Regression-based Mediation Analysis Research Articles

Flood stressors and mental distress among community-dwelling adults in Ghana: a mediation model of flood-risk perceptions

ABSTRACT Extant research has linked flooding with mental distress (MD) among flood-prone populations, but the mechanisms underlying this association remain largely unknown. This paper examines the association of flood stressors with MD among households in flood-prone communities in Ghana and estimates whether flood risk perceptions mediated the association. The study involved 767 household heads aged ≥20 years [mean = 47.3 ± 13.7); males = 61.4%]. Flood stressors were assessed using a 15-item Flood Stress-related Scale, while the Kessler Psychological Distress Scale (K10) was used to assess MD. Linear regression-based mediation analysis using Hayes’ PROCESS macro was performed to assess the indirect effect of flood stressors with MD through flood risk perceptions. After adjusting for potential confounders, flood stressors were significantly linked with higher risks of MD (β = .060-.080, p < .001). The mediation and bootstrapping analyses suggested that flood health risk perception partially mediated and accounted for 26.7% of the relationship between flood stressors and MD (direct effect: β = .060, Boots 95%CI: .041-.079; indirect effect: β = .022, Boots 95%CI: .015-.031; total effect: β = .082, Boots 95%CI: .063-.101). The link between flood stressors and MD risk is explained partially by flood health risk perception. Knowledge of households' flood risk perception is therefore critical for effectively managing the effects of flood stressors on MD.

The mediating effect of anxiety on the association between residual neurological impairment and post-stroke participation among persons with and without post-stroke depression

ABSTRACT Previous research has reported that residual neurological impairment and emotional factors play a role in regaining successful participation post-stroke. The objective of this study was to investigate the mediating impact of anxiety on the association between residual neurological impairment and participation in survivors with and without post-stroke depressive symptoms. Participants (N = 79) were classified into 2 categories, those with post-stroke depressive symptoms (N = 40) and those without post-stroke depressive symptoms (N = 39). Variables measured in this study: residual neurological impairment (NIH Stroke Scale Score), participation (Reintegration to Normal Living Index), depressive symptoms (Patient Health Questionnaire-9), and trait anxiety (State-Trait Anxiety Inventory). A regression-based mediation analysis was conducted for each group of participants. The majority of participants had some level of anxiety. Residual neurological impairment predicted participation in stroke survivors both with (β = -.45, p = .003) and without (β = -.45, p = .004) post-stroke depressive symptoms. Anxiety mediated this relationship in participants with depressive symptoms (β = -.19, 95% CI = -.361 ∼ -.049), but not in participants without depressive symptoms (β = -.18, 95% CI = -.014 ∼ .378). Depressive and anxious symptoms should both be addressed to best facilitate participation by stroke survivors.

Mental Health Symptoms Mediate the Association of Subjective Cognitive Function with Participation after Stroke

<h3>Research Objectives</h3> To investigate if mental health (MH) symptoms - depression, apathy, and anxiety - mediate the association of subjective (SCF) and objective (OCF) measures of cognitive function with participation after stroke. <h3>Design</h3> A prospective cross-sectional study. We performed a regression-based mediation analysis using Hayes's PROCESS macro. 12 Models were built for three MH mediators in the association of SCF and OCF measures with two participation measures, respectively. <h3>Setting</h3> Community. <h3>Participants</h3> 74 persons with stroke. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> We used Patient Health Questionnaire-9 for depression, Apathy Evaluation Scale, and State-Trait Anxiety Inventory-Trait Anxiety Scale as MH mediators. The dependent variables were participation measured using Reintegration to Normal Living (RNL) and Activity Card Sort (ACS). Independent variables were SCF, measured using Stroke Impact Scale Memory and Thinking, and OCF, measured using Delis-Kaplan Executive Function System Trail-Making Test (Number-letter switching). <h3>Results</h3> In the model of RNL, depression (b=0.093, 95% CI=0.038∼0.157), apathy (b=0.134, 95% CI=0.071∼0.202), and anxiety (b=0.116, 95% CI=0.049∼0.194), were full mediators of the association between the SCF measure and RNL total score. For the ACS, apathy was the only mediator between the SCF measure and ACS total activity retention (b=0.144, 95% CI=0.032∼0.293). In both models, none of the MH measures were significant mediators of the association between the OCF measure and RNL or ACS after stroke (p>0.05). <h3>Conclusions</h3> These findings indicate that depression, apathy, and anxiety may be stronger mediators of the association between SCF with participation than for OCF with participation after stroke. Rehabilitation professionals should pay attention to measures of both SCF and OCF as they have different dynamics with MH symptoms and participation after stroke. <h3>Author(s) Disclosures</h3> None.

