Educational level as a moderator of the relationship between body mass index, blood pressure, and depressive symptoms in the Peruvian population: a moderated mediation analysis.

Conditional process modeling is a data analytical approach that combines statistical mediation and moderation analysis. Mediation analysis is used to uncover the mechanisms that underlie or explain a causal effect. It is well suited to statistically model causal processes that take place between a predictor variable and an outcome variable. Moderation analysis investigates whether an effect of a predictor variable on an outcome variable varies under different conditions or for different individuals. Conditional process models (also referred to as moderated mediation models or mediated moderation models) combine the ideas of mediation and moderation. Thus they are well suited to investigate how processes between cause and outcome vary depend on characteristics of the individuals or their contexts. This article introduces the foundations of mediation, moderation, and conditional process analysis. Statistical estimation, testing, and interpretation are covered for simple linear models. References regarding more advanced models are provided.

In the past decade, moderated mediation analysis has been extensively and increasingly employed in social and behavioral sciences. With its widespread use, it is particularly important to ensure the moderated mediation analysis will not bring spurious results. Spurious effects have been studied in both mediation and moderation analysis, but this issue remains unexplored in moderated mediation analysis. To fill this gap, we examined the conditions under which a spurious moderated mediation effect in a dual stage moderated mediation model might occur. Specifically, with a hypothetical example and three theorems, we illustrated how the index of moderated moderated mediation may conclude a moderated mediation effect which does not actually exist. As a remedy to rule out the spurious results, we proposed two methods which are simple and easy to implement. Based on the simulation results, we offer researchers some practical guidelines to apply the methods in empirical research.

BackgroundArthritis primarily affects older people and is a prominent cause of their activity impairment. This study aimed to examine the mediating role of depressive symptoms in the relationship between social participation and activity impairment, as well as to determine whether sex moderated the mediating effect.MethodsA total of 2247 older patients with arthritis were included from the China Health and Retirement Longitudinal Study between 2015 and 2018. We first examined a simple mediation model where depressive symptoms were a mediator between social participation and activity impairment. Furthermore, sex was systematically integrated into the model as a moderator. The mediation model and moderated mediation model were analyzed using PROCESS macro.ResultsMediation analysis revealed that the association between social participation and activity impairment was partially mediated by depressive symptoms (B = -0.10, 95% CI = [-0.14, -0.06]) with intermediary effect of 28.6%. Moderated mediation analysis indicated that mediation model was moderated by sex. The indirect effect of social participation on activity impairment among female patients (B = -0.15, 95% CI = [-0.21, -0.09]) was stronger than male patients (B = -0.04, 95% CI = [-0.09, -0.01]).ConclusionSocial participation was the key protective factor associated with depressive symptoms and activity impairment among arthritis patients. Encouraging arthritis patients to social participation and improving the depressive symptoms might avoid activity impairment, especially for female patients.

Medication adherence has a critical impact on the well-being of older adult patients with hypertension. As such, the current study aimed to investigate the mediating role of health literacy between frailty and medication adherence and the moderating role of educational level. This cross-sectional study included patients admitted to the geriatric unit of a hospital. Participants were interviewed using the four-item Morisky Medication Adherence Scale, the Frailty Phenotype Scale, and the Health Literacy Management Scale. Spearman's correlation coefficients were used to assess the association between variables. Mediation and moderated mediation analyses were performed using Process version 4.1 via Model 4 and 14, respectively. Data from 388 participants were analyzed. The median (IQR [P25-P75]) score for medication adherence was 4.00 (2.00-4.00). Results revealed that after controlling for age, sex, hypertension complication(s) and body mass index, frailty significantly contributed to medication adherence (βtotal -0.236 [95% confidence interval (CI) -0.333 to -0.140]). Medication adherence was influenced by frailty (βdirect -0.192 [95% CI -0.284 to -0.099]) both directly and indirectly through health literacy (βindirect -0.044 [95% CI -0.077 to -0.014]). Educational level moderated the pathway mediated by health literacy; more specifically, the conditional indirect effect between frailty and medication adherence was significant among older adult hypertensive patients with low, intermediate, and high educational levels (effect -0.052 [95% CI -0.092 to -0.106]; effect -0.041 [95% CI -0.071 to -0.012]; effect -0.026 [95% CI -0.051 to -0.006]). The relationship between frailty and medication adherence in older adult patients with hypertension was found to have mediating and moderating effects. A moderated mediation model was proposed to investigate the effect of frailty on medication adherence. It was effective in strengthening medication adherence by improving health literacy and reducing frailty. More attention needs to be devoted to older adult patients with hypertension and low educational levels.

