnology, Persian Gulf Research Institute, Persian Gulf University, Bushehr, Iran [email protected] References Maul, K. M. et al. Child abuse in Pakistan: A qualitative study of knowledge, attitudes and practice amongst health professionals. Child Abuse & Neglect 88, 51–57 (2019). 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Systematic review and meta-analysis of the effect of adverse childhood experiences (ACEs) on brain-derived neurotrophic factor (BDNF) levels. Psychoneuroendocrinology 151, 106071 (2023). Nelson, C. A., Bhutta, Z. A., Harris, N. B., Danese, A. & Samara, M. Adversity in childhood is linked to mental and physical health throughout life. BMJ 371, m3048 (2020). Additional Declarations No competing interests reported. Supplementary Files ACENEW3.sav HighlightsofACEstudy1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3899456","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":275141269,"identity":"7ddd05d1-6b10-4661-ba42-6a0376257ee4","order_by":0,"name":"Rabia Fatima","email":"","orcid":"","institution":"University of the Punjab","correspondingAuthor":false,"prefix":"","firstName":"Rabia","middleName":"","lastName":"Fatima","suffix":""},{"id":275141270,"identity":"8503fcf1-76c7-45e7-ae15-3992fc25fecf","order_by":1,"name":"Javeria Saleem","email":"","orcid":"","institution":"University of the 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University","correspondingAuthor":true,"prefix":"","firstName":"Gholamreza","middleName":"","lastName":"Abdi","suffix":""}],"badges":[],"createdAt":"2024-01-26 08:46:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3899456/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3899456/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57328476,"identity":"cc06147b-f445-40c9-a7c8-22787e05df14","added_by":"auto","created_at":"2024-05-29 07:48:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":792804,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3899456/v1/1f75d3d7-9200-4ae1-875f-cd77394e5577.pdf"},{"id":51763180,"identity":"892006df-27c9-4e6a-91ed-239ff24267c3","added_by":"auto","created_at":"2024-02-28 17:11:12","extension":"sav","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":7286,"visible":true,"origin":"","legend":"","description":"","filename":"ACENEW3.sav","url":"https://assets-eu.researchsquare.com/files/rs-3899456/v1/a7fac45af8a38eba26e23677.sav"},{"id":51763181,"identity":"1bebdd7a-2f30-4525-927d-622f1d16c384","added_by":"auto","created_at":"2024-02-28 17:11:12","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13168,"visible":true,"origin":"","legend":"","description":"","filename":"HighlightsofACEstudy1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3899456/v1/dc57fb50d6ea6fe442dd4e67.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Co-occurrence and Latent Class Analysis of Adverse Childhood Experiences in University Students in Lahore, Pakistan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdverse childhood experiences (ACEs) are psychosocial factors with a significant impact on all determinants of health. It is a worldwide issue that affects people of all ages, socioeconomic statuses, and cultures\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The term ACE is similar to and often used interchangeably with childhood trauma or childhood maltreatment\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Traumatic events during childhood include physical and emotional abuse, sexual abuse, mental illness, substance misuse at home, and household dysfunction, such as separation, divorce, domestic violence, or imprisonment \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMultiple studies have shown that there is an association between ACEs and health problems in adulthood, such as obesity, mental disorders, high blood pressure\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003c/sup\u003e depression, diabetes, irregular sleep patterns\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003c/sup\u003e lung cancer, metabolic issues, inflammation, liver diseases\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, and mental health issues\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Children and adolescents who are exposed to multiple types of ACEs are more at risk of developing adult health risk behaviors and diseases since there is a graded link between the scores of ACEs and health outcomes. Maxia Dong, in one of her studies, found a dose-response relationship between the number of adversities experienced as a child and the risk of developing ischemic heart disease in the future\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAccording to recent studies, college students experience high rates of maltreatment and lifelong rates of potentially traumatic incidents. Although the majority of all 18- to 19-year-olds are enrolled in college, there are very few studies on ACEs in college/university students. A study conducted in Ireland looked at childhood adversities in college students and discovered that 35% of them had at least two ACEs. However, in the United States, college students reported between 38% and 53% of lifetime unfavourable events\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of public health, ACEs have been connected to HIV risk exposure, lifetime alcoholism, opioid addiction, homelessness\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e early smoking, depressive and anxious states, and early death. Julia Herzog in her study asserted that the effects of early exposure to unpleasant experiences (ACEs) may activate toxic stress during or after ACE exposure and affect children's normal brain development\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eACEs