Constructive communication patterns as related to relationship satisfaction, seizure severity, and patient activation among people with epilepsy

PurposePeople with epilepsy (PWE) must manage their condition properly for both quality and longevity of life. Effective self-management is critical and can be monitored via levels of patient activation (i.e., a continuum of taking a passive vs active role in personal healthcare) and the presence/severity of seizures. One known influencer of self-management is the quality of one’s intimate relationship, a documented area of major concern for PWE. Here we examined a critical facet of PWEs’ intimate relationships—(un)constructive communication with their partner. MethodsUsing data from a web-based survey of 89 PWE, and regression-based mediation analyses, we examined associations with patient activation and seizure severity. We added further explanatory utility by examining relationship satisfaction as a mediator of those links. ResultsThere were positive links between more constructive communication, more patient activation, and less severe seizures. The explanatory path of constructive communication to better relationship satisfaction to lower seizure severity emerged as a significant partial mediation (i.e., direct effect remained significant), while relationship satisfaction fully mediated (i.e., direct effect became non-significant) the link between constructive communication and greater patient activation. ConclusionOur results provide insight into how relationship processes may impact the experience of epilepsy, including seizure severity and patient activation. Future research is needed.

Inflammation mediates approximately one quarter of excess relative all-cause mortality in persons with rheumatoid arthritis: the Trøndelag Health Study

Inflammation may contribute to excess mortality in rheumatoid arthritis (RA) patients. We investigated associations to all-cause mortality of the inflammation markers high-sensitivity C-reactive protein (CRP), lactoferrin (neutrophil activation marker), and neopterin (monocyte activation marker). From the population-based Trøndelag Health Study (3rd wave 2006–2008), 316 RA patients and 43,579 controls were included. Lactoferrin and neopterin were quantified in a nested cohort (n = 283 RA patients, n = 3698 controls). Follow-up was until death found by linkage to the Norwegian Cause of Death Registry or 31.12.2018. All-cause mortality was analyzed using Cox regression and Cox regression-based mediation analysis. Having RA (hazard ratio (HR): 1.25, 95%CI: 1.00, 1.56, p = 0.048), and CRP ≥ 3 mg/L (HR: 1.50, 95%CI: 1.41, 1.60, p < 0.001) were associated with all-cause mortality. The overall excess relative mortality risk of having RA was 38%. CRP ≥ 3 mg/L mediated approximately 1/4 of this risk (p < 0.001). In the nested cohort, CRP ≥ 3 mg/L (HR: 1.51, 95%CI: 1.26, 1.80, p < 0.001) and neopterin (HR: 1.17, 95%CI: 1.01, 1.36, p = 0.031) were associated with all-cause mortality. In conclusion, CRP levels ≥ 3 mg/L mediated approximately a quarter of the 38% excess relative all-cause mortality risk associated with RA. Using definitions of RA remission with emphasis both on joint status and the level of general inflammation may help guide the most efficient treatment regimens.

Abstract 5940: Impact of obesity on sexual functioning in women with gynecologic cancer pre-and post-radiotherapy