Background: The evidence on the association between benevolent childhood experience (BCE) and depressive symptoms in students is complex. This study aims to explore the underlying mediation mechanism of BCE toward depressive symptoms and whether this link was moderated by the family relationship among Chinese undergraduates.Methods: From March 2021 to May 2021, a cross-sectional study was conducted in China, and 1821 undergraduates were recruited in this study. Participants were asked to complete a self-reported electronic questionnaire. The software SPSS PROCESS macro was used to test the mediation and mediated moderated modeling analysis.Results: Mediation analysis indicated that uncertainty stress (US) partly mediated the link between BCE and depressive symptoms (indirect effect = −0.47, 95% bootstrap CI = −0.55, −0.39). The indirect effect of the US accounted for 39.63% of the total variance in depression. Moderation analysis indicated that the association between the US and depressive symptoms was significantly modified by family relationships (interact effect = −0.019, P < 0.001). An integrative moderated mediation analysis indicated that the indirect effect from BCE to depressive symptoms through the US was also moderated by family relationships (interact effect = −0.012, P = 0.014).Conclusion: Uncertainty stress plays a key role in bridging BCE and depressive symptoms while the family relationship can buffer the impact of the US on depressive symptoms among Chinese undergraduates. Enhancing tolerance of uncertainty and improving family relationships are needed to protect undergraduates from depressive symptoms.

Integrating moderation and mediation models has been a popular topic of study in social science methodology. A moderated mediation model is a combination of both moderation and mediation models. When a mediation effect is moderated by a moderator, the effect is termed moderated mediation and the model is a moderated mediation model. There are three common types of moderated mediation models: first-stage moderated mediation, second-stage moderated mediation, and dual-stage moderated mediation. Three methods of testing moderated mediation models are based on the Bootstrap asymmetric confidence interval and the Bayesian asymmetric credible interval. These methods include a subgroup approach, difference approach, and products of coefficients approach. The products of coefficients approach is recommended to analyze first-stage or second-stage moderated mediation models. The difference approach is recommended to analyze dual-stage moderated mediation models. A simulation study found that the Bayesian credible interval without informative prior yielded higher power than the Bootstrap percentile confidence interval, and comparable power to the Bootstrap bias-corrected confidence interval. In the present study, we used an example to illustrate how to conduct the proposed procedure by using MPLUS and WinBUGS software. MPLUS and WinBUGS programs are provided in the appendix to facilitate the implementation of the Bootstrap method to analyze moderated mediation effects. The programs can be managed easily by empirical researchers. To explore the present situation and problems of using three moderated mediation analysis methods in psychological researches in China, this article reviewed 12 studies published in Chinese psychological journals, retrieved from the CNKI database, since 2009 to 2014.

It has long been known that lower socioeconomic status (SES) is a potent risk factor for cardiovascular disease.1 Much effort has been devoted to identifying the mechanisms responsible for this risk, because knowledge of these mechanisms is essential to guide the development of interventions to prevent or ameliorate the health-damaging effects. By showing that increased systolic blood pressure (SBP) levels in persons of lower educational attainment in a large sample drawn from the Paris metropolitan area are mediated to a significant extent by increased body mass index (BMI), waist circumference, and resting heart rate (HR), the report by Chaix et al2 in this issue of Hypertension makes an important contribution toward achieving this goal. Much work remains to be done, however, because the proportion of the association between lower individual education and elevated SBP explained by BMI/waist circumference and resting HR is 28.0% and 14.7%, respectively, meaning that a substantial proportion of the effect of lower education on SBP is mediated by other factors. Moreover, although it is helpful to know that one way lower education gets inside the body to raise blood pressure is via increased BMI, central fat accumulation, and resting HR, it is by no means clear how lower education gets inside the body to influence these mediators of increased blood pressure. Psychosocial risk factors like hostility, depression, and social isolation are increased in lower SES groups3,4 and, therefore, deserve attention …

Health-related quality of life (HRQoL) is poor in patients with heart failure. Psychological (ie, depressive symptoms [DS], anxiety, and perceived control) and physical (ie, functional status) factors are associated with HRQoL. The dynamic relationships among these variables and their impact on HRQoL remain unclear, limiting the ability to design effective interventions. Our aim was to evaluate a moderated mediation model, in which the association between perceived control and HRQoL was hypothesized to be mediated by DS and anxiety in the presence of a moderator, functional status. Patients (N = 426) with heart failure completed the Control Attitudes Scale-Revised to measure perceived control, Duke Activity Status Index for functional status, Patient Health Questionnaire-9 for DS, Brief Symptom Inventory for anxiety, and Minnesota Living with Heart Failure Questionnaire for HRQoL. We performed a moderated parallel mediation analysis. Higher levels of perceived control were associated with better HRQoL through lower levels of anxiety and DS in the presence of functional status (index of moderated mediation for DS, b = 0.029; 95% confidence interval, 0.016-0.045; for anxiety: b = 0.009, 95% confidence interval, 0.002-0.018). The effect of perceived control on psychological symptoms was stronger at low and moderate functional statuses; however, this effect diminished with increasing functional status. Functional status moderated the indirect effects of perceived control on HRQoL through DS and anxiety in patients with heart failure. Efforts to improve HRQoL by targeting perceived control may be more effective when considering DS and anxiety in patients with low to moderate levels of functional status.