are widely prevalent globally, and some researchers have found that low- and middle-income nations have higher rates of ACEs than high-income countries \u003csup\u003e \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e \u003c/sup\u003e owing to limited resources and less social health care\u003csup\u003e \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e \u003c/sup\u003e. Accumulating evidence shows that ACE is now considered a public health concern\u003csup\u003e \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e \u003c/sup\u003e. For instance, according to a population survey carried out in Mexico by UNICEF in 2016, 63% of children had suffered physical or psychological violence in the year prior. In the US and UK, however, the prevalence of having at least one ACE was 59% and 46%, respectively. In low middle-income countries, where the majority of children and teenagers live, many forms of challenges, or polyvictimization, are more common than in high-income countries, which increases the burden of health issues\u003csup\u003e \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e \u003c/sup\u003e. The results of the survey indicated that ACEs may have a greater healthcare cost compared to other causes of healthcare utilization. Evidence generally suggests that people with ACEs may need healthcare services more frequently, especially specialized emergency services. Estimates place the lifetime cost per victim at \u003cspan\u003e$\u003c/span\u003e400,533. Half of the ACEs that are checked for are related to child abuse and neglect. A total of 124\u0026nbsp;billion USD, or 210,012 USD per victim in 2010 currencies, was projected to represent the economic burden associated with these illnesses in 2008 \u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough there is a dearth of reliable prevalence data for Pakistan, it is estimated that the country's prevalence may be approximately 50% \u003csup\u003e13,14\u003c/sup\u003e. It should be noted that Pakistan has a high proportion of the youthful population, with 70\u0026nbsp;million children under the age of 18. Many of these children are living in poverty and have high rates of malnutrition, issues such as child labor, and homelessness. It is difficult to discuss this sensitive subject, and it has become socially taboo due to conservative cultural ideas and corporal punishment. This is made worse by a lack of institutional and national financing for child protection, as well as a lack of knowledge in this area, all of which contribute to an atmosphere where children are exposed to abuse\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. There is no previous study performed in Pakistan that focused on the co-occurrence of multiple childhood adversities or their correlation. This study aims to determine the prevalence of ACEs in university students in Lahore, Pakistan, and their correlations with each other along with a Latent Class Analysis. In the cultural prospect of this region, the co-occurrence of multiple ACEs is very common as some of them have become a part of the societal norms and family system. This study will provide a better understanding of patterns of Adverse Childhood Experiences and help policymakers in planning prevention campaigns in the future.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting and data collection:\u003c/h2\u003e \u003cp\u003eA random sampling method was used, by a system-generated list, to select three universities in Lahore, Pakistan. Subsequently, an online version of the ACE International Questionnaire (ACE-1Q) was circulated among various departments within these universities. The study included students from different educational levels, and a stratified sampling technique was employed to ensure the selection of students for data collection, thereby guaranteeing a representative sample across various education levels within the student population. Subsequently, students were randomly selected from each group, ensuring the study's accurate representation of the entire student population.\u003c/p\u003e \u003cp\u003e In order to confirm their voluntary participation in the study and informed consent for the researchers to use their data in a confidential and anonymous manner, online written consent was obtained from all participants prior to their participation in the study. The questionnaire utilized in this research incorporated a consent statement as the first question, wherein participants were required to indicate their agreement to participate in the study before proceeding with the survey. Only responses from participants who provided explicit consent were included in the analysis. Since this is a sensitive subject from a cultural standpoint, the online ACE-IQ version was employed to protect participants' privacy and confidentiality. These were the universities that were chosen:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUniversity of Lahore\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUniversity of Central Punjab\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe University of Punjab.