PURPOSE:Adults with fewer financial resources often have poor self-care. Rural dwellers commonly have fewer financial resources than urban dwellers and are often stereotyped as fatalistic about health. We examined whether fatalism mediates the association of financial status with cardiovascular disease (CVD) self-care in rural adults in economically distressed areas. We hypothesized that those with fewer financial resources would have poorer self-care, and fatalism would mediate this relationship. METHODS:We enrolled 1,122 adults (53 ± 15 years) at risk for CVD. Financial status was reflected by individuals' perceptions of how well they made "ends meet" with their financial resources, fatalism by the CVD-Fatalism Instrument, and self-care of CVD risk factors by the Medical Outcomes Study-Specific Adherence Scale. We used conditional process analysis with the PROCESS macro. FINDINGS:Financial status was directly associated with self-care. Those with enough (C'1 = -1.57, P = .016) and those with not enough to make ends meet (C'2 = -3.51, P = .003) compared to those with more than enough had worse self-care. Those with higher levels of fatalism had worse self-care (b = -1.78, P = .001). Financial status was indirectly associated with self-care through fatalism. Compared to those with more than enough, those with not enough (indirect effect = -.269, 95% confidence interval = -.609, -.021) and enough (indirect effect = -.182, 95% confidence interval =-.376, -.041) had higher fatalism levels and thus worse self-care. CONCLUSIONS:Poor financial status drives fatalism in rural dwellers, which in turn results in poor self-care.

Background: Heart failure (HF) is frequently complicated by renal dysfunction, which is consistently associated with worse health-related quality of life (HRQoL). However, the indirect pathways underlying this association remain insufficiently explored. Patient-centered outcomes (PCOs), including depressive symptoms, functional status, adherence to recommended self-care strategies, and self-care behaviors, may mediate this relationship. Objectives: We aimed to examine whether PCOs mediate the relationship between renal dysfunction and HRQoL in HF. Methods: A cross-sectional secondary analysis (N = 518) was conducted using baseline data from patients with HF in the Research and Interventions for Cardiovascular Health (RICH) Heart Program Database. Depressive symptoms (Patient Health Questionnaire-9), functional status (Duke Activity Status Index), adherence to recommended self-care strategies (Medical Outcomes Study Specific Adherence Scale), self-care behaviors (Self-Care of Heart Failure Index), and HRQoL (Minnesota Living with Heart Failure Questionnaire) were assessed. The PROCESS macro (Model = 4) was used to determine the indirect effects of renal dysfunction on HRQoL. Results: Renal dysfunction had significant indirect effects on HRQoL only through depressive symptoms (Indirect effect = 4.57, SE = 1.39, 95% Bootstrap Confidence Interval [CI]:1.92, 7.33), functional status (Indirect effect = 3.41, SE = 0.68, 95% Bootstrap CI: 2.06, 4.82), and self-care management (Indirect effect = 1.14, SE = 0.50, 95% Bootstrap CI: 0.32, 2.29) controlling for age and gender. Conclusions: Our findings indicate that renal dysfunction can lead to worse HRQoL by increasing depressive symptoms, decreasing functional status, and decreasing self-care management. Interventions targeting these factors may improve HRQoL in this population.

Background Chronic stress is associated with promotion of inflammation and development of metabolic syndrome, as well as deterioration of diet quality. Inflammation can be modified by changes in dietary intake. Objective The aim of this study was to test the hypothesis that diet quality mediates the relationship of chronic stress with inflammation in patients with metabolic syndrome. Methods Participants with metabolic syndrome (n = 73, 62 ± 12 years old, 71% female) completed questionnaires on chronic stress (Perceived Stress Scale-10) and diet quality (Healthy Eating Index-2020). The Perceived Stress Scale-10 was dichotomized. The Healthy Eating Index-2020 score was used as a continuous variable, and higher scores indicate better diet quality. Inflammation was assessed using plasma high-sensitivity C-reactive protein (log-transformed). We used PROCESS in SPSS to test the hypothesis. Results Patients in the higher stress group had lower Healthy Eating Index-2020 scores (worse diet quality) than those in the lower stress group (57 ± 13 vs 64 ± 10, P = .01). Diet quality mediated the relationship between chronic stress and inflammation (indirect effect, 0.211; 95% bootstrap confidence interval, 0.006–0.496). Higher stress was associated with lower diet quality (effect, −7.152; 95% confidence interval, −13.168 to −1.137) that was associated with increased inflammation (effect, −0.030; 95% confidence interval, −0.052 to −0.007). Conclusions Our findings show the important role of diet quality in the relationship of chronic stress with inflammation in patients with metabolic syndrome. Healthcare providers should encourage patients with higher stress to improve diet quality, which can decrease inflammation.

