Defense Date
2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Social and Behavioral Health
First Advisor
Jessica G. LaRose, PhD
Abstract
Purpose: This purpose of this study was: 1) to elucidate how healthcare delivery and psychosocial factors contribute to psychological distress among African American and White breast cancer survivors, and 2) to examine whether healthcare delivery and psychosocial factors mediate the association between race and psychological distress.
Methods: A sequential explanatory mixed methods study design was employed, which was guided by the model of cancer related worries, depression and anxiety. Quantitative aims leveraged a prospective cohort study of women with hormone receptor positive (HR+) breast cancer (N=243) for this secondary analysis. Sociodemographic variables, clinical information, healthcare delivery and psychosocial factors were self-reported via validated surveys. Univariable and multivariable linear regression models were used to examine the association between healthcare delivery and psychosocial factors with psychological distress. Path model analysis was used to examine whether healthcare delivery and psychosocial factors mediated the association between race and psychological distress. Primary qualitative data was collected via semi-structured interviews (N=30), to understand how the healthcare delivery and psychosocial factors identified in the quantitative sample contributed to psychological distress among African American and White breast cancer survivors. Interviews were transcribed verbatim and analyzed using thematic analysis approach as outlined by Braun and Clarke.
Results: In the univariable regression model analysis, patient provider communication (p=0.004), patient satisfaction (p< 0.001), trust in provider (p=0.007), self-efficacy (p=0.007), quality of life (p< 0.001), and social support (p=0.001) had an inverse and a statistically significant association with psychological distress. In the multivariable regression model, quality of life (p< 0.001) had an inverse and a statistically significant association with psychological distress. Compared to their White counterparts, African American survivors had lower levels of patient provider communication (p=0.021), patient satisfaction (p=0.03) and quality of life (p< 0.001), and higher levels of medical mistrust (p< 0.001), discrimination in healthcare settings (p< 0.001), and religiosity (p< 0.001). The path model showed that medical mistrust (p< 0.001), patient satisfaction (p< 0.001) and quality of life (p< 0.001) mediated the association between race and psychological distress. Interviews provided detailed insights not captured in the survey data, including medical mistrust of health insurance procedures and race-based discrimination among African American survivors, which contributed to psychological distress.
Conclusion:
Healthcare delivery and psychosocial factors operate in a nuanced and interconnected manner to shape breast cancer related psychological distress. Findings underscore the need for multidimensional and culturally appropriate psychological distress management interventions for breast cancer survivors. Quality of life measures can serve as important screening tools to identify survivors at greater risk of psychological distress. Efforts to improve outcomes for African American breast cancer survivors should focus on addressing medical mistrust and discrimination via institutional and provider level interventions.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
4-8-2026
Included in
Mental and Social Health Commons, Population Health Commons, Social and Behavioral Sciences Commons