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sample size:\u003c/h2\u003e \u003cp\u003eThe design of a cross-sectional study was utilized to determine the prevalence of ACEs as it is the most appropriate study design to find the prevalence of any issue in a large population size\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The target audience totalled more than 100,000 people. The confidence interval was chosen to be 95%, and the standard deviation was chosen to be 5% to determine the suitable sample size. The calculation determined that a sample size of 289 students was necessary; however, to account for data collection errors, we used a sample size of 309 students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection tool:\u003c/h2\u003e \u003cp\u003eThe prevalence of ACEs was determined using the World Health Organization's preapproved and reliable ACE-IQ questionnaire. A total of 41 items make up the ACE-IQ, which includes demographic data, details about marriage, relationships with parents and guardians, family environments, and personal experiences with abuse, violence, and peer and community violence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eTo calculate the prevalence of ACEs, descriptive statistics were employed to analyse the quantitative data gathered through questionnaires. The analysis of the ACE-IQ was conducted following WHO guidelines, which required the researchers to score each respondent's ACEs before calculating the prevalence and percentage of each ACE domain in the study population. The data were further analysed by cross-tabulation and chi-square tests to determine the relationship between the occurrences of different ACEs. For latent class analysis, we employed the most useful statistical R package version 4.2.3. This analysis included both the Cramer V and latent class analysis. Cramer\u0026rsquo;s V quantifies associations among several categorical variables, such as emotional neglect, physical neglect, witnessing domestic violence, and mental illness at home, corresponding to physical abuse, sexual abuse, bullying, and peer/community violence, respectively. Furthermore, the LCA method was applied to multiple variables that identified three latent classes. The LCA variables consisted of emotional neglect, physical neglect, substance abuse at home, mental illness at home, incarceration of a family member, parental divorce, parental death, witnessing domestic violence, physical abuse, sexual abuse, bullying, exposure to war, and peer/community violence. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations:\u003c/h2\u003e \u003cp\u003e Before data collection, all study participants provided informed written consent. According to the online version of the ACE questionnaire, only participants who fully comprehend the topic and are willing to participate should fill out the questions. Before it began, the study project was fully explained to the participants. The World Health Organization-approved protocol was meticulously adhered to, and the study only included adults. In accordance with ethical standards and guidelines, all methods described in this study were conducted following the principles outlined in the Helsinki Declaration and in compliance with relevant regulations and institutional policies. Before beginning this study, an institutional review board (IRB) letter (Ref no. D/42/FIMS) was obtained from the institutional review board of the University of Punjab.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eEach response form was scored, and the frequency and percentage values for each domain were then used to determine the prevalence of every category of adverse childhood experiences. All domains had a prevalence that ranged from 30 to 85%, with community/peer violence exposure being the highest at 82.9% and physical abuse exposure coming in at 65.2%. There were 97.73% of participants with at least one ACE score, 93.52% with at least two ACE scores, and 80.25% with at least three ACE scores. A total of 69.57% (CI, 95%) of participants had four or more ACEs. Frequency estimation was used to measure the participants' demographics.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable no.1 Demographics of study participants\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e184\u003c/p\u003e \u003cp\u003e122\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61%\u003c/p\u003e \u003cp\u003e38%\u003c/p\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003cp\u003eGovernment employee\u003c/p\u003e \u003cp\u003eNongovernment employee\u003c/p\u003e \u003cp\u003eSelf employed\u003c/p\u003e \u003cp\u003eStudent only\u003c/p\u003e \u003cp\u003eMissing value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e36\u003c/p\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e237\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.3%\u003c/p\u003e \u003cp\u003e11.7%\u003c/p\u003e \u003cp\u003e9.7%\u003c/p\u003e \u003cp\u003e76.5%\u003c/p\u003e \u003cp\u003e0.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eNever married\u003c/p\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e278\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.7%\u003c/p\u003e \u003cp\u003e90.3%\u003c/p\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable No. 2 Prevalence of subcategories of Adverse Childhood Experiences in the study population\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdverse experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical Neglect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional neglect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSexual abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorce/separation of parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeath of either of the parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWitnessing domestic Violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposure to someone with substance abuse problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental illness at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHaving a family member incarcerated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBullying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity/Peer Violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposure to war or terrorism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCo-occurrence of Adverse Childhood Experiences:\u003c/h2\u003e \u003cp\u003eThe likelihood of different childhood adversities co-occurring in our study population was determined by applying the chi-square test to find the association between different adversities, and the strength of the association between these experiences, i.e., physical abuse, sexual abuse, bullying, peer violence, and emotional neglect, physical neglect, witnessing domestic violence, and mental illness at home, was determined by applying the Cramer-V test. The results are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLikelihood of co-occurrence between different Adverse Childhood Experiences with a substantial p-value (0.05 or less).