Abstract Background: As the prevalence of obesity in women increases in the US, a better understanding of the effect of obesity on women with gynecologic cancer (GynCa) is imperative. However, whether obesity impacts sexual functioning (SF) in GynCa patients has been understudied. Limited studies have used body mass index (BMI) as the only obesity indicator, which may result in a misunderstanding of the effect of obesity on SF in GynCa patients with different body compositions. This study aimed to explore the role of obesity via two different measures in determining SF in GynCa patients pre-and post-radiotherapy (RT). Methods: In this secondary analysis, obesity was measured pre-RT by both BMI and body fat percentage (BFP). BFP was calculated by using the Clinica Universidad de Navarra-Body Adiposity Estimator. SF, physical and emotional well-being were assessed pre-RT by the Female Sexual Function Index and the Functional Assessment of Cancer Therapy-General. At 6 months post-RT, SF was reassessed. Generalized linear models (GLM) and generalized linear mixed models (GLMM) with a log-link were implemented to identify the effect of obesity (using BMI and BFP) on SF pre-and post-RT. Regression-based mediation analysis was used to identify mediating effects of physical and emotional well-being between obesity and SF. Results: Among 54 (24 cervical and 30 endometrial) patients, 48% were Black, 52% were married or in a domestic partnership, and 59% were treated with surgery and/or chemotherapy pre-RT (i.e. prior treatment). Less patients were classified as being obese when obesity was measured by BMI (48%) compared to BFP (61%). Patients with endometrial cancer and prior treatment history were more likely to be obese and reported better SF. Unadjusted GLM showed that patients with obesity had better SF than those without obesity pre-RT regardless of obesity measures (BMI p = .018; BFP p = .016). However, we found no association between obesity (both BMI-and BFP-based obesity) and SF pre-RT after adjusting for cancer type and prior treatment history. GLMM showed that BFP-based obesity had a negative effect on the improvement in SF from pre-RT to post-RT (p = .013) after adjusting for cancer type and prior treatment history. Patients without BFP-based obesity showed a significant improvement post-RT (p = .019), but those with obesity (per BFP) showed no changes in SF post-RT (p = .949) compared to pre-RT. BMI-based obesity did not affect the changes in SF post-RT. We found no mediation effects of physical and emotional well-being between obesity and SF. Conclusions: Obesity may play a negative role in SF improvement in GynCa patients post-RT. More rigorous research and clinical attention to obesity measurement are necessary to determine the association between obesity and SF in GynCa patients and thus lead to the discovery of new interventions for this long-neglected topic of SF in GynCa patients, particularly for those who are obese. Citation Format: Haerim Lee, Deborah W. Bruner, Yi-Juan Hu, Jinbing Bai, Tony Y. Eng, Joseph W. Shelton, Pretesh R. Patel, Namita Khanna, Isabelle Scott, Katherine A. Yeager. Impact of obesity on sexual functioning in women with gynecologic cancer pre-and post-radiotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5940.

Mediator Role of Social Appearance Anxiety in the Relationship between Socio-Cultural Attitudes towards Appearance and Body Image Flexibility

This study examines the role of social appearance anxiety in the relationships between socio-cultural pressures, internalization of socio-cultural values, and body image flexibility. Designed as correlational survey research, the study sample comprises 748 students in a university in Turkey. Data of the study is collected with three data collection tools: "Socio-Cultural Attitudes Towards Appearance Scale", “Social Appearance Anxiety Scale”, and “Body Image Flexibility Scale”. A simple mediation model, which was applied with regression-based mediation analysis, shows that social appearance anxiety is a mediator on the relationships between socio-cultural pressures, internalization of socio-cultural values, and body image flexibility.

The Half-Truth Effect and Its Implications for Sustainability

Misinformation on sustainability has become a widespread phenomenon in many different contexts. However, relatively little is known about several important determinants of belief in misinformation, and even less is known about how to debias that belief. The present research proposes and investigates a new effect, the half-truth effect, to explain how message structure can influence belief in misinformation. Two survey-based experiments were conducted to show that people exhibit greater belief in a false claim when it is preceded by a true claim, even if the two claims are logically unrelated. Conversely, when a false claim is presented before the true claim, it reduces the belief in the entire statement. Experiment 1 shows the basic half-truth effect. Experiment 2 investigates an individual difference, propensity to believe meaningless statements are profound, which impacts the half-truth effect. Both experiments also investigate debiasing of the false information. The results of the experiments were analyzed using analysis of variance and regression-based mediation analysis. Results show that belief in misinformation is dependent on message structure, and show that the order in which true and false elements are presented has a strong influence on belief in sustainability misinformation. Finally, we present a discussion of how policy makers can use these findings to identify those people who are most likely to be swayed by the misinformation, and then design responses to debias sustainability misinformation.

Association Between Parental Feeding Styles and Excess Weight, and Its Mediation by Diet in Costa Rican Adolescents