Introduction:Functional status is a predictor of rehospitalization and mortality in patients with heart failure (HF). The purpose of this study was to test the variables in the Multidimensional Model of Functional Status (MMFS) as determinants of functional status. Methods:Using structural equation modelling, we analysed data from 520 patients with HF to determine the best multivariate model of functional status. In the MMFS, the potential determinants of functional status include demographic, clinical, psychosocial, behavioural and symptom burden variables. We measured functional status using the Duke Activity Status Index. Other variables were collected by standardized questionnaires and patient interviews. Results:Patients who were older, less educated, or had greater comorbidity burden or greater symptom burden had worse functional status. Sex, body mass index, depression, anxiety and social support were indirectly associated with functional status mediated by symptom burden. Being married was indirectly associated with better functional status via the pathways of more social support and fewer depressive symptoms through lower symptom burden. Conclusion:Multidimensional variables proposed in the MMFS were directly and indirectly associated with functional status. Among these variables, symptom burden is the most important mediator. Targeting these variables, especially symptom burden, may improve patients' functional status.

BACKGROUND:Heart failure (HF) subtype, depressive symptoms, and physical inactivity independently contribute to survival outcomes, but the effect of the interaction of these variables on survival outcomes remains unknown. OBJECTIVES:We aimed to determine whether depressive symptoms and engagement in physical activity differentially interact to predict the combined endpoint of all-cause death or rehospitalization among patients with HF and reduced (HFrEF) or preserved ejection fraction (HFpEF). METHODS:This study was a secondary analysis. The sample was categorized by the presence or absence of depressive symptoms, and engagement or non-engagement in physical activity. Cox proportional hazard modeling was used to predict the combined endpoint of all-cause death or rehospitalization. RESULTS:A total of 1002 patients with HF were included (mean age 64.3 ± 12.7 years; 637 males [64 %]; 844 White [84 %]). Among them, 35.3 % did not engage in physical activity, while 64.7 % engaged in any level of physical activity, and 29.7 % had depressive symptoms. In both subtypes, depressive symptoms were associated with the highest risk of all-cause death or rehospitalization. Among patients with HFrEF, those with depressive symptoms who did not engage in physical activity were associated with a 136 % higher risk of the combined endpoint, while among those with HFpEF, depressive symptoms and engagement in physical activity were associated with a 78 % higher risk. CONCLUSIONS:Depressive symptoms and lack of physical activity predicted the combined endpoint of all-cause death or rehospitalization among patients with HFrEF, while depressive symptoms alone were the strongest predictor among patients with HFpEF.

BACKGROUND:There are significant health disparities among rural populations, especially in the prevalence and management of coronary heart disease and heart failure. Social determinants of health (SDOH) play a crucial role in these disparities, influencing access to care, mental health, and overall quality of life (QOL). Depressive symptoms, common among rural patients with coronary heart disease and heart failure, may further exacerbate these challenges by mediating the relationship between SDOH and QOL. OBJECTIVES:We aimed to examine the association between SDOH and QOL among rural patients with coronary heart disease and heart failure, as well as to determine whether depressive symptoms mediate this relationship. METHODS:A cross-sectional analysis (N = 124) was conducted using data from a randomized controlled trial. The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences questionnaire was used to measure SDOH, depressive symptoms were assessed using the Patient Health Questionnaire-9, and QOL was evaluated using Short Form-12. We performed hierarchical multiple regression and mediation analyses. RESULTS:Higher SDOH risk scores were significantly associated with lower QOL (B= -0.319; p < 0.001). Depressive symptoms mediated this relationship (indirect effect: a*b = -0.624, 95 % confidence interval (CI)= [-1.045, -0.273]), suggesting that individuals with higher SDOH risk had worse depressive symptoms, which in turn led to lower QOL. CONCLUSION:The SDOH were associated with QOL in rural patients with coronary heart disease and heart failure, and depressive symptoms mediated this relationship. Findings highlight the need for targeted interventions addressing both social determinants and mental health to improve QOL.

