Date of Award
Spring 2023
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Public Health
First Advisor
Lichtman, Judith
Abstract
Introduction: Psychosocial factors may play important roles in the recovery of young adults (age≤55 years) after an acute myocardial infarction (AMI), yet little is known about the impact of marital status and marital stress as an independent exposure. This dissertation aims to examine the relationship between marital status, marital stress, and post-AMI health outcomes, with a focus on younger adults.Methods: A systematic review was conducted to understand the association between marital/partner status and patient-reported outcomes among AMI survivors. Next, we used data from the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), an observational cohort study which enrolled individuals aged 18-55 years with AMI in the United States (2008-2012), to examine the relationships between marital status, marital stress, and post-AMI health outcomes among younger adults with AMI. Marital status was self-reported at baseline and was categorized into “married/partnered” and “unpartnered (i.e., divorced, widowed, and single).” Marital stress was measured using the Stockholm Marital Stress Scale among married/partnered participants and categorized as “absent/mild,” “moderate,” and “severe.” Health outcomes included physical/mental health status (Short Form-12), generic health status (EuroQol-5 Dimensions Visual Analog Scale), cardiac-specific quality of life (QoL) and angina (Seattle Angina Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and hospital readmission (all-cause and cardiac readmission) through one year after AMI. Lastly, we conducted mediation analyses to examine whether and to which extent do psychosocial factors (i.e., depression and low social support) explain the association between marital stress and cardiac-specific QoL. Interactions of the exposure variable with sex were tested in all these associations. Results: Findings from the systematic review of 34 included studies suggested that married/partnered AMI survivors reported higher health-related QoL during their recovery compared to unpartnered individuals. However, there was no association between marriage/partnership and better functional, symptomatic, or personal recovery outcomes. In the analysis of VIRGO participants, we found that unpartnered individuals were more likely to be readmitted to a hospital within the first year of recovery compared to married/partnered individuals. The association attenuated and remained significant after adjusting for demographic and socioeconomic factors (Hazard Ratio [HR]=1.16; 95% confidence interval [CI], 1.01 to 1.34), but was not significant after further adjusting for clinical and psychosocial factors (HR=1.10; 95% CI, 0.94 to 1.28). Among married/partnered individuals, self-reported severe marital stress was significantly associated with worse mental health (β = -2.13, standard error [SE]=0.75, p=0.004), generic health status (β = -3.87, SE=1.46, p=0.008) and cardiac-specific QoL (β = -6.41, SE=1.65, p<0.001), and greater odds of angina symptoms (odds ratio [OR]=1.49, 95% CI: 1.06 to 2.10, p=0.023) and all-cause readmissions (OR=1.45, 95% CI: 1.04 to 2.00, p=0.006) at one year post AMI, after adjusting for baseline health score, patient demographics, and socioeconomic factors. Participants with severe marital stress reported lower physical health and greater odds of cardiac readmissions compared to those with absent/mild marital stress, but these associations were not statistically significant after covariate adjustment. In the mediation analysis, we found a significant direct effect from severe marital stress to lower cardiac-specific QoL (β = -4.83, 95% CI, -6.98 to -2.49, p<0.001). Depression and low social support significantly mediated 11.5% (natural indirect effect [NIE] = -0.63, 95%CI, -1.15 to -0.10, p=0.014) and 13.5% (NIE = -0.69, 95%CI, -1.10 to -0.29, p<0.001) of the total relationship, respectively. Sex differences were not evident in any of these associations. Conclusions: Unpartnered status and severe marital stress were associated with worse outcomes one-year post AMI for younger adults, including higher risk of hospital readmissions and worse self-reported health, compared to married/partnered individuals or those with lower level of marital stress. In addition to stress experienced in marriage or committed relationship, multiple facets of social relationships may play important roles in AMI recovery and warrant further investigation. Routine screening and the creation of interventions to support patients with relational stress (e.g., couples counseling, family-based health education) may represent an important addition to current care that might improve young adults’ recovery from an AMI.
Recommended Citation
Zhu, Cenjing, "Understanding the Role of Marital Status and Marital Stress on Health Outcomes for Young Adults after Acute Myocardial Infarction" (2023). Yale Graduate School of Arts and Sciences Dissertations. 898.
https://elischolar.library.yale.edu/gsas_dissertations/898