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"17\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndependent adversities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"16\" nameend=\"c17\" namest=\"c2\"\u003e \u003cp\u003eDependent adversities\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePhysical abuse\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eSexual abuse\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e \u003cp\u003e\u003cb\u003eBullying\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c17\" namest=\"c14\"\u003e \u003cp\u003e\u003cb\u003ePeer/Community violence\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEmotional neglect\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e\u003cb\u003ef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e146 47.2\u003c/p\u003e \u003cp\u003e56 18.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e43 13.9\u003c/p\u003e \u003cp\u003e64 20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e62 20.1\u003c/p\u003e \u003cp\u003e26 8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e126 40.8\u003c/p\u003e \u003cp\u003e94 30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e116 37.5\u003c/p\u003e \u003cp\u003e61 19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e73 23.6\u003c/p\u003e \u003cp\u003e59 19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e157 50.8\u003c/p\u003e \u003cp\u003e100 32.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003e32 10.4\u003c/p\u003e \u003cp\u003e20 6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical neglect\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e73 23.6\u003c/p\u003e \u003cp\u003e129 41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e21 6.8\u003c/p\u003e \u003cp\u003e86 27.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e39 12.6\u003c/p\u003e \u003cp\u003e49 15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e55 17.8\u003c/p\u003e \u003cp\u003e165 53.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e59 19.1\u003c/p\u003e \u003cp\u003e118 38.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e35 11.3\u003c/p\u003e \u003cp\u003e97 31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e84 27.2\u003c/p\u003e \u003cp\u003e173 56.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003e10 3.2\u003c/p\u003e \u003cp\u003e42 13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWitnessed domestic violence\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e167 54\u003c/p\u003e \u003cp\u003e35 11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e41 13.3\u003c/p\u003e \u003cp\u003e66 21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e68 22.0\u003c/p\u003e \u003cp\u003e20 6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e140 45.3\u003c/p\u003e \u003cp\u003e80 36.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e131 42.4\u003c/p\u003e \u003cp\u003e46 14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e77 24.9\u003c/p\u003e \u003cp\u003e55 17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e181 58.6\u003c/p\u003e \u003cp\u003e76 24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003e27 8.7\u003c/p\u003e \u003cp\u003e25 8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental illness at home\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e45 14.6\u003c/p\u003e \u003cp\u003e157 50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8 2.6\u003c/p\u003e \u003cp\u003e99 32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e29 9.4\u003c/p\u003e \u003cp\u003e59 19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e24 7.8\u003c/p\u003e \u003cp\u003e196 63.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e37 12.0\u003c/p\u003e \u003cp\u003e140 45.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e16 5.2\u003c/p\u003e \u003cp\u003e116 37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e43 13.9\u003c/p\u003e \u003cp\u003e214 69.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003e10 3.2\u003c/p\u003e \u003cp\u003e42 13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese results show that physical abuse, bullying, and peer violence adversities have a likelihood of co-occurrence with emotional neglect and witnessing domestic violence, whereas sexual abuse has the likelihood of co-occurrence with emotional neglect, physical neglect, and witnessing domestic violence. The result of the Cramer-V test shows that there is a weak to moderate association between the selected experiences in our dataset, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of the Cramer-V test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical abuse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSexual abuse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBullying\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeer/Community violence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmotional neglect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical neglect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWitnessing domestic violence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental illness at home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eLatent Class Analysis:\u003c/h2\u003e \u003cp\u003eTo further study the co-occurrence or grouping of certain adversities within our dataset, a latent class analysis test was applied, and as a result, the data were divided into three different classes, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e5\u003c/span\u003e. According to the estimated probabilities, Class 1 exhibits High/Multiple ACEs, Class 2 includes Low ACEs and Class 3 has Neglect, Physical Abuse, and Violence-related ACEs. The percentages of our population in Classes 1, 2, and 3 were 21.38%, 39.26%, and 39.36%, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Latent Class Analysis (LCA)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClass 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClass 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClass 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEmotional neglect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePhysical neglect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubstance abuse at home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMental illness at home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIncarcerated family member\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDivorce/separation of parents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDeath of either of the parents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWitnessing domestic violence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePhysical abuse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSexual abuse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBullying\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCommunity violence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eExposure to war\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor decades, the factors related to the health of human beings have been rigorously studied. In today's world, most diseases have been studied with well-established causation factors, and more advanced treatment options are being researched. However, in the modern research domain, focus has been diverted towards the exploration of distal and indirect factors that may lead to the development of chronic diseases in the long term\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. One such factor being studied over the past two decades is childhood adversities\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The Centres for Disease Control has defined adverse childhood experiences (ACEs) as being exposed to any of the following categories: childhood physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, substance abuse in the household, mental illness in the household, having a family member incarcerated, divorce or separation of parents, death of either of parents, witnessing domestic violence, bullying, peer or community violence, and war\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRecent studies have concluded that ACEs are a major public health concern, as they act as predisposers of many chronic diseases in adult life, e.g., heart diseases, lung diseases, respiratory diseases, gastrointestinal diseases, sexual/reproductive diseases, mental health diseases, and the development of social health disorders and behavioural problems that may start early in the victim's life\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. There is a growing body of research on the consequences of ACEs around the globe, including diverse races and ethnicities\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Unfortunately, in Asian countries such as Pakistan, studies in this area are very scarce. A few studies have been performed, but most of them include the female population\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Our study targeted the young population, i.e., university students, as this age group makes up the majority of our population, and they can comprehend and provide the most appropriate data. Globally, there are a few studies on university students, and they show that the prevalence of ACEs is high among them \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Our study included both male and female students enrolled in 3 major universities in Lahore selected through a random sampling method. The results of our study indicate a potentially high prevalence of ACEs compared to previous studies performed in Pakistan. Almost 80% of the sample population had experienced 3 or more ACEs, which is a cut-off point indicated in global studies for a high risk of developing health and behavioural issues later in life\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The most prevalent categories of ACEs in this study population were exposure to community/peer violence (82.9%) and exposure to physical abuse (65.2%). Apart from the high prevalence rates, another important aspect of this study was the determination of correlation between various categories inside the broad term of adverse childhood experiences, which has been studied in a few studies, indicating that some of the childhood adversities co-occur due to positive correlation between them \u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Our study data indicated that there is a moderately positive correlation between emotional neglect, witnessing domestic violence, physical abuse, and sexual abuse. Physical neglect was also found to be mildly and positively correlated with physical abuse, sexual abuse, and peer/community violence. Exposure to witnessing domestic violence was positively correlated with physical abuse, sexual abuse, and bullying and peer/community violence.