BACKGROUND:Depressive symptoms, anxiety, and inadequate social support are predictors of health-related quality of life (HRQoL) in persons with heart failure, but the prediction of HRQoL is multifaceted, and mechanisms underlying association are unknown. Self-care maintenance may moderate associations among these predictors, which is essential to better heart failure outcomes. OBJECTIVES: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 persons with heart failure. METHODS:We conducted a secondary analysis using cross-sectional data collected from 167 participants. Participants completed Patient Health Questionnaire-9, Brief Symptom Inventory, Multidimensional Scale of Perceived Social Support, Self-Care of Heart Failure Index version 6.2, and Minnesota Living with Heart Failure Questionnaire for depressive symptoms, anxiety, social support, self-care maintenance, and HRQoL, respectively. PROCESS macro was used for the analysis. RESULTS: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. The beneficial effect of social support on depressive symptoms and anxiety varied with self-care maintenance, suggesting a dose-response moderation effect. DISCUSSION:Findings suggest that an increment in social support reduces depressive symptoms and anxiety, which further improves HRQoL. This relationship was more profound when the self-care maintenance was at a higher level. Our study emphasizes the need to focus on improving HRQoL by promoting positive social support that can decrease depressive symptoms and anxiety in persons with heart failure-particularly in those with low or moderate levels of self-care maintenance.

PURPOSE:The purposes of this study were to (1) identify predictors of sedentary time and (2) determine whether sociodemographic risk factors associated with sedentary time are mediated by sleep disturbances in younger (<60) and older (≥60) depressed rural patients with CVD. METHODS:Depressed rural patients with CVD completed surveys and wore ActiGraph GT9X Link monitors to measure sedentary time and sleep parameters (total sleep time and wake-after-sleep-onset [WASO]). Hierarchical regression analysis was conducted to identify factors associated with sedentary time, followed by a multi-group path analysis to examine how significant factors identified in the regression were associated with sedentary time, comparing the two age groups, and whether this association was mediated by parameters reflecting sleep disturbances. FINDINGS:Participants (n = 222) were predominantly White with an average age of 58 years and 52% were unemployed due to illness. Age, employment status, and WASO were significantly associated with sedentary time. Path analysis showed a significant mediating effect of age on sedentary time through WASO in the younger group (n = 115). However, the mediating effect of WASO on the relationship between age and sedentary time was not significant in the older group (n = 107). CONCLUSIONS:The findings highlight the critical roles of age and sleep disturbances in promoting physical inactivity, with sleep disturbances being particularly influential in younger patients. Tailoring interventions by age groups may enhance strategies to mitigate CVD risk associated with inactivity.

BACKGROUND:Prolonged sedentary time has been linked to impaired cognitive outcomes. However, the impact of sedentary time on cognitive function at different degrees of rurality is not yet well understood in patients with cardiac diseases and depressive symptoms. PURPOSE:To determine whether degree of rurality moderates the relationship between sedentary time and cognitive function. METHODS:This study includes 135 coronary heart disease or heart failure patients, primarily residing in rural Kentucky, including Appalachian areas, United States. Sedentary time was measured by the average daily sedentary time (in minutes) using accelerometry (ActiGraph). Cognitive function was assessed using the Montreal Cognitive Assessment-Blind. Rurality was determined by Rural-Urban Commuting Area (RUCA) codes. Patients were categorized into two groups by rurality: (1) 89 patients in a less rural group (RUCA codes 4-6); and (2) 46 patients in a more rural group (RUCA codes 7-10). Data were collected May 2021-September 2022 and analyzed using the Hayes PROCESS macro in SPSS. RESULTS:Sedentary time predicted cognitive function (B = -0.006, p = 0.019), and this relationship was moderated by rurality (interaction term = 0.006, p = 0.022). Patients living in more rural areas had significantly worse cognitive function when sedentary for longer periods (p = 0.019); specifically, every 100-min increase in sedentary time was associated with a 0.6-point decrease in cognitive function score. However, this relationship was not observed in those living in less rural areas (p = 0.658). CONCLUSIONS:Testing the impact of interventions aimed at reducing sedentary time on cognitive function is warranted in this population, particularly for those living in highly rural areas.