ObjectivesParental feeding styles (PFS) influence children’s diet and weight; we aimed to evaluate this relationship in adolescents. MethodsCross-sectional study in 686 Costa Rican adolescents (13–18y). Parents responded to a questionnaire from which four validated PFS scores were derived: promotion (verbal encouragement of healthy eating); verbal sanctions/scolding (indirect control of healthy food intake); direct control over diet; instrumental/emotional (food to regulate emotions). Adolescents completed a 3-day food record, from which the validated Traditional Costa Rica Adolescents Diet Score (TCRAD) was defined. Excess weight was dichotomized following standards. Multivariate regression-based mediation analysis estimated the natural direct, indirect, and total effects (NDE/NID/TE) of the following pathway (general/sex-stratified): PFS → TCRAD → excess weight. ResultsExcess weight was present in 33% of adolescents. TCRAD mean was similar between excess weight categories. Each additional point of the direct control PFS score was associated with higher odds of excess weight [(TE-OR: 1.55; 95%CI: 1.04–2.31; p = 0.033), (NDE-OR: 1.52; 95%CI: 1.02–2.27; p = 0.039)]. This association was accentuated in boys vs. girls. A non-significant tendency for lower odds of excess weight was observed for the emotional PFS in boys [(TE-OR: 0.44; 95%CI: 0.19–1.05; p = 0.064), (NDE-OR: 0.43; 95%CI: 0.18–1.02; p = 0.056)] and the promotion PFS in the total sample (TE-OR: 0.74; 95%CI: 0.47–1.17; p = 0.202). TCRAD seemed to have a mediation role between the promotion PFS and excess weight (NID-OR: 0.94; 95%CI: 0.88–1.00; p = 0.056). ConclusionsHealthy eating behaviors encouraged by parents might benefit Costa Rican adolescents’ weight via dietary intake. In contrast, parents directly controlling food access and intake may adversely influence adolescents’ weight, especially in boys. Our work constitutes a first approach studying PFS and obesity among adolescents. Further research is needed to confirm the role of the promotion PFS in obesity prevention and evaluate the contribution of PFS to other diet-related outcomes among adolescents in diverse cultural contexts. Funding SourcesThe Mexican Council of Science and Technology; Fundación México en Harvard; The Costa Rican Ministry of Health; Inciensa Foundation.

Association between Parental Feeding Styles and Excess Weight, and Its Mediation by Diet, in Costa Rican Adolescents.

Background. Whereas parental feeding styles (PFS) influence children’s diet, less is known about this relationship in adolescents. Methods. A cross-sectional study in 686 Costa Rican adolescents (13–18 years) evaluated 4 validated PFS scores: healthy eating verbal encouragement; scolding; directly controlling diet; instrumental/emotional. Diet was evaluated through 3-day food records, deriving a Traditional Costa Rica Adolescents Diet Score (TCRAD). Excess weight (EW) measured by BMI was dichotomized following standards. Regression-based mediation analysis estimated the overall and sex-stratified odds ratios of EW for natural direct (NDE), natural indirect (NIE), and total effects (TE) of the pathway PFS→TCRAD→EW. Results. A one-unit increase in the direct control PFS score was associated with higher EW odds overall [(TE: 1.55; 95% CI: 1.04–2.31; p-value = 0.033), (NDE: 1.52; 95% CI: 1.02–2.27; p-value = 0.039)], and in boys [(TE: 2.13; 95% CI: 1.04–4.38; p-value = 0.039), (NDE: 2.10; 95% CI: 1.03–4.31; p-value = 0.042)]. Non-significant mediation by TCRAD was observed for the healthy eating verbal encouragement PFS overall (p-value = 0.06). Associations for the instrumental/emotional and scolding PFS were not significant. Conclusions. Direct diet control from parents may contribute to adolescents’ excess weight, particularly among boys. Parents encouraging healthy eating might support adolescents’ healthy weight through a healthy diet. Longitudinal research should clarify the association between PFS and diet-related outcomes among diverse adolescents.

Anxiety and Depression in a Non-Clinical Sample of Young Polish Adults: Presence of Meaning in Life as a Mediator

Early adulthood, between 18 and 25, is viewed as a decisive period of life for the prevention and treatment of anxiety and depression. Although the topic of their mutual relationship is well-known, little has been uncovered about the mechanism underlying this connection. To understand the indirect pathways between anxiety and depression, we chose the sense of meaning of life as a mediator because people’s beliefs that their lives are or can be purposeful may protect against depression. The sample was composed of 277 Polish young adults. A small majority of the participants were women (58.8%). The mean age was M = 22.11 (SD = 1.72). We used in the research the Direct Behavior Rating-Scale Items Scale, the Meaning in Life Questionnaire, and the Brief Screen for Depression. Correlational analysis showed that, consistent with past findings, anxiety correlated positively with depression and searching for meaning. It was also negatively associated with presence of meaning. Moreover, depression was negatively linked to presence of meaning and positively with searching for meaning. Regression-based mediation analyses (PROCESS macro 3.4) proved that the relationship between anxiety and depression was mediated by presence of meaning in life, suggesting that having a sense of meaning may be a pathway by which feelings of tension relative to adverse events protect against depression.

