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Depression as a Mediator between Disability and Health-Related Quality of Life in Stroke Survivors: A Causal Mediation Analysis

Year: 2026

Type: preprint

Abstract: Background Stroke disproportionately affects survivors in low-and middle-income countries, yet the pathway from disability to poor health-related quality of life (HRQOL) remains unquantified in Africa. Therefore, this study aimed to assess the extent to which depression mediates the relationship between disability and HRQOL among stroke survivors in Addis Ababa, Ethiopia. Methods A cross-sectional study was conducted among 364 stroke survivors at Zewditu Memorial Hospital and Yekatit 12 Medical College Hospital in Addis Ababa, Ethiopia. Disability was assessed using modified Rankin Scale. Depression was assessed using Patient Health Questionnaire-9 (PHQ-9), and HRQOL was assessed using the Stroke-Specific Quality of Life (SSQOL-49), dichotomized into poor and good HRQOL. Causal mediation analysis was used to assess the extent to which depression mediates the relationship of disability on HRQOL. Sensitivity analysis was conducted to assess the effect of unmeasured confounding. Results The prevalence of poor HRQOL was 60.7%, and 67% of survivors had minor to severe disability. All stroke survivors had minimal to severe depression. Depression, female sex, hypertension, cardiac disease and physical inactivity were factors associated with poor HRQOL. The proportion mediated was 39.1%. The total effect of disability on poor HRQOL was 0.223 (95% CI: 0.017–0.429, p = 0.004), the direct effect (average direct effect) of disability on poor HRQOL was 0.087 (95% CI: 0.019–0.214, p = 0.004) and the indirect effect average causal mediation effect was 0.136 (95% CI: 0.017–0.213, p = 0.004). The sensitivity analysis showed that unmeasured confounder needs a very strong correlation (ρ = 0.86) to nullify the indirect effect. The differences between subgroups were not statistically significant. Conclusion Depression mediated approximately two-fifths of the effect of disability on poor HRQOL of stroke survivors in Addis Ababa, Ethiopia. Sensitivity analysis indicated high robustness to unmeasured confounding (ρ = 0.86).

Source: Research Square

DOI: 10.21203/rs.3.rs-10600056/v1

Authors: Eden Fiseha Kassa, Lidya Genene, Chalachew Gashu Animut, Melat Amberbr Wondimagegnehu, Girma Taye Aweke

Institutions: Addis Ababa University, Oda Bultum University, Arsi University

Language: English

Topic: Stroke Rehabilitation and Recovery

Subfield: Rehabilitation

Field: Medicine

Domain: Health Sciences

SDGs: Good health and well-being, Reduced inequalities

Open Access status: green

OpenAlex ID: W7204257565