The social determinants of health (SDOH) have been recognized as an important contributor to an individual's health status. A valid and reliable instrument is needed for researchers and clinicians to measure SDOH. However, there is considerable variability in the screening methodologies, as well as a lack of standardization in definitions and methods for capturing and reporting SDOH data for both electronic health record software vendors and national experts on SDOH. The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) is a commonly used instrument for measuring SDOH. We evaluated the psychometric properties of the PRAPARE instrument in patients with coronary heart disease (CHD) and heart failure (HF), focusing on its reliability and validity for assessing SDOH. We assessed internal consistency, test-retest reliability, and construct validity using data from 234 patients with CHD and/or HF recruited from outpatient clinics in Kentucky. The PRAPARE instrument demonstrated high internal consistency (KR-20 score: 0.76) and test-retest reliability (correlation coefficient: 0.88). Factor analysis identified three distinct factors (Factor I: basic necessities and services, Factor II: housing and personal well-being, and Factor III: insurance, education, and work situation) of SDOH. PRAPARE scores were significantly correlated with depressive symptoms (PHQ-9 scores) and functional outcomes of sleep (FOSQ-10 scores). PRAPARE is a reliable and valid instrument for assessing SDOH in patients with CHD and HF, highlighting its potential for clinical and research applications.

Introduction: Caregivers are at high risk of cardiovascular disease (CVD), depression, and mortality compared to non- caregivers. Patient activation- one's knowledge, skills and confidence to manage their own health-is associated with improved self-management behaviors for several chronic conditions. Studies exploring patient activation among rural caregivers of patients with chronic diseases are lacking. Aims: To determine 1) demographic, socio-economic, and psychological characteristics associated with activation in rural caregivers, and 2) association between activation and reported adherence to recommended CVD risk reduction measures and affective symptoms in rural caregivers of patients with chronic diseases. Method: In this cross-sectional study, 277 rural caregivers were included (mean age 54 ± 14 years; 76% were female; and 70% were married). We measured sociodemographic factors using a standardized survey, activation using patient activation measure (PAM), caregiver burden using the Zarit Burden Interview, social support using the Medical Outcomes Study Social Support Survey, depression using the Patient Health Questionnaire-9, anxiety using the Brief Symptom Inventory– Anxiety subscale, and adherence to recommended CVD risk reduction measures using the Medical Outcomes Study (MOS) Specific Adherence Scale. Hierarchical regression analysis was performed. Results: In this study, patient activation was high (mean PAM 69 ± 26). Caregivers who reported low activation had significantly poorer social support, more depressive symptoms, higher anxiety level, and scored higher on food insecurity ( p <.05). High patient activation was associated with better adherence to recommended CVD risk reduction measures ( β = 0.17; p <.01), less depressive symptoms ( β = -0.2; p <.001), lower anxiety level ( β = -0.23; p <.001), and lower caregiver burden ( β = -0.15; p <.01) compared to those with the lowest scores. Conclusion: In rural caregivers, higher activation was associated with better adherence to health behavior recommendations and favorable self-reported outcomes. Greater attention should be given to patient activation and psychosocial factors to reduce CVD risk in this population.

