Author ORCID Identifier
Date Available
4-30-2027
Year of Publication
2025
Document Type
Doctoral Dissertation
Degree Name
Doctor of Philosophy (PhD)
College
Nursing
Department/School/Program
Nursing
Faculty
Dr. Debra K Moser
Faculty
Dr. Martha J Biddle
Faculty
Dr. Jia-Rong Wu
Abstract
There is a complex interplay among cardiovascular disease (CVD), social determinants of health (SDOH), psychosocial characteristics, behavioral factors, and quality of life (QOL), including health-related quality of life (HRQoL). Cardiovascular diseases, including coronary heart disease (CHD) and ischemic heart failure (HF), significantly impact QOL and HRQoL. In patients with CVD, SDOHs, psychosocial characteristics (i.e., diminished social support, depressive symptoms, anxiety, perceived control), and behavioral factors (i.e., worse functional status and poor self-care) significantly impact QOL and HRQoL. Identifying modifiable factors that affect QOL and HRQoL in patients with CVD assists researchers and clinicians in developing strategies to improve QOL and HRQoL. Therefore, the purpose of this dissertation was to (1) examine the interaction among SDOH, psychosocial characteristics, and behavioral factors in predicting QOL and HRQoL in urban and rural patients with CHD and HF, and (2) evaluate the validity and reliability of the SDOH screening tool in rural patients with CHD and HF.
This dissertation comprises four research studies. In the first published study, I employed the SPSS PROCESS macro (Version 4.2 by Andrew F. Hayes) to determine whether self-care maintenance moderates the direct and indirect effects of social support on HRQoL through psychological status (i.e., depressive symptoms and anxiety) in urban and rural patients with HF. In the second published study, I used a cross-sectional design to investigate a moderated mediation model, in which the association between perceived control and HRQoL was hypothesized to be mediated by depressive symptoms and anxiety in the presence of a moderator, functional status in urban and rural patients with HF. The third paper is the published study in which I evaluated the psychometric properties of the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) instrument to assess its reliability and validity in measuring SDOH among rural patients with CHD and HF. In the fourth study, I used cross-sectional data to examine the association between SDOH and QOL, focusing on the mediating role of depressive symptoms in rural patients with CHD and HF.
Results from the studies revealed that (1) self-care maintenance did not moderate the direct effect of social support on HRQoL, however, self-care maintenance moderated the indirect effect of social support on HRQoL through depressive symptoms and anxiety; (2) higher levels of perceived control were associated with better HRQoL through lower levels of anxiety and depressive symptoms in the presence of functional status, and the effect of perceived control on psychological symptoms was stronger at low and moderate functional statuses, however, this effect diminished with increasing functional status; (3) the PRAPARE instrument demonstrated robust psychometric properties, making it a valid and reliable tool for assessing SDOH in rural patients with CHD and HF; and (4) depressive symptoms mediate the relationship between SDOH and QOL, underscoring the need to address psychological distress in rural patients with CHD and HF.
This body of work highlights the critical role of SDOHs, psychosocial characteristics, and behavioral factors in shaping QOL and HRQoL among urban and rural patients with CHD and HF. These findings support the development of tailored interventions that target SDOH, psychosocial characteristics, and behavioral factors to improve QOL and HRQoL. My short-term goal is to conduct a pilot study to serve as a foundation for my longer-term goal of conducting a large-scale randomized trial to measure the effectiveness of a tailored intervention targeting SDOH, psychosocial characteristics, and behavioral factors to improve QOL and HRQoL.
Digital Object Identifier (DOI)
https://doi.org/10.13023/etd.2025.96
Funding Information
Chapter 4 and 5 was from Cognitive Behavioral Therapy for Depressive Symptoms in Rural Patients with Cardiac Disease, COMBAT trial, Patient-Centered Outcomes Research Institute (PCORI) contract AD-2019C3-17982).
Recommended Citation
Thapa, Ashmita, "Associations of Social Determinants of Health, Psychosocial Characteristics and Behavioral Factors with Quality of Life and Health-Related Quality of Life in Urban and Rural Patients with Cardiovascular Disease" (2025). Theses and Dissertations--Nursing. 74.
https://uknowledge.uky.edu/nursing_etds/74