Do Hypertensive Disorders of Pregnancy and Abnormal Placentation Mediate the Association between Advanced Maternal Age and Adverse Perinatal Outcomes?

A tertiary-hospital-based retrospective study (2011-2019) was conducted to determine the mediating role of hypertensive disorders of pregnancy and abnormal placentations between advanced maternal age and adverse neonatal outcomes. Data from a tertiary-hospital-based retrospective study (n= 23051) was used and conducted regression-based mediation analysis to assess the mediating role of hypertensive disorders of pregnancy and abnormal placentation between the advanced maternal age and adverse neonatal outcomes. After adjusting for confounding factors, the indirect effect of advanced maternal age on preterm births, perinatal mortality, and low birth weight mediated by hypertensive disorders of pregnancy was [aOR 4.95 (95% CI: 4.05, 5.85)], [aOR 2.82 (95% CI: 1.78, 3.86)], and [aOR 5.90 (95% CI: 4.93, 6.87)], respectively. The indirect effect of advanced maternal age on preterm births and low birth weight mediated by abnormal placentation was [aOR 6.83 (95% CI: 5.70, 7.97)] and [aOR 4.18 (95% CI: 3.26, 5.11)]. About, 23%, 37%, and 17% of the effect of advanced maternal age on preterm births, perinatal mortality, and low birth weight was mediated by hypertensive disorders of pregnancy, respectively. Furthermore, abnormal placentation mediates the association between advanced maternal age and preterm births by 18% and low birth weight by 23%. Hypertensive disorders of pregnancy and abnormal placentation partially mediate the association between advanced maternal age and adverse neonatal outcomes.

Social Support Fully Mediates the Association Between Communication Abilities and Social Participation Among Persons with Post-Stroke Aphasia

ABSTRACT Background Communication abilities have been considered to be a key influential factor for social participation in persons with post-stroke aphasia. Previous literature has shown that social support is positively associated with social participation post-stroke. However, few studies have investigated if social support mediates the negative impact of communication difficulties on social participation in persons with aphasia and without aphasia after stroke. Aims To investigate the mediation effect of social support on the association between communication abilities and social participation in persons with aphasia and without aphasia after stroke. Methods & Procedures A total of 116 participants who have had a stroke, including 60 persons with aphasia and 56 persons without aphasia, were enrolled. This study used a regression-based mediation analysis using Hayes’s PROCESS macro (SPSS model 4). Measures included the Medical Outcomes Study (MOS) - Social Support Survey as the mediator (perceived social support), the Stroke Impact Scale 2.0 (SIS) communication domain as the independent variable, and the Activity Card Sort (ACS) social activity domain as the dependent variable (social participation). Two separate models were built for persons with aphasia and without aphasia. As post hoc analyses, the four domains of MOS social support (emotional/informational support, affectional support, positive social interaction, and tangible support) were included as a mediator in four individual models. Outcomes & Results Our results showed that there was no difference in social participation between persons with aphasia and without aphasia after stroke. Perceived social support (b=0.180, 95% CI=0.054~0.352), including emotional/informational support (b=0.182, 95% CI=0.552~0.359), affectionate support (b=0.138, 95% CI=0.020~0.316), and positive social interaction (b=0.178, 95% CI=0.035~0.357), fully mediates the association between communication abilities and social participation in persons with aphasia, but did not for persons without aphasia (p>0.05). Conclusions The results indicate that perceived social support, specifically emotional/informational support, affectionate support, and positive social interaction, may be used as an intervention approach for improving social participation in persons with post-stroke aphasia.