Background: Black patients with heart failure (HF) have a higher physical and psychological distress which disproportionately worsens their health and quality of life (QOL) than those from other racial/ethnic groups. Black patients less commonly receive optimal therapy for HF than white patients, which can result in poorer functional status. Black patients report higher levels of depressive symptoms. Higher levels of depressive symptoms can further worsen functional status and lower QOL. Hypothesis: We hypothesized that depressive symptoms would predict QOL in Black patients with HF and that this relationship would be mediated by functional status. Methods: Using the RICH Heart Program HF Database, we included all 226 Black patients (57±12 years old, 49% male) with HF, who completed the Patient Health Questionnaire-9 to measure depressive symptoms, the Duke Activity Status Index for functional status, and the Minnesota Living with Heart Failure Questionnaire for QOL. Mediation analysis was performed using the PROCESS macro. Results: Depressive symptoms were directly associated with QOL (effect coefficient [c’] =2.386, 95% confidence interval [CI] = 2.549, 3.450). There was a significant indirect effect of depressive symptoms on QOL mediated by functional status (ab=0.614, 95% CI [0.406, 0.856]). Those with worse depressive symptoms had lower functional status (a = -0.901, p< 0.001), in turn, lower functional status was associated with worse QOL (b = -0.681 p<0.001). Conclusions: Depressive symptoms are directly associated with QOL and there also is an indirect association, mediated by functional status in Black patients with HF. Inequities in the management of HF among Black patients that contribute to these findings must be explored as the causes of the disparity in depressive symptoms are not yet known.

Background: Whether there are disparities in cognitive function in individuals living in rural areas compared to urban areas is unknown. Some investigators have found that rural residents have better cognitive function, while others report the opposite. Sedentary behavior is a major risk factor for cognitive health in patients with cardiac diseases; however, little is known about the impact of sedentary behavior on cognitive function at different degrees of rurality. Purpose: The aim of the study was to determine whether degree of rurality moderates the relationship between sedentary lifestyle and cognitive function among rural patients with coronary heart disease or heart failure. Methods: This study includes 135 coronary heart disease or heart failure patients residing in Appalachia (aged 59 ± 12 years, 53% female). Sedentary behavior was measured by the average daily sedentary time (in minutes) using accelerometry (ActiGraph). Cognitive function was assessed using the Montreal Cognitive Assessment-Blind. Rurality was determined by Rural-Urban Commuting Area (RUCA) codes. Participants were categorized into two groups based on degree of rurality: 1) 89 participants were included in a less rural group (RUCA codes 2−3 within Appalachia and RUCA codes 4−6 for micropolitan areas < 50,000 population); and 2) 46 participants were included in a more rural group (RUCA codes 7−10 for small towns < 9,999 population). Data were analyzed using the PROCESS macro in SPSS to test the proposed moderating effect controlling for age, gender, and depressive symptoms. Results: The time spent in sedentary behavior ranged from 3.2 to 13.3 hours per day, with an average of 7.9 ± 2.1 and a median of 7.8 hours per day. Sedentary behavior predicted cognitive function (B = −0.006, p = 0.012), but this relationship was moderated by rurality group (coefficient of rurality group*secondary behavior interaction term = 0.006, p = 0.029). Patients living in more rural areas had significantly worse cognitive function if they were sedentary for longer periods (p = 0.012), but this relationship was not observed in those living in less rural areas (p = 0.986). Conclusions: Although being sedentary is associated with worse cognitive function, degree of rurality significantly interacts with sedentary behavior in this association. Testing the impact of promoting physical activity on cognitive function is warranted in this population, particularly for those living in highly rural areas.

