| ObjectiveThe purpose of this study was to elucidate the impact of bereavement on the risk of stroke in middle-aged and elderly people in China.From the perspective of causal inference,this paper analyzes the natural direct effects of bereavement on the onset of stroke and the mediating effects of depression,and their difference in different gender and level of education,then clear the time-effect and dose-response relationship between the bereavement and risk of stroke,provide a scientific basis for prevention and intervention of the onset of stroke.MethodsData was derived from the 2011-2015 wave of the China Health and Retirement Longitudinal Study.The study population was aged 45 and over.Bereavement includes four kinds of bereavement types:spouse death,child death,parental death,and sibling death.Stroke was assessed through self-or proxy-reported physician diagnosis.Depression was measured by the 10-item Center for Epidemiologic Studies Depression Scale(CES-D-10).Descriptive analysis of stroke and bereavement was performed using ?2 test and t test;the direct and indirect effects of bereavement on the risk of stroke were analyzed based on the Marginal Structural Model(MSM),as well as the differences in gender,education level and bereavement duration.Meanwhile,the dose-response relationship was analyzed between bereavement type and number of bereavement and stroke risk.Multiple imputation method was used to deal with missing data using NORM software,and all statistical analyses were performed using Stata13.0.Results1.A total of 12,565 subjects were included in this study,among which female were slightly more(52.08%),64.07%lived in rural areas,and 46.07%had education level below primary school.During the follow-up,the number of stroke patients was 328,accounting for 2.61%of the total study population.There were 1,679 people(13.36%)who had experienced the death of spouse,and those who had experienced the death of children accounted for 13.71%of the total population.The vast majority(94.58)had experienced the death of their parents,while 53.63 percent had experienced the death of their siblings,with a similar proportion of males and females.2.Spouse death had a direct effect on stroke risk(OR=2.13,95%CI:1.20,2.48)and an indirect effect through depression(OR=1.24,95%CI:1.10,1.46).The direct effect of children's death on stroke risk was 1.64(95%Cl:1.1 7,2.48),and the natural indirect effect was 1.32(95%CI:1.14,1.62),?.The impact of parental death on the risk of stroke is mainly caused by direct effects(OR=2.50.95%CI:1.32,6.57).The death of siblings directly increased the risk of stroke by 56%(95%Cl:1.10,2.16),and the indirect effect was 1.24(95%CI:1.10,1.46).3.The results of gender stratification analysis showed that among males,the natural direct effect of widows was 2.13(95%CI:1.03,3.85).The death of children directly increased the risk of stroke by 48%(95%CI:1.06,2.66),and the indirect effect through depression was 1.32(95%CI:1.07,1.56).Among females,the direct effect of widows was 2.67(95%CI:1.66,4.35),and the indirect effect was 1.33(95%CI:1.11,1.53).Loss of children mainly affects the risk of stroke through the mediating effect of depression(OR=1.86,95%CI:0.92,3.04).Women who experienced parental death(OR=3.64,95%CI:2.07,7.58)and sibling death(OR=1.94,95%CI:1.23,3.35)had an direct increased risk of stroke.4.In the highly educated population,the direct effect of the funeral on the risk of stroke was 1.66(95%CI:1.02,2.60),and the indirect effect was 1.42(95%CI:1.05,1.84).In people with lower education levels,experiencing spousal deaths directly increased the risk of stroke by 1.28 times(95%CI:1.36,3.37),and the indirect effect was 1.19(95%CI:1.10,1.41).The loss of fungus directly increased the risk of stroke by 58%(95%CI:1.03,2.33),and the indirect effect was 1.28(95%Cl:1.05,1.55).Experience of parental death increases the risk of stroke by direct effects(OR=3.93,95%CI:1.01,4.92).Experiencing the death of siblings increased the risk of stroke by 41%(95%CI:1.02,2.19),and the indirect effect through depression was 1.09(95%CI:1.01,1.24).5.Within 2 years after bereavement,the risk of stroke was increased by 1.04 times(95%CI:1.04,3.71),and the mediating effect of depression was statistically significant(OR=1.07,95%CI:1.01,1.41).Bereavement increases the risk of stroke by 95%through direct effect,and increases the risk of stroke by 20%through indirect effect of depression(95%CI:1.14,2.94).More than 2 years after bereavement,spouse death increased the risk of stroke by 1.03 times(95%CI:1.37,3.16),and the indirect effect through depression was 1.21(95%CI:1.01,1.47).The impact of child death on stroke risk is mainly through indirect effects of depression(OR=1.37,95%CI:1.12,1.78).ParentaI death was mainly affected by direct effects(OR=2.47,95%CI:1.01,7.17).Expernencimg sibling death directly increased the risk of stroke by 69%(95%CI:1.18,2.68),with an indirect effect of 1.07(95%CI:1.01,1.20).6.The results of dose-response relationship analysis showed that the more types of bereavement people experienced,the higher the risk of stroke,and the risk of stroke increased by 3.46 times in people who experienced four types of bereavement(95%CI:1.80,6.96).The more times of bereavement people experienced,the higher tihte risk of stroke,and the 3.26 fold increased rnsk of stroke in people who lost more than 5 relatives(95%CI:1.83,6.69).Conclusions1.In the general population,spousal death,child death,parental death,and sibling death directly increase the risk of stroke.The proportion of mediators in which depression is ranked is the children death>spouse death>sibling death,and no mediating effect of depression is found in the relationship between parental death and rnsk of stroke.2.Among women,four types of bereavement are risk factors for stroke;among men,only widowhood and loss children are risk factors for stroke.3.Among the less educated people,the four types of bereavement are risk factors for stroke;among the people with higher education level,only children death is a risk factor for stroke.4.Four types of bereavement have a long-term effect on the risk of stroke,and only children death and spouse death have a short-term effect on the risk of stroke.5.People who experienced the more types of bereavement and more times of bereavement had the higher risk of stroke. |
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