Distress facing increased genetic risk of cancer: The role of social support and emotional suppression

ObjectivesHealthy individuals from hereditary cancer families undergoing genetic testing for cancer susceptibility (GTC) report more distress when they perceive their social support as low and suppress their emotions. This study aimed to explore how suppressing emotions and perceiving others as unsupportive are related with cancer-risk distress. MethodsWe performed a regression-based mediation analysis to assess if expressive suppression mediates or is mediated by perceived social support in the relation with cancer-risk distress. Participants were 125 healthy adults aged over 18 (M = 36.07, SD = 12.86), mostly female (72,4%), who undergone GTC to assess the presence of hereditary breast and ovarian cancer or Lynch syndromes. ResultsControlling for age and gender, we found a moderate size indirect effect of social support on cancer-risk distress through expressive suppression (β = −0.095) and a direct effect of expressive suppression on cancer-risk distress. ConclusionsWhen healthy individuals from hereditary cancer families perceive their social network as less responsive, they tend to not express their emotions, which relates to increased distress facing GTC. Practice implicationsPractitioners may assess cancer-risk related distress before the GTC and offer distressed individuals interventions focused on changing emotion regulation strategies in a safe group context.

Auditory outcome following aneurysmal subarachnoid haemorrhage

Auditory deficits are increasingly recognised following aneurysmal subarachnoid haemorrhage (aSAH) and are thought to be of central rather than peripheral origin. Central hearing impairment, also known as auditory processing disorder (APD), often coexists with cognitive deficits and it is thought that APD has both auditory and cognitive elements. The aim of this study was to assess auditory outcome following aSAH and its relationship with cognition. A retrospective case-controlled study design was employed with aSAH cases and matched controls identified from the UK Biobank. Auditory and cognitive outcomes were assessed using the digit triplet test (DTT) and a test of psychomotor reaction time, respectively. Best DTT score was compared between cases and controls using the t-test. A regression-based mediation analysis was performed to assess whether cognition mediated auditory outcome. 270 aSAH patients with auditory outcomes were identified with an average follow-up of 106 months. A matched control cohort of 1080 individuals was also identified. The aSAH cohort had significantly impaired best DTT scores compared to matched controls (p = 0.002). Cognition significantly mediated auditory outcome following aSAH, accounting for 9.8% of the hearing impairment after aSAH. In conclusion significant hearing impairment follows aSAH. The deficit is bilateral and non-progressive. There is a link with cognitive deficit, pointing to a central rather than peripheral source, in keeping with an auditory processing disorder. All aSAH patients should be asked about hearing difficulty at follow-up and when present it should be investigated with peripheral and central auditory assessments, as well as cognitive tests.

Encouraging gameful experience in digital game-based learning: A double-mediation model of perceived instructional support, group engagement, and flow

In the current digitalization era, digital game-based learning (DGBL) is used in education to engage and motivate students. Gameful experience (GE) is a crucial precondition to determine the effectiveness of these games. However, previous research focused solely on the effects of games on inter alia student engagement, and empirical research regarding GE is lacking. Therefore, this study provides deeper insights into GE by empirically investigating the factors that encourage students’ GE. Grounded in the theory of experience, a double-mediation model is developed that considers the direct relationship between perceived instructional support and students’ GE and examines the mediating roles of group engagement and flow in this direct relationship. Data from 336 students participating in a team-based business simulation game at two universities in Germany were analyzed using regression-based mediation analysis via SPSS Process. The results revealed that perceived instructional support promoted students’ GE. Moreover, group engagement and flow sequentially doublemediated the positive relationship between perceived instructional support and GE.Thus, to encourage students’ GE, educators and education institutions should provide appropriate instructional support that promotes group engagement as well as flow among students.

Long-Term Cognitive Outcome following Aneurysmal Subarachnoid Haemorrhage

ObjectivesSurvivors of aneurysmal subarachnoid haemorrhage (aSAH) frequently suffer from cognitive dysfunction. The aim of this study was to assess, in a large sample size with long term follow-up, the characteristics of cognitive dysfunction following aSAH and explore whether cognitive deficits mediate employment outcome. Materials and methodsIn this retrospective case-controlled study, aSAH survivors (n = 884) were identified from the UK Biobank and compared to matched controls (n = 3536). Controls were propensity score matched according to age, sex, Townsend deprivation score, educational status and relevant medications known to influence cognition. Cognitive outcomes and employment status were compared between cases and controls using group comparison and cross-tabulation tests. A regression-based mediation analysis was performed to assess whether cognitive deficits mediate employment status following aSAH. ResultsPsychomotor reaction time and employment status significantly differed between aSAH cases and controls with slower reaction times (p < 0.001) and more unemployment or inability to work due to illness (p < 0.001) in the aSAH cohort at a mean follow-up of 125 months. Psychomotor slowing was estimated to mediate a significant proportion (6.59%) of the effect of aSAH on employment status. ConclusionsPsychomotor reaction time and employment status differed significantly between aSAH cases and control matched individuals in the UK Biobank. Psychomotor slowing following aSAH had a discernible impact on employment status. Psychomotor reaction time and employment status are practical to acquire and can be used as surrogate measures of outcome in future studies of aSAH survivors.