Background: Disparities in coronary heart disease (CHD) and other chronic related conditions, such as poor sleep quality and psychological distress, have been observed in rural areas. Both conditions can negatively affect disease progression, possibly through their impact on physical activity. The relationships, however, among sleep quality, psychological distress, and physical activity among depressed rural CHD patients have not been examined. Purpose: The purpose of this study was to determine the association of sleep quality (i.e., sleep fragmentation [frequent sleep interruption] and nocturnal/sleep movement [increased rates of movement, ‘tossing and turning’ during sleep]) and psychological distress (i.e., anxiety and perceived stress) with levels of physical activity (i.e., sedentary, light, and moderate to vigorous) in depressed rural patients with CHD. Methods: A total of 142 depressed rural CHD patients (aged 57.0±11.9 years, 97% White) completed surveys on demographic characteristics, anxiety (Brief Symptom Inventory), and stress (Perceived Stress Scale-4). Participants also wore accelerometer activity monitors for seven days (ActiGraph GT9X Link) to capture physical activity levels and sleep quality. Three different hierarchical regression models were conducted to predict each level of physical activity (sedentary, light, and moderate-vigorous) with predictor variables entered in blocks. Block 1 included demographic variables (i.e., age, sex, marital status, employment status). Block 2 included sleep quality measures, and Block 3 included psychological distress. Results: Participants spent 466±126.0 min/day while awake being sedentary, 483±119.9 min/day in light activity, and 90±65.9 min/day in moderate to vigorous activity. We found that stress was significantly associated with greater sedentary time (B = 6.56, p = .043) and less time in light activity (B = -7.99, p = .024). Nocturnal/sleep movement was significantly associated with increased sedentary time (B = 3.14, p < .001) and decreased time in light (B = -5.29, p =.002) and moderate-vigorous activity (B = -2.58, p = .003). Anxiety was not associated with physical activity. Conclusions: Poor sleep quality and greater perceived stress are associated with a more sedentary lifestyle, a major risk factor for CHD. Addressing both stress and sleep management may play a role in reducing CHD risks associated with inactivity among depressed rural patients with CHD.

Background: Physical activity (PA) is essential following an acute cardiac event. Cardiac rehabilitation (CR) is commonly prescribed, and PA after CR is recommended. Because of age-related changes in functional ability and multi-comorbidity, many older cardiac patients struggle to continue performing PA at home after CR. Depressive symptoms and anxiety are prevalent in cardiac patients and associated with poor self-care, including lack of daily PA. Yoga has been demonstrated to improve psychological and physical health outcomes in cardiac patients, but it is unknown whether yoga, modified for older CR patients - Gentle Yoga - is beneficial in managing psychological distress and maintaining PA following phase II CR. Our specific aims are to:1) determine the feasibility and acceptability of a modified gentle yoga intervention delivered via video conferencing for older cardiac patients; 2) compare, at 3-month follow-up, the effects and determine effect sizes of a gentle yoga intervention versus control on psychological health and physical health. Methods: We are conducting a 2-group (intervention versus control) randomized controlled pilot study. The intervention is a 12-week gentle yoga program delivered via video conference. Short-term effects will be evaluated at 3-month. Conclusion: This study is designed to be suited for older cardiac patients who would not have access to supervised PA opportunities after facility-based CR to enhance PA. This study will provide data about the feasibility and acceptability of the protocol for older cardiac patients and will offer effect sizes to determine sample size for a fully powered randomized controlled trial.

Background: Heart failure (HF) is not a homogeneous condition, and comorbidities, such as renal dysfunction, commonly complicate the clinical picture. However, differences in patient-centered outcomes (PCO), such as depressive symptoms, health-related quality of life, functional status, adherence, and self-care behaviors, have not been explored in patients with HF with and without renal dysfunction. Hypothesis: We hypothesized that there is a significant difference in PCO between patients diagnosed with heart failure with renal dysfunction and those without renal dysfunction. Methods: A secondary data analysis was conducted using the RICH Heart Program Heart Failure Database. We included 517 patients (61 ± 13 years old, 66% male, 66% NYHA class III/IV) with HF with (22%) and without (78%) renal dysfunction. Depressive symptoms were measured using the Patient Health Questionnaire-9, health-related quality of life using the Minnesota Living with Heart Failure Questionnaire, functional status using the Duke Activity Status Index, adherence using the Medical Outcomes Study Specific Adherence Scale, and Self-care using the Self-care of Heart Failure Index. Independent samples t-tests were conducted to compare PCO between the two groups. Results: All PCO were significantly different between the two groups. Compared to patients without renal dysfunction, those with renal dysfunction had worse depressive symptoms (8.1 ± 5.9 vs 10.0 ± 6.0, respectively, p = 0.001), poorer health-related quality of life (50.5 ± 24.9 vs 58.0 ± 25.6, p = 0.005, respectively), and lower functional status (11.7 ± 11.7 vs 77.0 ± 7.1, p < 0.001, respectively). Patients with renal dysfunction had better scores on self-reported adherence (29.2 ± 6.0 vs 25.6 ± 7.7, p < 0.001), self-care maintenance (61.6 ± 21.1 vs 54.3 ± 23.2, p = 0.03), and self-care management (60.9 ± 23.0 vs 53.8 ± 22.9, p = 0.04) than those without. Conclusions: Even though patients with HF and renal dysfunction reported better adherence and self-care behaviors, they still had higher levels of depressive symptoms, worse health-related quality of life, and lower functional status. This suggests that knowledge of their comorbidity prompted better self-care, but other PCO remained poor. Increased attention to promoting specific self-care behaviors that focus on renal dysfunction in the context of HF should be tested to determine if PCO can be improved in this patient population.