Association between enacted stigma, internalized stigma, resilience, and depressive symptoms among young men who have sex with men in China: a moderated mediation model analysis

Preventing suicide among adolescents with depression remains a global health priority. Entrapment has been shown to be associated with suicidality, with depressive symptoms potentially accounting for part of this association, and these associations may vary by gender. To clarify these relationships, this study examined the statistical associations among entrapment, depressive symptoms, and suicidality, with particular attention to the statistical mediating role of depressive symptoms and the moderating role of gender. This study utilized a cross-sectional design, recruiting 406 adolescents with depressive disorders (79.6% female). Entrapment (Entrapment Scale), depressive symptoms (PHQ-9), and suicidality (SBQ-R) were assessed. Mediation and moderated mediation models (PROCESS macro, Models 4 and 8) were tested with age as a control variable, and bootstrapping procedures (5,000 resamples) were used to evaluate the robustness of the effects. Results indicated that (1): female participants reported significantly higher levels of entrapment, depressive symptoms, and suicidality than males (2); entrapment was positively associated with both depressive symptoms and suicidality (3); depressive symptoms statistically mediated the relationship between entrapment and suicidality; and (4) gender moderated the direct association, while the indirect (statistical mediation) association showed no significant gender differences. These findings suggest that the observed pattern of associations is consistent with theoretical models of suicidality, while also highlighting the importance of gender-sensitive clinical considerations: for males, clinical care should prioritize identifying and alleviating entrapment, whereas for females, comprehensive management addressing both entrapment and depressive symptoms may be more effective.

Objectives The present study investigated a moderated mediation model in which depressive symptoms mediated the relationship between childhood psychological maltreatment and death obsession, with meaning in life moderating both components of the indirect pathway. Method The sample for the present study consisted of 904 older adults (50.2% women), aged between 65 and 91 years (M age= 71.23, SD = 5.72), residing in an urban region of Türkiye. Self-report measures assessing childhood psychological maltreatment, depressive symptoms, death obsession, and meaning in life were administered. Data were analyzed using moderated mediation analysis. Results Results indicated that childhood psychological maltreatment was positively associated with both depressive symptoms and death obsession. Furthermore, depressive symptoms significantly mediated the link between early maltreating experiences and death-related cognitive preoccupations. Critically, meaning in life moderated both the association between childhood maltreatment and depressive symptoms and the pathway from depressive symptoms to death obsession. These associations weakened as perceived meaning in life increased, suggesting a protective buffering effect on the indirect effect. Conclusion These findings underscore the enduring psychological consequences of early relational maltreatment and emphasize the importance of fostering existential resources such as life meaning to mitigate depressive and death-related vulnerabilities in older adulthood.

BackgroundFamily dysfunction and insecure attachment are established risk factors for adolescent depressive symptoms, yet individual differences in sensory processing may influence vulnerability to these environmental stressors.ObjectiveTo explore the mediating role of insecure attachment and the moderating effect of sensory processing sensitivity (SPS) in the relationship between family functioning and adolescent depressive symptoms.MethodsThis study employed a cross‐sectional design, with 503 adolescents recruited via convenience sampling in October 2023. Participants completed self‐report questionnaires assessing family functioning, insecure attachment, SPS, and depressive symptoms. SPSS 26.0 was used to conduct moderated mediation analyses to examine the complex interactions among these variables.ResultsThe results showed that family functioning was directly associated with adolescent depressive symptoms and also was indirectly associated with depressive symptoms through insecure attachment. Additionally, SPS was found to statistically moderate both the direct and indirect pathways. Specifically, the negative association between poor family functioning and depressive symptoms and the statistical mediating pathway through insecure attachment were more pronounced in adolescents with higher SPS.ConclusionImpaired family functioning and insecure attachment were associated with higher levels of depressive symptoms in adolescents. SPS appeared to strengthen these associations, highlighting the importance of considering individual differences in sensory sensitivity when addressing adolescent mental health. Tailoring interventions to strengthen family support and attachment security, especially for adolescents with heightened SPS, may help mitigate the risk of depressive symptoms. This study emphasizes the need for family‐centered interventions to foster resilience against adolescent depressive symptoms.