\u003c/p\u003e \u003cp\u003eAccording to the results of the latent class analysis, there were three classes in our dataset, i.e., high/multiple ACEs, low ACEs, and neglect- and violence-related ACEs. These results are consistent with previously performed studies internationally \u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitation and Strength:\u003c/h2\u003e \u003cp\u003eThe limitations of this study include a small sample size. The strength of this study is that it is the first study of its kind focusing on the correlation among different childhood adversities and their latent class analysis performed in Pakistan.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study concluded that the prevalence of ACEs is very high in university students in Lahore, with a moderately strong correlation among different adversities, which may increase the likelihood of their co-occurrence. Further studies should provide a better understanding of their relationship to obtain insights into their prevention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe would like to thank our study participants for their cooperation and for allowing us to collect data from them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding source:\u0026nbsp;\u003c/strong\u003eThis was a self-funded study and was not funded by any source.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e The purpose of the study was explained to the participants, and those who gave consent to participate in the study were included in the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eAll authors have approved the final version of the manuscript to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eData are available upon request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRF: conceptualization; methodology; data curation; formal analysis; writing original draft preparation\u003c/p\u003e\n\u003cp\u003eJS: conceptualization; methodology; data curation; validation; supervision\u003c/p\u003e\n\u003cp\u003eMI: conceptualization; methodology; formal analysis; data curation; supervision\u003c/p\u003e\n\u003cp\u003eZA: formal analysis; data curation; writing review and editing\u003c/p\u003e\n\u003cp\u003eFI: methodology; resources; writing review and editing\u003c/p\u003e\n\u003cp\u003eGMJB: methodology; resources; writing review and editing\u003c/p\u003e\n\u003cp\u003eJF: methodology; resources; writing review and editing\u003c/p\u003e\n\u003cp\u003eSM: methodology; data curation; writing review and editing\u003c/p\u003e\n\u003cp\u003eGA: formal analysis; data curation; writing review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGholamreza Abdi\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepartment of Biotechnology, Persian Gulf Research Institute, Persian Gulf University, Bushehr, Iran\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\[email protected]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaul, K. 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BMJ 371, m3048 (2020).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adverse Childhood Experiences, Co-occurrence, Latent Class Analysis, Lahore","lastPublishedDoi":"10.21203/rs.3.rs-3899456/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3899456/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAdverse childhood experiences (ACEs) are one of the major public health concerns and act as a predisposing factor leading to numerous chronic health issues. This study aims to determine the prevalence and likelihood of the co-occurrence of different childhood adversities and explore the latent classes in university students in Lahore, Pakistan. An online version of the ACE-IQ was used to collect data from students of randomly selected universities in Lahore with their consent. Descriptive statistics, the chi-square test, Cramer-V, and latent class analysis (LCA) were applied to the collected dataset. All domains had a prevalence of between 30 and 85%, with community/peer violence exposure being the most common (82.9%), followed by physical abuse exposure (65.2%). According to the LCA results, three classes were observed, i.e., Class 1, High/Multiple ACEs; Class 2, Low ACEs; and Class 3, Neglect, Physical Abuse and Violence related ACEs. The percentages of our population in Classes 1, 2, and 3 were 21.38%, 39.26%, and 39.36%, respectively. This study concluded that the prevalence of ACEs is very high in university students in Lahore, with a moderately strong correlation among different adversities, which increases the likelihood of their co-occurrence.\u003c/p\u003e","manuscriptTitle":"Exploring the Co-occurrence and Latent Class Analysis of Adverse Childhood Experiences in University Students in Lahore, Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-28 17:11:07","doi":"10.21203/rs.3.rs-3899456/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ad57fc4-5451-4476-acfd-083dc9a2562d","owner":[],"postedDate":"February 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28996803,"name":"Biological sciences/Psychology"},{"id":28996804,"name":"Earth and environmental sciences/Environmental social sciences"},{"id":28996805,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2024-05-29T07:40:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-28 17:11:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3899456","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3899456","identity":"rs-3899456","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}