Psychosocial Adaptation After Heart Transplantation: The Chain-Mediating Effect of Self-Esteem and Death Anxiety on Social Support and Quality of Life in China

Heart transplantation represents a pivotal intervention for end-stage heart failure, extending survival. However, it imposes profound physical, psychological, and social challenges that often undermine recipients' quality of life (QoL). These challenges are especially pronounced in collectivist cultural contexts like China, where familial obligations and stigma surrounding chronic illness intensify existential burdens. Grounded in theoretical frameworks including Coping Theory, Self-Determination Theory, Socioemotional Selectivity Theory, and Terror Management Theory, this cross-sectional study explored the interplay between social support and QoL among Chinese heart transplant recipients, elucidating the mediating roles of self-esteem and death anxiety, as well as their sequential chain-mediating pathway. Employing validated psychometric instruments, including the Social Support Rating Scale (SSRS), Rosenberg Self-Esteem Scale (RSES), Templer Death Anxiety Scale (T-DAS) and SF-36 Health Survey, along with chain-mediation modeling, the analysis revealed that social support exerts a direct positive influence on QoL, supplemented by indirect effects through enhanced self-esteem, reduced death anxiety, and a chained cognitive-existential mechanism linking these factors. These insights highlight the complex psychosocial dynamics of post-transplant adaptation, advocating for targeted and culturally attuned interventions. These interventions include family-based support programs, self-esteem enhancement strategies, and death anxiety counseling. The aim is to promote holistic rehabilitation and sustained well-being among heart transplant recipients in China's context.