BackgroundStudies have shown a close association between home and community-based healthcare services (HCBHS) utilization and depressive symptoms in older adults. However, no studies have explored the underlying mechanism of this relationship in rural China. This study was designed to evaluate the roles of instrumental activities of daily living (IADL) and marital status in the association between HCBHS utilization and depressive symptoms in Chinese rural older adults.MethodsData were obtained from the 2018 China Health and Retirement Longitudinal Study, and 5,981 rural respondents (≥ 60 years old) were included. Depression scores were calculated using the ten-item Center for Epidemiological Studies Depression Scale. Moderated mediation analysis was carried out applying Hayes’ PROCESS macro (Model 7).ResultsHCBHS utilization had a direct and negative effect on depressive symptoms. Furthermore, marital status moderated the association between HCBHS utilization and IADL, which belonged to the indirect influence of the first half on the association between HCBHS utilization and depressive symptoms. HCBHS utilization was associated with IADL in single but not in married respondents.ConclusionThe results demonstrated that marital status moderated the indirect relationship between HCBHS utilization and depressive symptoms, with HCBHS utilization being negatively associated with IADL among single but not married respondents. The government should focus on rural older adults, especially those who are single and have poor IADL function, and improve the provision of HCBHS to alleviate depressive symptoms.

IntroductionHigh-intensity interval training (HIIT) may improve cardiorespiratory fitness (CRF) and mental health. The current observer-blinded RCT investigates the sparsely studied efficiency of HIIT in reducing psychotic and non-psychotic symptoms in schizophrenia and complements previous studies by investigating whether symptom reduction following HIIT is associated with, putatively partly mediated by, increased VO2max.MethodsParticipants (outpatients meeting diagnostic criteria for schizophrenia) were randomized to HIIT (n = 43) or a comparison group performing low-intensity active video gaming (AVG) to control for social interaction (n = 39). Both interventions consisted of two supervised sessions/week for 12 weeks and a 4 months follow-up. Effects on overall symptoms and symptom domains [PANSS (0–6 scale), five-factor model] were estimated using mixed-effects models (intention-to-treat, n = 82). Underlying mechanisms were analyzed using moderated mediation analyses (n = 66). We anticipated that HIIT would reduce overall symptoms, particularly depressive symptoms, more than AVG, and symptom reduction would be associated with, putatively mediated through, improved VO2max.ResultsDepressive symptoms (baseline score 3.97, 95% CI: 3.41, 4.52), were −1.03 points more reduced in HIIT than AVG at post-intervention (95% CI: −1.71, −0.35, p = 0.003), corresponding to a small to moderate effect size (d = 0.37) and persisting at follow-up. There was a small reduction in overall symptoms, but no significant between-group differences were observed. Change in VO2max correlated negatively with the change in depressive symptoms. Mediation analysis showed a significant effect of change in VO2max on change in depressive symptoms within HIIT. The total effect was moderated by group, and depressive symptoms were more reduced in HIIT. Direct effects, not mediated through VO2max, were non-significant. Indirect effects, mediated through VO2max, were non-significant, but the moderated mediation test indicated a non-significant trend of 0.4 points (95% CI: −1.188, 0.087) and a larger reduction in depressive symptoms through VO2max in HIIT.ConclusionHIIT reduced depressive symptoms more than AVG, which persisted at follow-up. HIIT may serve as a complementing treatment option targeting these symptoms in individuals with schizophrenia, even before they reach clinical depression. Depressive symptoms are important to prevent, stabilize, and treat due to their negative implications for psychological wellbeing and long-term functional outcome. Reduction in depressive symptoms was associated with improved VO2max, and non-significant trends in the data supported that improved VO2max may be part of the complex mechanisms underlying the anti-depressive effect of HIIT.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT02205684].

Although several studies have documented an inverse association between stressful events and sleep quality, much less is known about the factors that might moderate or buffer against the adverse effects of psychosocial stress on sleep. Building on previous research, we employ national cross‐sectional survey data from the 2017 Baylor Religion Survey (n= 1,410) to test whether the association between recent stressful events and sleep quality varies according to several dimensions of religious involvement. We also formally assess whether any attenuation of the association between stressful events and sleep quality is at least partially mediated or explained by lower levels of depressive symptoms (mediated moderation). Our moderation analyses indicate that the inverse association between stressful events and sleep quality is in fact attenuated by religious cognitions (secure attachment to God and assurance of salvation), but not religious attendance or private religiousness. We also observe direct evidence of mediated moderation through depressive symptoms for both religious cognitions. Taken together, our results demonstrate that religious cognitions may buffer against stress‐related sleep disturbance by helping people avoid symptoms of depression.