Correction to: Regression-based mediation analysis: a formula for the bias due to an unobserved precursor variable

Correction to: Regression-based mediation analysis: a formula for the bias due to an unobserved precursor variable

Dietary patterns and cardiometabolic risks in diverse less-developed ethnic minority regions: results from the China Multi-Ethnic Cohort (CMEC) Study.

Background In Western developed countries, food-based dietary patterns have been associated with the risk of cardiometabolic diseases, but little is known about such associations in less developed ethnic minority regions (LEMRs), where the cardiometabolic disease burden is growing rapidly and food patterns differ substantially.Methods Between May 2018 and September 2019, we recruited 99556 participants aged 30-79 years from the China Multi-Ethnic Cohort (CMEC) Study. We measured habitual dietary intake with validated food frequency questionnaire (FFQ) and then calculated dietary pattern scores for two of the most studied a priori dietary patterns, i.e., Dietary Approaches to Stop Hypertension (DASH) and alternative Mediterranean (aMED) style diets, and three a posteriori dietary patterns. Four cardiometabolic risks, including hypertension, diabetes, dyslipidaemia and metabolic syndrome (MetS), were newly diagnosed by medical examination and blood tests. We estimated adjusted odds ratios (OR) relating various dietary pattern scores to cardiometabolic risks using marginal structural models under the guidance of directed acyclic graphs. For the above associations, we further calculated the proportion mediated by overweight (PM) using regression-based mediation analysis for better public health implications.Findings The final study sample consisted of 68834 participants. Among them, we newly diagnosed 12803 hypertension, 3527 diabetes, 16342 hyperlipidaemia, and 8198 MetS cases. Overall, all 5 dietary patterns showed considerable associations with risks of hypertension and MetS. Comparing the highest with the lowest quintiles, the DASH score showed the strongest inverse associations with risks of hypertension (OR=0.74, 95% CI:0.70-0.79; PM=10%) and MetS (OR=0.79, 95% CI:0.74-0.85; PM=35%); conversely, scores of the localized a posteriori Yunnan-Guizhou plateau dietary pattern in LEMRs showed the strongest positive associations with risks of hypertension (OR=1.44, 95% CI:1.35-1.52; PM=10%) and MetS (OR=1.35, 95% CI:1.26-1.46; PM=33%), with all P values for trend <0.001. These associations were consistent in various subgroups defined by sex, age, smoking and physical activity, but with magnitudes that differed substantially across different ethnic regions and urbanicity. By investigating the single-component effects of dietary patterns, the dairy intake component contributed a major proportion to the beneficial effects of DASH (41.9% for hypertension and 100.5% for MetS).Interpretation Substantial socioeconomic status and ethnic disparities in diet quality and related cardiometabolic risks were seen in LEMRs, with hypertension being the top diet-related cardiometabolic risk. Our findings support that DASH provides superior dietary guidance compared to aMED for reducing cardiometabolic risks in LEMRs. In particular, the dairy intake encouraged by DASH may produce considerable beneficial effects.Funding This study was funded by the National Key R&D Program of China; full funding sources listed in the acknowledgements.

Creating Gameful Experience as an Innovative Approach in the Digital era

In the current digitalization era, games have become a crucial new method for digital game-based learning (DGBL) in higher education. Regarding the use of games in DGBL, the development of meaningful learning experiences within games, i.e., gameful experience (GE), among students is decisive, as GE is a necessary precondition determining the effectiveness of games. Therefore, this study provides deeper insights into the GE and empirically investigates the factors creating GE among students. Grounded in the theory of experience, a double-mediation model is developed that considers instructional support, group engagement, and flow as determinants of students’ GE. Based on data from 336 students participating in a team-based business simulation game at two universities in Germany, regression-based mediation analysis revealed that instructional support promoted students’ GE. However, in this relationship, the interpersonal factor, group engagement, alone did not indirectly create students’ GE in terms of absorption and dominance. Instead, the individual factor, flow, mediated the corresponding relationship. Furthermore, group engagement and flow together sequentially double-mediated the relationship between instructional support and GE. Consequently, in the context of DGBL, appropriate instructional support as well as high levels of group engagement and flow are important to create students’ GE.