Background: Rural family caregivers experience high levels of stress, burden, and psychological distress related to caregiving and are at higher risk for cardiovascular disease (CVD) compared to non-caregivers. Health activation (known also as patient activation) is an indicator of engagement in self-care and is defined as an individual’s knowledge, skill, and confidence in managing health. Better health activation is associated with better health outcomes. Because rural individuals are at greater risk of CVD and have fewer supportive resources than those in urban environments, we wanted to determine the relationship of health activation with risk for future CVD in this population. Objective: The purpose of this study was to examine the association of health activation with risk for future CVD among rural family caregivers of patients with chronic illness. Methods: This was a cross-sectional study using baseline data from a randomized controlled trial of an intervention to reduce CVD risk for rural caregivers. We measured health activation using the Patient Activation Measure. The predicted10-year risk of CVD was assessed using the Framingham risk score. Covariates potentially related to cardiovascular risks among caregivers were collected including stress (Perceived Stress Scale-Cohen), anxiety (Brief Symptom Inventory), depressive symptoms (Patient Health Questionnaire-9), and caregiver burden (Zarit Burden Interview). Generalized linear regression was used to analyze data. Results: Of 217 caregivers (mean age 53 ± 13 years, 79% female), 48% were caring for a spouse, 20% were caring for a parent, and the remaining 32% were caring for a sibling, a child, or other relatives. Caregivers with higher health activation had a lower risk of developing CVD in the future based on their Framingham risk score (B = -0.081, SE= 0.039, 95% CI= -0.158 to -0.004, p=0.038), independent of the other covariates. Every 10-point increase in health activation score was associated with a nearly 1-point (0.81) decrease in Framingham risk score. Conclusions: Health activation is a good predictor of future risk for developing CVD. Development and testing of interventions to promote health activation before people develop CVD is suggested to decrease the risk of future CVD.

Purpose: The purpose of this systematic review was to examine the impact of diabetes self-management education (DSME) programs on A1C levels of Black/African American adults with type 2 diabetes. Methods: Authors followed PRISMA guidelines and searched PubMed and CINAHL databases to identify articles published from 2000 to date. The primary outcome was A1C and participation in a DSME program among Black/African Americans with diabetes. Results: Nine high-quality randomized control trials (RCTs) were included in this review. Sample sizes ranged between 48 and 211. Studies reported Black/African American samples ranging from 23% to 57% (n = 4), 4 reported 100%, and 1 reported 96%. Most (56%) reported a statistically significant decline in A1C levels postprogram, whereas 44% noted insignificant changes. All the studies compared the DSME intervention effect to a control group or another type of diabetes self-management program. Conclusion: The results suggest that DSME programs can be effective at lowering A1C levels in Black/African American adults; however, more research with larger sample sizes of Black/African Americans is warranted. The availability of meta-analyses and more RCTs could also further strengthen the external validity of this review. Additionally, future studies focused on A1C outcomes within DSME programs not combined with other self-management interventions among Black/African Americans can advance science regarding the impact of DSME programs among this disparate population.

Background: Depressive symptoms are prevalent in patients with coronary heart disease (CHD) and heart failure (HF) living in rural areas and are associated with worse health outcomes. Cognitive behavioral therapy (CBT) has been shown to be effective at improving depressive symptoms in patients with CHD and HF. Traditional CBT is not accessible to many rural individuals, thus alternative virtual modalities are being tested to ascertain their effectiveness. Cognitive impairment is a core feature of depressive disorders and is prevalent in up to 95% of all clinical depression diagnoses. It is unknown how cognition impacts the reduction of depressive symptoms in patients utilizing virtual CBT interventions. Aim: To determine if cognition moderates the impact of two different modalities of virtual CBT on depressive symptoms over a 12-month period. Methods: This is an on-going 12-month randomized comparative effectiveness trial. Participants with at least mild depressive symptoms were randomly assigned to CBT with either a video-conference with a therapist or a self-directed internet-based application. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ9) and were measured at baseline, 3-, 6-, and 12-months. Cognition was measured at baseline using two instruments, the MOCA and the Mini-Cog. Those with significant cognitive dysfunction were excluded from the study. Scores were standardized from both instruments using Z-scores and separated by the median into lower cognitive function and higher cognitive function. Repeated measures ANOVA was performed to determine whether cognitive function interacted with either intervention to produce an effect on depressive symptoms over time. Results: Participants (n=305) were 58±12 years old, 49% female, and had 13±3 years of education. Baseline PHQ-9 scores showed no significant difference between lower and higher cognition groups. (12±6 vs 11±5, respectively, p=.17). There was no interaction of cognition by intervention group on depressive symptoms (p=0.217). Both intervention groups had significant decreases in depressive symptoms over time (p<0.001 for time effect). There was no between-group difference in improvement of depressive symptoms (p=0.059). Conclusion: Both cognitive groups experience significant symptom reduction with virtual CBT, suggesting effectiveness regardless of cognitive function in rural CHD and HF patients, provided significant cognitive dysfunction is absent.

Background: Depressive symptoms (DS) are highly prevalent in patients with cardiovascular diseases (CVD). Sedentary behavior is associated with DS, and together they worsen CVD health outcomes. Rural patients exhibit greater incidence of DS and physical inactivity than their urban counterparts. While females and younger adults are more likely to experience DS in general, how sedentary time (ST) interacts with age and sex on DS in rural patients with CVD has not been elucidated. Hypothesis: Age and sex multiplicatively moderate the association of daily ST with DS in rural patients with CVD. Methods: A total of 226 (58±12 [range 23-80] years old, 49% female) rural patients with CVD were included. The Patient Health Questionnaire-9 was used to measure DS. Patients wore the ActiGraph GT9X Link for 4 to 7 days to measure ST (minutes/day on average). We used PROCESS to test the moderated moderation model. The pick-a-point approach was used for probing a three-way interaction. Results: We found a significant three-way interaction among daily ST ( X ), age ( Z ), and sex ( W ) [B=-.0016, t (218)=-3.631, p =.0004], which indicates the magnitude of the moderation by sex on the effect of daily ST on DS depended on age. Moderated moderation explained 10.1% of the variance in DS ( p =.002). The pick-a-point approach indicated significant conditional interactions between ST and sex at the youngest and oldest ages (Figure). Among younger adults, there was a significantly positive association of ST with DS in females compared to males [θ XW → Y |( Z =30)=.034; F (1;218)=8.363; p =.004], while a significantly positive association of ST with DS was found in males compared to females among older adults [θ XW → Y |( Z =70)=-.028; F (1;218)=11.431; p =.001]. However, among middle-aged adults, the association of sedentary time with DS was not significantly moderated by sex ( p =.59). Conclusions: The findings of the study indicate a complex interaction of age and sex in the relationship of ST with DS and suggest an age- and sex-stratified intervention to improve depressive symptoms. Future research is warranted to examine factors that influence sex differences in the association of ST with DS in different age groups.